br Image based breast cancer screening will
Image-based breast cancer screening will spread globally
Although heavily debated during the last decades, it has been shown that regular invitation to mammography screening reduces breast cancer mortality with up to 23e40% in women aged 50e69 years, the latter number pertaining to women who actually attend . In the position paper on mammography from World Health Organization it is described how screening is cost-effective in upper-middle income countries but not, currently, for lower-middle income countries . We believe this will change due to improving economic resources and due to an increasing breast cancer incidence in low- and middle-income countries. When a country is unable to provide this on a population-wide scale there is an increasing risk that opportunistic screening will gain ground. Even though certain individuals might experience a benefit, we agree with the statement of WHO that “Opportunistic screening or screening that is not well organized run the risk of causing more harm than good and should not be implemented in any setting”.
to an adequate screening modality
- Image-based breast cancer screening will spread globally
- Awareness of mammography shortcomings will increase
- Tomosynthesis will become an established screening modality
observable biological correlates
Medical disciplines will be more closely integrated for the full benefit of th
IMPROVEMENTS IN IMAGING
- Contrast-enhancement will make mammography an
- The usefulness of automated ultrasound will be determined
- Minimally invasive image-guided procedures will replace open surgery for smaller lesions
enable MRI as a screening modality in certain subgroups
Fig. 1. Graphical abstract with summary of predictions.
Awareness of mammography shortcomings will increase
Before mammography screening was introduced during the 1990's there was no prevention for breast cancer. There is now a strive to challenge and try to improve the one-size-fits-all model for breast cancer screening with mammography, given the short-comings when it comes to for instance high breast density and reduced sensitivity. From the scientific D AP5 perspective there are numerous ongoing trials on personalized or risk stratified screening involving stratification based on breast density, family history, genetics etc. From the women's perspective, a more widespread awareness of the higher breast cancer risk associated with higher breast density in synergy with the knowledge of the limitations with 2D mammography has encouraged lobby groups to establish. In the US, this has eventually stimulated the density legislation in a majority of states mandating notification of risks associated with breast density directly to women undergoing mammography .
Tomosynthesis will become an established screening modality
It is a well-known fact that 2D mammography has limitations when it comes to sensitivity of breast cancer detection in screening, especially in women with dense breasts where normal structures in the breast may hide a tumor . 3D mammography, or digital breast tomosynthesis, is a development of the mammography method which partly may overcome the overlapping tissue effect inherent in 2D mammography and the results from several pro-spective screening trials show improvement in cancer detection with at least 30% . Whether 3D mammography will (comple-ment or) replace 2D mammography in screening is still an open question, since evidence of the effects on breast cancer mortality is challenging to prove. 3D mammography screening trials with breast cancer mortality as endpoint will not take place, although meta-analyses with surrogate measures such as reduction in
interval cancer rates and analysis of tumor biology may orient us in a near future.
Mammographic breast compression will be optimized
Another focus for recent optimization in mammography is better breast compression. Guidelines for correct breast compres-sion remain very vague . Justified breast compression is an important issue both from an attendance (comfort) point-of-view as well as from the image quality and diagnostic perspective in order to ensure compression of the relevant parts of the breast for tissue separation. Two large studies with up to 200.000 screening mammograms showed that the sensitivity was lower in the highest compression group, after adjustments for breast volume and den-sity [7,8]. When it comes to 3D mammography it has been shown that less compression may be used, still with a superior screening performance, as compared to 2D mammography . It is worth noticing that the mentioned studies were all performed in coun-tries where quite high pressures in general are applied and more studies are needed to further elucidate the effects of compression in different settings. Many manufacturers are working on better so-lutions for compression with flexible paddles etc to optimise comfort and image quality. We foresee that coming generations of women will put higher demands on comfort during mammography and further optimization is to be seen.