Beyond mammography: new frontiers in breast cancer screening

Abstract

Breast cancer screening remains a subject of intense and, at times, passionate debate. Mammography has long been the mainstay of breast cancer detection and is the only screening test proven to reduce mortality. Although it remains the gold standard of breast cancer screening, there is increasing awareness of subpopulations of women for whom mammography has reduced sensitivity. Mammography also has undergone increased scrutiny for false positives and excessive biopsies, which increase radiation dose, cost, and patient anxiety. In response to these challenges, new technologies for breast cancer screening have been developed, including low-dose mammography, contrast-enhanced mammography, tomosynthesis, automated whole breast ultrasound, molecular imaging, and magnetic resonance imaging. Here we examine some of the current controversies and promising new technologies that may improve detection of breast cancer both in the general population and in high-risk groups, such as women with dense breasts. We propose that optimal breast cancer screening will ultimately require a personalized approach based on metrics of cancer risk with selective application of specific screening technologies best suited to the individual's age, risk, and breast density.

Figure 1

49 year-old female with palpable mass, left breast. (a.) Cranio-caudal (CC) and medio-lateral oblique (MLO) low energy mammographic views demonstrate a focal asymmetry in the left central breast with adjacent biopsy clip (arrows). Contrast enhanced mammography in the CC (c.) and MLO (d.) projections demonstrate multiple enhancing masses in the left lower inner quadrant extending to the nipple (arrows). Ultrasound guided core biopsy confirmed the presence of multifocal invasive mammary carcinoma with lobular features. Images courtesy of Dr. Maxine S. Jochelson, MD., Director of Radiology Breast and Imaging Center, Memorial Sloan Kettering Cancer Center and Associate Professor of Radiology, Weill Medical College of Cornell University.

Figure 2

35-year old female with a palpable mass above the left nipple. (a.) CC and (b.) MLO mammographic views show heterogeneously dense breasts and subtle architectural distortion in the left upper outer quadrant (arrows). Tomographic slices in the CC (c.) & MLO (d.) projections demonstrate a 1.6 cm spiculated mass in the left upper outer quadrant (arrows). Subsequent mastectomy showed grade III invasive ductal carcinoma (IDC). Images reprinted with permission. Courtesy of Dr. Linda R.N. Greer, M.D., Medical Director and Radiologist, Breast Health & Research Center, John C. Lincoln Health Network in Phoenix, Arizona.

Figure 3

55 year-old female with dense breast parenchyma and normal screening mammogram, who underwent automated whole breast screening ultrasound. (a) Axial sonographic image from the right breast at 12 o’clock shows a 10 mm irregular hypoechoic mass with angular margins and posterior acoustic shadowing (arrow). (b.) Coronal reformatted image from a screening AWBUS demonstrates a 10 mm hypoechoic mass at 12 o’clock in the right breast (arrow). Ultrasound guided core biopsy showed IDC. Images courtesy of U-Systems, Inc. Sunnyvale, California.

Figure 4

33 year-old female with known BRCA 2 mutation. (a.) CC and (b.) MLO mammographic views of the left breast demonstrate heterogeneously dense breast parenchyma and no identifiable masses, calcifications or other abnormality. c.) Axial contrast enhanced MRI subtraction sequences with kinetic overlay (d.) demonstrate a 1.5 cm rapidly enhancing irregular mass (arrow) with irregular margins and adjacent clumped ductal enhancement measuring up to 8.0 cm in greatest dimension. Ultrasound guided biopsy and subsequent mastectomy showed multi-centric grade III IDC with high-grade ductal carcinoma in situ (DCIS).

Figure 5

78 year-old female with history of right lumpectomy and radiation therapy for invasive lobular carcinoma four years prior presents with increasing heaviness to the right breast after recent trauma. a.) CC and (b.) MLO mammographic views of the right breast demonstrate post lumpectomy changes with stable skin thickening, unchanged since the prior study. BSGI in the CC (c.) and (d.) MLO views demonstrate multiple areas of increased radiotracer uptake (presented as white on black) consistent with multifocal metabolically active disease. Subsequent mastectomy confirmed multi-centric invasive lobular carcinoma. Images courtesy of Dr. Michael Portillo, M.D., Susan Cheek Needler Breast Centers, Morton Plant Mease Healthcare, Clearwater, Florida.