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Comment
. 2024 Oct 1;184(10):1222-1231.
doi: 10.1001/jamainternmed.2024.4224.

Breast Cancer Screening Using Mammography, Digital Breast Tomosynthesis, and Magnetic Resonance Imaging by Breast Density

Natasha K Stout  1 , Diana L Miglioretti  2 , Yu-Ru Su  3 , Christoph I Lee  4 , Linn Abraham  3 , Oguzhan Alagoz  5 , Harry J de Koning  6 , John M Hampton  5 , Louise Henderson  7 , Kathryn P Lowry  8 , Jeanne S Mandelblatt  9 , Tracy Onega  10 , Clyde B Schechter  11 , Brian L Sprague  12   13   14 , Sarah Stein  1 , Amy Trentham-Dietz  15 , Nicolien T van Ravesteyn  6 , Karen J Wernli  3 , Karla Kerlikowske  16 , Anna N A Tosteson  17
Affiliations
Comment

Breast Cancer Screening Using Mammography, Digital Breast Tomosynthesis, and Magnetic Resonance Imaging by Breast Density

Natasha K Stout et al. JAMA Intern Med. .

Abstract

Importance: Information on long-term benefits and harms of screening with digital breast tomosynthesis (DBT) with or without supplemental breast magnetic resonance imaging (MRI) is needed for clinical and policy discussions, particularly for patients with dense breasts.

Objective: To project long-term population-based outcomes for breast cancer mammography screening strategies (DBT or digital mammography) with or without supplemental MRI by breast density.

Design, setting, and participants: Collaborative modeling using 3 Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer simulation models informed by US Breast Cancer Surveillance Consortium data. Simulated women born in 1980 with average breast cancer risk were included. Modeling analyses were conducted from January 2020 to December 2023.

Intervention: Annual or biennial mammography screening with or without supplemental MRI by breast density starting at ages 40, 45, or 50 years through age 74 years.

Main outcomes and measures: Lifetime breast cancer deaths averted, false-positive recall and false-positive biopsy recommendations per 1000 simulated women followed-up from age 40 years to death summarized as means and ranges across models.

Results: Biennial DBT screening for all simulated women started at age 50 vs 40 years averted 7.4 vs 8.5 breast cancer deaths, respectively, and led to 884 vs 1392 false-positive recalls and 151 vs 221 false-positive biopsy recommendations, respectively. Biennial digital mammography had similar deaths averted and slightly more false-positive test results than DBT screening. Adding MRI for women with extremely dense breasts to biennial DBT screening for women aged 50 to 74 years increased deaths averted (7.6 vs 7.4), false-positive recalls (919 vs 884), and false-positive biopsy recommendations (180 vs 151). Extending supplemental MRI to women with heterogeneously or extremely dense breasts further increased deaths averted (8.0 vs 7.4), false-positive recalls (1088 vs 884), and false-positive biopsy recommendations (343 vs 151). The same strategy for women aged 40 to 74 years averted 9.5 deaths but led to 1850 false-positive recalls and 628 false-positive biopsy recommendations. Annual screening modestly increased estimated deaths averted but markedly increased estimated false-positive results.

Conclusions and relevance: In this model-based comparative effectiveness analysis, supplemental MRI for women with dense breasts added to DBT screening led to greater benefits and increased harms. The balance of this trade-off for supplemental MRI use was more favorable when MRI was targeted to women with extremely dense breasts who comprise approximately 10% of the population.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Stout reported grants from the National Institutes of Health/National Cancer Institute (NIH/NCI) and the Patient-Centered Outcomes Research Institute (PCORI) to institution during the conduct of the study. Dr Miglioretti reported grants from PCORI and NCI during the conduct of the study. Dr Su reported grants from NIH and PCORI during the conduct of the study; grants from NIH outside the submitted work. Dr Lee reported personal fees from American College of Radiology Journal editorial board work, texbook royalties from McGraw Hill, Inc, Oxford University Press, and UpToDate, Inc, outside the submitted work. Dr Abraham reported grants from NCI during the conduct of the study. Dr Alagoz reported grants from NIH during the conduct of the study; ownership of Innovo Analytics, LLC; personal fees from Bristol Myers Squibb, and personal fees from Exact Sciences outside the submitted work. Dr de Koning reported grants from Erasmus MC during the conduct of the study; personal fees from Bayer for model review outside the submitted work. Dr Hampton reported grants from NCI to insitution directly supporting the project during the conduct of the study. Dr Henderson reported grants from NIH during the conduct of the study. Dr Lowry reported grants from NCI during the conduct of the study. Dr Mandelblatt reported grants from Georgetown University grant subcontract for time and effort during the conduct of the study; in addition, Dr Mandelblatt had a patent pending (PCT/US2022/028741) filed by Georgetown University titled “Use of RAGE inhibitors to Treat Cancer-Related Cognitive Decline” and licensed to Cantex Pharmaceuticals. Dr Mandelblatt had waived her rights and will not receive any renumeration, consideration, or revenue generated from this license or the patents and patent applications licensed thereunder. Dr Onega reported grants from NCI during the conduct of the study. Dr Schecter reported grants from NIH during the conduct of the study. Dr Sprague reported grants from PCORI and grants from NIH during the conduct of the study. Dr Trentham-Dietz reported grants from NCI and grants from PCORI during the conduct of the study. Dr van Ravesteyn reported grants from PCORI (PCS-1504-30370) and grants from NIH/NCI (U01CA199218) during the conduct of the study; fees paid to institution from Wickenstones outside the submitted work. Dr Wernli reported grants from NCI and grants from PCORI during the conduct of the study. Dr Kerlikowske reported grants from NCI (P01CA154292) and grants from PCORI (PCS-1504-30370) during the conduct of the study. Dr Tosteson reported grants from PCORI and NIH/NCI during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Outcome Trade-Offs for Breast Cancer Screening Strategies Evaluated
Outcome trade-offs shown are false-positive recalls per breast cancer death averted and false-positive biopsy recommendations per breast cancer death averted for the 9 screening strategies with digital mammography (DM), digital breast tomosynthesis (DBT) and supplemental breast magnetic resonance imaging (MRI) by the extent of breast density by screening interval (biennial and annual) and stratified by initiation age (50, 45, 40 years). Results shown for an exemplar model (model E). The top row shows false-positive recalls per breast cancer death averted. The bottom row shows false-positive biopsy recommendations per breast cancer death averted. Gray bands indicate the values for biennial screening with DM. All strategies stop screening at age 74 years. The 9 strategies, from left to right, start with DM for all women and switch to DBT by breast density and then add MRI by breast density. Breast density was categorized using the American College of Radiology’s Breast Imaging Reporting and Data System (BI-RADS): category A being almost entirely fatty; category B, scattered fibroglandular densities; category C, heterogeneously dense; and category D being extremely dense.
See this image and copyright information in PMC

Comment on

References

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