Ruud Pijnappel Professor of Radiology, UMC Utrecht. Chair Dutch Expert Centre for Screening Board EUSOBI

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1 Ruud Pijnappel Professor of Radiology, UMC Utrecht Best practice in Breast Imaging: what s new and what women need to know and Update on the Second Implementation Report of the 2003 Council Recommendation on Mammography Screening Chair Dutch Expert Centre for Screening Board EUSOBI

2 Breast Imaging What s new and what women should know Screening

3 Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New

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5 Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%

6 Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%

7 Problem with Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%

8 Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%

9 Problem with Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%

10 Density from a patients perspective Am I Dense? What does that mean for me? What to do next? Howcome I am confronted with breast cancer, while my screening mammography was only 5 months ago?

11 To inform women Q A Am I Dense? Density measurement depends on Radiologist and / or automated system used

12 Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?

13 Sensitivity reduction c d -7% -13% Heterogeneously dense Extremely dense Sensitivity reduction of mammography compared to Average Price, E et al. Radiology :3 dec

14 Breast Density and mammographic sensitivity a b c d 0-9% -18% -29%

15 Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?

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17 Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?

18 RR to average density c 1,2 d 2,1 Heterogeneously dense 40% Extremely dense 10% Sickles, EA et al Radiol Clin North Am 2010;48(5):

19 Impact of this RR? Breast Density is not a strong risk factor! BIRADS d RR 1 first degree post menopausal BC It makes no sense to consider half of the population at high risk

20 Conclusion Density RR BC risk Masking

21 Density from a patients perspective Am I Dense? What does that mean for me? What to do next? How come I am confronted with breast cancer, while my screening mammography was only 5 months ago?

22 1 2 3 Risk assessment How willing are you to have a benign biopsy? Consider: Supplemental screening? Q: What to do next?

23 Which supplemental screening?

24 Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New

25 Tomosynthesis Slices Multiple low dose projections Reduce parenchymal noise

26 Overlapping tissue on 2D Camouflage lesions Mimic lesions Lesion superimposed in 2D

27 3D Mammography (Tomosynthesis)

28 Tomosynthesis & Density Beneficial?

29 Health Technol Assess 2015 Jan; 19(4):1-36 (UK) JAMA 2016, 315(16): (USA) Density & Tomosynthesis Not THE solution for extremely dense BI-RADS d

30 Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New

31 Ultrasound as supplemental screening High risk population Clinical breast examination Inclusion of different density categories Studies not uniform Debate Reimbursement and costs

32 The cost-effectiveness ratio for each year of healthy life gained was $

33 3D US THE solution in dense breasts?

34 Automated Whole Breast Ultrasound

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36 3D Ultrasound Automated breast US should be still considered as an investigational modality. It should be offered to woman in the context of well-designed prospective studies approved by Ethical Committees.

37 Density & 3D US No solid scientific evidence for dense mammography

38 Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New

39 CESM Contrast Enhanced Spectral Mammography

40 CESM image example A B C Permission of dr. Marc Lobbes, radiologist MUMC (NL)

41 CESM - Radiation dose: + 80% - IV contrast Lobbes et al Eur Radiol DOI /s00330

42 CESM vs MRI 25% ACR 4 (BIRADS D) CESM >> Mammography CESM MRI Fallenberg et al Eur Radiol (2014) 24:256

43 MRI No data available for average risk groups and density One on-going RCT on density (extreme dense) and MRI in NL DENSE trial: results 2018

44 2014: Gadolinium!

45 EMA ema.europa.eu

46 Gadolinium retention 2017 EMA suspension of 4 linear GCCAs No evidence for neurotoxcity Long term safety unknown

47 Summary Q What to do next? US Tomosynthesis MRI / CESM Recall / biopsy very common High percentage of FP biopsy Insurance? Double Dose (2D + 3D) Not for BI-RADS d No solid evidence To inform women

48 Q A How come I am confronted with breast cancer, while my screening mammography was only 5 months ago? 1. Problem of masking To inform women

49 Q A How come I am confronted with breast cancer, while my screening mammography was only 5 months ago? 1. Problem of masking 2. Although detection is lower if you have dense breast tissue, compared to lucent tissue, mammographic screening still detects most cancers. To inform women

50 Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New

51 Thermography No replacement for mammography Insufficient evidence to screen with thermography 1. Breast Cancer Research and Treatment ACR J. Am. Coll. Rad. 2013; 10; ACR J. Am. Coll. Rad. Vol. 13 Issue 11 Suppl. Nov R45-R49 4. Breast Disease Vol. Reprint, pp1-5; Breast Care 2016; 11:

52 Breast Imaging What s new and what women should know Screening

53 Breast Cancer Screening in Europe

54 Screening

55 eu/recommendations Age 2. New screening methods Tomosynthesis 3. Tailored screening in Density Tomosynthesis Ultrasound (US) MRI

56 Age

57 Age

58 Age

59 Age

60 Should screening use Tomosynthesis

61 3D US in addition to mammography in dense breast

62 Tomosynthesis in addition to mammography in dense breast

63 Hand held US in addition to mammography in dense breast

64 MRI in addition to mammography in dense breast

65 Screening mammography

66 <5% world population of woman has access to screening mammography Screening mammography

67 <5% has access to screening Healthcare system Finance Staff Politics Knowledge Healthcare providers Decision makers Not only about equipment and new technology!!

68 Support and awareness

69 Thank you Europa Donna Breast Radiologist Breast Screening Expert Centre EUSOBI