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
Breast Imaging What s new and what women should know Screening
Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New
Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%
Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%
Problem with Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%
Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 10%
Problem with Breast Density Almost entirely fatty Scattered areas of fibroglandular density Heterogeneously dense Extremely dense 10% 40% 40% 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?
To inform women Q A Am I Dense? Density measurement depends on Radiologist and / or automated system used
Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?
Sensitivity reduction c d -7% -13% Heterogeneously dense Extremely dense Sensitivity reduction of mammography compared to Average Price, E et al. Radiology 2013 269:3 dec
Breast Density and mammographic sensitivity a b c d 0-9% -18% -29%
Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?
Masking Sensitivity reduction of mammography Risk factor Age Fam history Gene mutation Q: What does it mean for me?
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):859-878
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
Conclusion Density RR BC risk Masking
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?
1 2 3 Risk assessment How willing are you to have a benign biopsy? Consider: Supplemental screening? Q: What to do next?
Which supplemental screening?
Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New
Tomosynthesis Slices Multiple low dose projections Reduce parenchymal noise
Overlapping tissue on 2D Camouflage lesions Mimic lesions Lesion superimposed in 2D
3D Mammography (Tomosynthesis)
Tomosynthesis & Density Beneficial?
Health Technol Assess 2015 Jan; 19(4):1-36 (UK) JAMA 2016, 315(16):1784-1786 (USA) Density & Tomosynthesis Not THE solution for extremely dense BI-RADS d
Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New
Ultrasound as supplemental screening High risk population Clinical breast examination Inclusion of different density categories Studies not uniform Debate Reimbursement and costs
The cost-effectiveness ratio for each year of healthy life gained was $ 325 000
3D US THE solution in dense breasts?
Automated Whole Breast Ultrasound
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.
Density & 3D US No solid scientific evidence for dense mammography
Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New
CESM Contrast Enhanced Spectral Mammography
CESM image example A B C Permission of dr. Marc Lobbes, radiologist MUMC (NL)
CESM - Radiation dose: + 80% - IV contrast Lobbes et al Eur Radiol DOI 10.1007/s00330
CESM vs MRI 25% ACR 4 (BIRADS D) CESM >> Mammography CESM MRI Fallenberg et al Eur Radiol (2014) 24:256
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
2014: Gadolinium!
EMA ema.europa.eu
Gadolinium retention 2017 EMA suspension of 4 linear GCCAs No evidence for neurotoxcity Long term safety unknown
Summary Q 1 2 3 3.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
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
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
Density Tomosynthesis 3D Ultrasound CESM MRI Real or Fake New
Thermography No replacement for mammography Insufficient evidence to screen with thermography 1. Breast Cancer Research and Treatment 2013 2. ACR J. Am. Coll. Rad. 2013; 10; 11-14 3. ACR J. Am. Coll. Rad. Vol. 13 Issue 11 Suppl. Nov. 2016 R45-R49 4. Breast Disease Vol. Reprint, pp1-5; 2016 5. Breast Care 2016; 11: 260-264
Breast Imaging What s new and what women should know Screening
Breast Cancer Screening in Europe
Screening
http://ibc.jrc.ec.europa. eu/recommendations 2017 1. Age 2. New screening methods Tomosynthesis 3. Tailored screening in Density Tomosynthesis Ultrasound (US) MRI
Age 1 2 3 4 40-44 45-50 50-69 70-74
Age 1 40-44
Age 2 4 45-50 70-74
Age 3 50-69
Should screening use Tomosynthesis
3D US in addition to mammography in dense breast
Tomosynthesis in addition to mammography in dense breast
Hand held US in addition to mammography in dense breast
MRI in addition to mammography in dense breast
Screening mammography
<5% world population of woman has access to screening mammography Screening mammography
<5% has access to screening Healthcare system Finance Staff Politics Knowledge Healthcare providers Decision makers Not only about equipment and new technology!!
Support and awareness
Thank you Europa Donna Breast Radiologist Breast Screening Expert Centre EUSOBI r.pijnappel@lrcb.nl