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    Original Investigation
    Imaging
    July 28, 2020

    Screening Performance of Digital Breast Tomosynthesis vs Digital Mammography in Community Practice by Patient Age, Screening Round, and Breast Density

    Author Affiliations
    • 1Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle
    • 2Kaiser Permanente Washington Health Research Institute, Seattle
    • 3Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis
    • 4Department of Medicine, University of California, San Francisco
    • 5Department of Epidemiology and Biostatistics, University of California, San Francisco
    • 6Department of Radiology, University of North Carolina, Chapel Hill
    • 7Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
    • 8Department of Surgery, University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington
    • 9Department of Radiology, University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington
    • 10The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hamsphire
    • 11Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago
    JAMA Netw Open. 2020;3(7):e2011792. doi:10.1001/jamanetworkopen.2020.11792
    Key Points español 中文 (chinese)

    Question  Does screening performance of digital breast tomosynthesis vs digital mammography differ by breast density, age, or screening round in community practice?

    Findings  In this comparative effectiveness study assessing 1 584 079 screening examinations across 46 US facilities, the largest improvements in recall and cancer detection rates with digital breast tomosynthesis were observed on baseline screens. On subsequent screens, both recall and cancer detection rates improved using digital breast tomosynthesis vs digital mammography for women aged 40 to 79 years with heterogeneously dense breasts and for women aged 50 to 79 years with scattered fibroglandular density; by contrast, performance was similar in women with extremely dense breasts.

    Meaning  Women undergoing baseline screening may benefit most from digital breast tomosynthesis, whereas on subsequent screens, the benefits of digital breast tomosynthesis may vary by age and density category.

    Abstract

    Importance  Digital mammography (DM) and digital breast tomosynthesis (DBT) are used for routine breast cancer screening. There is minimal evidence on performance outcomes by age, screening round, and breast density in community practice.

    Objective  To compare DM vs DBT performance by age, baseline vs subsequent screening round, and breast density category.

    Design, Setting, and Participants  This comparative effectiveness study assessed 1 584 079 screening examinations of women aged 40 to 79 years without prior history of breast cancer, mastectomy, or breast augmentation undergoing screening mammography at 46 participating Breast Cancer Surveillance Consortium facilities from January 2010 to April 2018.

    Exposures  Age, Breast Imaging Reporting and Data System breast density category, screening round, and modality.

    Main Outcomes and Measures  Absolute rates and relative risks (RRs) of screening recall and cancer detection.

    Results  Of 1 273 492 DM and 310 587 DBT examinations analyzed, 1 028 891 examinations (65.0%) were of white non-Hispanic women; 399 952 women (25.2%) were younger than 50 years; and 671 136 women (42.4%) had heterogeneously dense or extremely dense breasts. Adjusted differences in DM vs DBT performance were largest on baseline examinations: for example, per 1000 baseline examinations in women ages 50 to 59, recall rates decreased from 241 examinations for DM to 204 examinations for DBT (RR, 0.84; 95% CI, 0.73-0.98), and cancer detection rates increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08). On subsequent examinations, women aged 40 to 79 years with heterogeneously dense breasts had improved recall rates and improved cancer detection with DBT. For example, per 1000 examinations in women aged 50 to 59 years, the number of recall examinations decreased from 102 with DM to 93 with DBT (RR, 0.91; 95% CI, 0.84-0.98), and cancer detection increased from 3.7 with DM to 5.3 with DBT (RR, 1.42; 95% CI, 1.23-1.64). Women aged 50 to 79 years with scattered fibroglandular density also had improved recall and cancer detection rates with DBT. Women aged 40 to 49 years with scattered fibroglandular density and women aged 50 to 79 years with almost entirely fatty breasts benefited from improved recall rates without change in cancer detection rates. No improvements in recall or cancer detection rates were observed in women with extremely dense breasts on subsequent examinations for any age group.

    Conclusions and Relevance  This study found that improvements in recall and cancer detection rates with DBT were greatest on baseline mammograms. On subsequent screening mammograms, the benefits of DBT varied by age and breast density. Women with extremely dense breasts did not benefit from improved recall or cancer detection with DBT on subsequent screening rounds.

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