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Original Investigation
February 28, 2019

Association of Digital Breast Tomosynthesis vs Digital Mammography With Cancer Detection and Recall Rates by Age and Breast Density

Author Affiliations
  • 1Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Cancer Research and Biostatistics, Seattle, Washington
  • 3Department of Radiology, University of Vermont, Burlington
  • 4University of Vermont Cancer Center, University of Vermont, Burlington
  • 5Department of Pathology, University of Vermont, Burlington
  • 6Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 7Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 8The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 9Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 10Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
  • 11Department of Radiology, University of Washington, Seattle
  • 12Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
  • 13Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin, Madison
  • 14Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
  • 15Translational Research Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 16Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 17Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 18Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 19Department of Surgery, University of Vermont, Burlington
JAMA Oncol. 2019;5(5):635-642. doi:10.1001/jamaoncol.2018.7078
Key Points

Question  Is breast cancer screening with digital breast tomosynthesis (DBT) associated with improved cancer detection rates across all age and breast density groups compared with digital mammography, and are cancer types detected with DBT different from those detected by digital mammography alone?

Findings  In this cohort study of 50 971 breast cancer screening examinations using DBT and 129 369 screening examinations using digital mammography, DBT was associated with increased specificity and increased cancer detection across all age and breast density groups. Invasive cancers detected by DBT were more likely to be smaller and node negative compared with cancers detected by digital mammography, particularly in women aged 40 to 49 years.

Meaning  The findings suggest that screening examinations using DBT detect smaller, node-negative invasive cancers compared with digital mammography, especially among women aged 40 to 49 years; routine mammographic screening may have a favorable risk-benefit ratio for this age group.

Abstract

Importance  Breast cancer screening examinations using digital breast tomosynthesis (DBT) has been shown to be associated with decreased false-positive test results and increased breast cancer detection compared with digital mammography (DM). Little is known regarding the size and stage of breast cancer types detected and their association with age and breast density.

Objective  To determine whether screening examinations using DBT detect breast cancers that are associated with an improved prognosis and to compare the detection rates by patient age and breast density.

Design, Setting, and Participants  This retrospective analysis of prospective cohort data from 3 research centers in the Population-based Research Optimizing Screening Through Personalized Regimens (PROSPR) consortium included data of women aged 40 to 74 years who underwent screening examinations using DM and DBT from January 1, 2011, through September 30, 2014. Statistical analysis was performed from November 8, 2017, to August 14, 2018.

Exposures  Use of DBT as a supplement to DM at breast cancer screening examination.

Main Outcomes and Measures  Recall rate, cancer detection rate, positive predictive value, biopsy rate, and distribution of invasive cancer subtypes.

Results  Among 96 269 women (mean [SD] patient age for all examinations, 55.9 [9.0] years), patient age was 56.4 (9.0) years for DM and 54.6 (8.9) years for DBT. Of 180 340 breast cancer screening examinations, 129 369 examinations (71.7%) used DM and 50 971 examinations (28.3%) used DBT. Screening examination with DBT (73 of 99 women [73.7%]) was associated with the detection of smaller, more often node-negative, HER2–negative, invasive cancers compared with DM (276 of 422 women [65.4%]). Screening examination with DBT was also associated with lower recall (odds ratio, 0.64; 95% CI, 0.57-0.72; P < .001) and higher cancer detection (odds ratio, 1.41; 95% CI, 1.05-1.89; P = .02) compared with DM for all age groups even when stratified by breast density. The largest increase in cancer detection rate and the greatest shift toward smaller, node-negative invasive cancers detected with DBT was for women aged 40 to 49 years. For women aged 40 to 49 years with nondense breasts, the cancer detection rate for examinations using DBT was 1.70 per 1000 women higher compared with the rate using DM; for women with dense breasts, the cancer detection rate was 2.27 per 1000 women higher for DBT. For these younger women, screening with DBT was associated with only 7 of 28 breast cancers (25.0%) categorized as poor prognosis compared with 19 of 47 breast cancers (40.4%) when screening with DM.

Conclusions and Relevance  The findings suggest that screening with DBT is associated with increased specificity and an increased proportion of breast cancers detected with better prognosis compared with DM. In the subgroup of women aged 40 to 49 years, routine DBT screening may have a favorable risk-benefit ratio.

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