Should tailored screening with digital breast tomosynthesis, in addition to digital mammography, vs. digital mammography alone be used for early detection of breast cancer in asymptomatic women with high mammographic breast density in organised screening programmes?
For asymptomatic women, with high mammographic breast density, in the context of an organised screening programme, the ECIBC's Guidelines Development Group (GDG) suggests not implementing tailored screening with both digital breast tomosynthesis (DBT) and digital mammography (DM).
Conditional recommendation against the intervention
Very low certainty of the evidence
The only subgroup assessed in this recommendation was women with high mammographic breast density.
Considerations for implementation and policy making
The GDG members felt that information and education for women about dense breasts iscritical. This includes information about limitations or uncertainty about effects of tomosynthesis. For the population here, those with dense breast tissue, it is important that the context of increased risk and lesser accuracy of 2D mammography be explained. The opinion of women on tomosynthesis depends on the quality and impartiality of the education provided to them on the evidence behind this modality for tailored screening, including the limitations of tomosynthesis. Inappropriate worry about radiation dose should be dealt with in case programmes are using the DBT plus DM combination.
In general, the GDG believed it is important to educate women and health professionals on the risk of radiation in the context of possible benefits of screening. The GDG members considered that this regimen would involve establishing a baseline, based on breast density, after the first examination, and a cut-off point which determines which women should be offered DBT.
There are currently ongoing trials exploring the automation of breast density measurement. There is a need for improvement in data management and storage for screening organisations. Women will have to attend a breast screening centre that has DBT technology available.
Monitoring and evaluation
Feasibility and acceptability could be assessed in monitoring of programmes.
Quality control procedures and quality standards should be further developed. Standards should be developed in particular for the image quality of synthesised 2D images from the tomosynthesis technology.
There is a need for research examining the classification of mammographic breast density and standardisation of the classification systems used for breast density, including technology for the automation of the determination of breast density.
Research should also aim at establishing the appropriate density threshold for additional imaging.
An optimal combination of screening modalities in women with high breast density should be conducted in the research setting.