Screening programmes play a crucial role in early breast cancer detection. Mammography remains the best method to detect breast cancer in an early stage. Mammography is a technique of imaging which produces a 2D image of the 3D organ. Digital breast tomosynthesis is a pseudo-3D imaging technique based on a series of low dose images of the breast from different angles and therefore has the potential to overcome the tissue superposition issue thus improving detection of breast lesions.
Should screening using digital breast tomosynthesis in addition to digital mammography vs. digital mammography alone be used in organised screening programmes for early detection of breast cancer in asymptomatic women?
For asymptomatic women with an average risk of breast cancer, the ECIBC's Guidelines Development Group (GDG) suggests not using both digital breast tomosynthesis (DBT) and digital mammography (DM) in the context of an organised screening programme.
Conditional recommendation against the intervention
Very low certainty of the evidence
Women with high mammographic breast density are likely to benefit most from the increased detection capability of DBT. The GDG developed a specific recommendation for this subgroup on the use of DBT in addition to DM vs DM alone in the context of an organised screening programme.
Considerations for implementation and policy making
- Evidence will be emerging from ongoing and future breast cancer screening trials on DBT that may influence the current recommendation.
- Inappropriate worry about radiation dose should be dealt with in case programmes that are using the DBT in addition to DM combination. In general, the GDG believes it is important to educate women and health professionals on the risk of radiation in the context of possible benefits of screening.
- There will be significantly increased data storage needs for screening programmes using DBT in addition to DM as compared DM alone.
- Additional time is needed for radiologists to read tomosynthesis images, and therefore even more for the DBT in addition to DM examination compared to DM alone.
- The GDG noted that health equity in access to screening should be considered due to different resource settings and the capacity for different countries to pay for DBT in addition to DM over DM alone.
Monitoring and evaluation
- Quality control/standardisation of the technology for better image storage should be undertaken.
- Standards should be developed for the image quality of tomosynthesis.
- In case DBT in addition to DM is used in some pilot, screening monitoring and evaluation programmes should be able to distinguish test done with DBT and with DM, stratified standard indicators should be computed.
- The currently included studies only present data from first round DBT in addition to DM screening studies, thus the effects for several patient-important outcomes, which need a longer follow-up period, could not be taken into account. Research on several screening rounds of DBT in addition to DM are warranted.
- Further research is needed to build the evidence on benefits and harms of DBT in addition to DM compared to DM alone through comparison of direct outcomes, including impacts of interval cancer detection, stage of breast cancer at detection and mortality reduction or projection of mortality reduction (i.e. modelling starting from incidence of advanced stages and interval cancer).
- Further research information on harms of DBT in addition to DM, including rates of overdiagnosis of breast cancer, are warranted.
- Research investigating the cost-effectiveness of a breast cancer screening programme using DBT in addition to DM is needed to inform decision-making on breast cancer screening.
- Research is needed to define the quality parameters that would need to be fulfilled for breast cancer screening programmes that decide to use DBT in addition to DM.
- Evidence on implementation challenges of screening programmes already using DBT in addition to DM should be collected. To do that, screening programmes should be able to produce stratified indicators (see monitoring and evaluation considerations).
- Research regarding distribution of tumour grade/biology/prognostic measures in the additionally detected cancers might help in clarifying the amount of possible overdiagnosis.