There are variations in the assessment pathways for women recalled at screening, and the imaging assessment pathway with the best diagnostic outcome is poorly understood. This paper examines the efficacy of five imaging modalities for the assessment of screen-recalled breast lesions. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) strategy was employed to identify studies that assessed the efficacy of imaging modalities in the assessment of lesions recalled at screening from the following eight databases: Medline, Web of Science, Embase, Scopus, Science Direct, PubMed, CINAHL, and Global Health. Search terms included “Breast assessment” AND “Diagnostic Workup” OR “Mammography” AND “Digital Breast tomosynthesis” AND “contrast enhanced mammography and Magnetic Resonance imaging” AND “breast ultrasound”. Studies that examined the performance of digital mammography (DM), digital breast tomosynthesis (DBT), handheld ultrasound (HHUS), contrast-enhanced mammography (CEM), and magnetic resonance imaging (MRI) in screen-recalled lesions were reviewed. Meta-analyses of these studies were conducted using the MetaDisc 2.0 software package. Results: Fifty-four studies met the inclusion criteria and examined between one and three imaging modalities. Pooled results of each imaging modality demonstrated that CEM has the highest sensitivity (95; 95% CI: 90–97) followed by MRI (93; 95% CI: 88–96), DBT (91; 95% CI: 87–94), HHUS (90; 95% CI: 86–93), and DM (85; 95% CI: 78–90). The DBT demonstrated the highest specificity (85; 95% CI: 75–91) followed by DM (77; 95% CI: 66–85), CEM (73; 95% CI: 63–81), MRI (69; 95% CI: 55–81), and HHUS (65; 95% CI: 46–80). Conclusions: The CEM, MRI, DBT, and HHUS demonstrate excellent performance in correctly identifying and classifying cancer lesions referred for diagnostic work-up, but HHUS, MRI, and CEM have a more limited ability to discriminate benign lesions than DBT and DM.
