Screening outcome and surgical treatment during and after the transition from screen‐film to digital screening mammography in the south of The Netherlands

Abstract

We determined screening outcome of subsequent screens during and after the transition from screen-film mammography (SFM) to full-field digital mammography (FFDM). A consecutive series of 102,863 subsequent (SFM screens with a prior SFM screen (SFM-SFM cohort), 91,941 FFDM screens with a prior SFM screen (FFDM-SFM cohort) and 90,407 FFDM screens with a prior FFDM screen (FFDM-FFDM cohort) were obtained between January 2006 and July 2013. The referral rate and cancer detection rate (CDR) per 1,000 screens were higher at FFDM-SFM than at SFM-SFM (2.7% vs. 1.2% (p < 0.001) and 7.0 vs. 4.9, p < 0.001), at the expense of a lower positive predictive value (PPV) of referral (25.8% vs. 39.6%, p < 0.001). These parameters were comparable for FFDM-SFM and FFDM-FFDM. Ductal carcinoma in situ (DCIS) and invasive cancer rates increased during transition and remained stable after transition. The rate of DCIS of intermediate grade increased during the transition from 0.2 per 1,000 screened women at SFM-SFM to 0.6 at FFDM-SFM (p < 0.001) and 0.5 at FFDM-FFDM (p 5 0.001). Compared to SFM-SFM, a significantly higher rate of invasive cancers were stage T1a-b at FFDM-SFM (p < 0.001) and FFDM-FFDM (p < 0.001). Breast conserving surgery rates increased during transition (p < 0.001) and remained stable afterwards. The CDR and referral rate remained significantly higher at FFDM than at SFM, at the expense of a decreased PPV of referral. During transition, DCIS was more often of intermediate grade and invasive cancers were of smaller size.Full-field digital mammography (FFDM) has replaced screenfilm mammography (SFM) in most breast cancer screening programs. FFDM improves workflow and there is emerging evidence that digital mammography is superior to SFM with respect to cancer detection, especially in women under the age of 50 years and in women with radiographically dense breasts. 1,2Previous studies have shown conflicting results when comparing SFM and FFDM outcome at screening mammography. Certain studies report no differences in cancer detection rates (CDRs), 3-5 whereas others find an increased 6-8 or decreased CDR 9 at FFDM. Higher CDRs at digital screening usually come with higher referral rates.10 Reports on the impact of FFDM on the positive predictive value (PPV) of referral also vary, but higher referral rates at digital mammography usually increased the number of women falsely referred. 7,11,12 Studies on the effect of the transition to FFDM on the pathology of breast cancer found at breast cancer screening have also shown conflicting results. Early studies have shown that the increased detection of breast cancer at FFDM was predominantly due to the detection of higher detection rates of ductal carcinoma in situ (DCIS). This observation intensified the discussion about over-diagnosis at screening mammography, that is, the detection of slow-growing tumours that would rarely have caused symptoms let alone death. 12-14On the other hand, several recent studies suggest that digital mammography appears to add to the detection of hi...

Trends in frequency and outcome of high‐risk breast lesions at core needle biopsy in women recalled at biennial screening mammography, a multiinstitutional study

“…Weber et al . also found that the recall rate for suspicious calcifications remained significantly higher at digital screening, resulting in a permanently higher CNB rate for these lesions per 1,000 screens, compared to the period of screen‐film mammography . We observed a significant increase in the number of asymmetries as mammographic abnormality during the last 3 years of inclusion, as well as a significant decrease in the number of suspicious masses as reason for recall.…”

“…Communication between radiologists, pathologists and surgical oncologists is crucial to determine whether a high‐risk lesion should either be monitored by regular radiologic follow‐up imaging or whether excision can be considered. Stereotactic core needle biopsy (SCNB) is performed more often since the introduction of digital mammography in breast cancer screening, probably because digital mammography has a higher sensitivity for the detection of small calcifications compared to screen‐film mammography . It is not clear, however, to which degree high‐risk lesions are more frequently diagnosed in screened women.…”

“…Stereotactic core needle biopsy (SCNB) is performed more often since the introduction of digital mammography in breast cancer screening, probably because digital mammography has a higher sensitivity for the detection of small calcifications compared to screen-film mammography. 7 It is not clear, however, to which degree high-risk lesions are more frequently diagnosed in screened women. It also remains indistinct whether these lesions have a significant impact on the diagnostic surgical excision rate to obtain a final tissue diagnosis.…”

Interval breast cancer characteristics before, during and after the transition from screen-film to full-field digital screening mammography

“…We previously reported a higher cancer detection rate during the transition from screen-film to full-field digital screening mammography [5], and this finding persisted in the second round of digital screening [10]. This increased detection rate, however, came along with more false-positive screen results and therefore a decreased positive predictive value of recall.…”

“…Details on screening outcome at screen-film mammography screening and the 1st and 2nd round of digital screening have been published previously [3, 10]. The transition from screen-film to digital screening mammography may increase the proportion of ductal carcinoma in-situ (DCIS) and smaller invasive cancers at the first digital screening round [3, 4, 11], but does not appear to result in a change of the tumor characteristics of the interval cancers [4, 5].…”