Ultraschall Med 2016; 37(02): 170-175
DOI: 10.1055/s-0041-108004
Review
© Georg Thieme Verlag KG Stuttgart · New York

The Problem of Mammographic Breast Density – The Position of the DEGUM Working Group on Breast Ultrasound

Zur Problematik der mammografisch dichten Brust – Positionspapier des AK Mammasonografie der DEGUM
M. P. Mueller-Schimpfle
1   Radiology, Neuroradiology and Nuclear Medicine, Frankfurt Höchst Hospital, Frankfurt am Main, Germany
,
V. C. Brandenbusch
2   Radiology, Diagnostic Breast Center Turmcarree, Frankfurt am Main, Germany
,
F. Degenhardt
3   Gynecology, Franziskus Hospital, Bielefeld, Germany
,
V. Duda
4   Gynecology, University of Marburg, Germany
,
H. Madjar
5   Gynecology, DKD, Wiesbaden, Germany
,
A. Mundinger
6   Breast Center, Marienhospital, Osnabrück, Germany
,
R. Rathmann
7   Radiology, Schwarzer Baer Practice, Hannover, Germany
,
M. Hahn
8   Gynecology, University of Tübingen, Germany
› Author Affiliations
Further Information

Correspondence

Dr. Markus Peter Mueller-Schimpfle
Klinik für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Frankfurt Höchst
Gotenstraße 6–8
65929 Frankfurt am Main
Germany   
Phone: ++ 49/69/31 06 28 18   
Fax: ++ 49/69/31 06 25 11   

Publication History

26 July 2015

18 August 2015

Publication Date:
16 February 2016 (online)

 

Abstract

Mammographic breast density correlates with breast cancer risk and also with the number of false-negative calls. In the USA these facts lead to the “Breast Density and Mammography Reporting Act” of 2011. In the case of mammographically dense breasts, the Working Group on Breast Ultrasound in Germany recommends explaining the advantages of adjunct imaging to women, depending on the individual breast cancer risk. Due to the particular structure of German healthcare, quality-assured breast ultrasound would be the first choice. Possible overdiagnosis, costs, potentially increased emotional stress should be addressed. In high familial breast cancer risk, genetic counselling and an intensified early detection program should be performed.


#

Zusammenfassung

Die mammografisch dichte Brust ist mit einem erhöhten Risiko einerseits für die Entstehung von Brustkrebs und andererseits für die Maskierung von Karzinomen in der Mammografie korreliert. Dies hat in einer zunehmenden Zahl von Staaten der USA zur gesetzlichen Verpflichtung geführt, die mammografische Brustdichte an die Frau wie auch an den behandelnden Arzt weiterzugeben. Der Arbeitskreis Mammasonografie empfiehlt die Mitteilung der Brustdichte und die Aufklärung der betroffenen Frauen über die Vorteile individualisiert ergänzender Verfahren in Abhängigkeit vom Gesamterkrankungsrisiko der Frau; aufgrund der deutschen Gesundheitsstruktur mit Erfahrung und Qualitätssicherungsprogrammen insbesondere die ergänzende Durchführung einer Mammasonografie unter Sicherung von Struktur-, Prozess-, und Ergebnisqualität. Die Probleme möglicher Überdiagnostik, zusätzlicher Kosten und erhöhten emotionalen Stress sind bei der Aufklärung zu berücksichtigen. Bei familiärer Hochrisikokonstellation sollte eine humangenetische Beratung durchgeführt, eine genetische Testung und intensivierte Früherkennung unter Einbeziehung der MR-Tomografie erwogen werden.


#

Initial situation

Mammography is the only method for the early detection of breast cancer which was able to show a positive effect on the reduction of breast cancer mortality in different population-based studies [1]. The proportion of early mammographic detection on the one hand and treatment development on the other hand with respect to the observed breast cancer mortality reduction over the past few years is difficult to determine [2]. Nevertheless, even in times of state-of-the-art treatment concepts, the initial tumor size at diagnosis remains an essential and indisputable prognostic factor [3].

Consequently, the importance of imaging for the early detection of breast cancer remains undiminished. The effect of smaller tumor sizes on possible future therapeutic approaches will become increasingly differentiated in the future, not least in combination with molecular genetics and tumor risk categories [4]. In addition, there are indicators of an increase in the effectiveness of early detection imaging through greater individualization depending on the individual risk [5].


#

Breast density in diagnosis

High mammographic breast density plays an important role in two respects: increased breast cancer risk and masking of breast cancer in mammography. Firstly, a 4 – 5-fold increased risk for the development of breast cancer was detected in a meta-analysis when women with a very low breast density were compared with women who had a very high breast density [6] [7] [8] [9]. Secondly, density has an effect on the detection rate and especially on the certainty of the exclusion of breast cancer (sensitivity, negative predictive value) [10]. A decreasing sensitivity and increasing number of false-positive findings with the volumetric glandular tissue density was also recently shown for full-field digital mammography [11].

For these reasons, a law was developed in the USA in 2011 (Breast Density and Mammography Reporting Act of 2011) which stipulates that mammography facilities must inform both the referring doctor and the patient of the patient’s individual breast density (“patient's individual measure of breast density”) in writing. This law has now been passed and is in force in 21 states in the USA. Other states are currently working on a law or have already introduced it for passage [12].

In a US study of 9232 women in follow-up after breast cancer (therefore not originating from a population-based screening collective), no relationship was found between breast density and breast cancer mortality [13]. In contrast, in a randomized controlled trial of women with dense breasts from the Kopparberg collective of the Swedish screening program, both an increased incidence of breast cancer (relative risk increase RR 1:57) and an increased breast cancer mortality (RR 1.91) were found in 15 658 women aged between 45 and 59 years. [14]

The ACR BI-RADS standards have become largely accepted in Germany in recent years, albeit with small semantic or content modifications or comments from professional societies or consensus conference publications [15] [16] [17] [18] [19]. The standardized assessment of breast density thereby also found its way into Germany, even though it had not been previously reflected in the agreement of quality assurance measures in accordance with § 135 para. 2 SGB V for curative mammography [20]. Although the luminance in image display devices is regulated here, there is no information regarding mammographic density.

In contrast, the S3 guideline has referred to mammographic density in terms of breast cancer risk and the risk of masking a lesion since 2004 [21]. In the first update in 2008, supplementary breast ultrasound is already required after a mammogram with ACR density types III/IV [22]. Although mammography screening was introduced nationwide in Germany and with high quality standards, the striking lack of information about different breast densities is very problematic, especially for women to make an informed decision. In the official download area of the mammography screening program, brochures and leaflets are available which do not contain any reference to the issue of breast density [23]. The decision regarding participation in comprehensive, quality-assured mammography screening in Germany should be made by each woman after informed assessment of benefit and harm.

It remains to be seen whether this will change as a result of the decision made by the German Medical Assembly in 2014. In the paper, it was stated that: "The responsible doctors participating in the mammography screening program are requested to perform mammography according to the medical standard and to inform the attending doctor of the complete results." What is meant by “complete results” was not specified. It may be assumed, however, that the result classification (according to BI-RADS) and breast density are meant, but not a detailed description of the results which may be barely achievable and financeable in the context of a population-based screening program. Furthermore, reference is made in the explanatory statement that the follow-up care of patients must be guaranteed. In particular, reference is made to the Patients' Rights Act [24].

No specific reference was made to breast density in the decision of the Medical Assembly. However, this can inevitably be made from what was said above. Since breast density is an important predictor for the risk of developing breast cancer for women as well as for breast cancer detection, this has potential consequences for further care. In addition, breast density – divided into 4 levels according to the American College of Radiology – is documented in a standardized format in the mammography report. Here, the current BI-RADS lexicon shows that the subjective density assessment on 4 levels in the USA has led to uniform distribution of density documentation over many years [25].

One concern related to the relaying of breast density to German mammography screening clients could be that women would be left alone with the consequence of their breast density, as there is uncertain evidence for further procedures in such cases. This could eventually lead patients into the network of qualitatively heterogeneous providers of individual health services (IGel: individuellen Gesundheitsleistungen), the significance of which is unclear.

Very diverse opinions have been published on the basic implementation of further imaging procedures in mammographically dense breasts in asymptomatic women with normal risk [26] [27] [28].


#

Additional techniques for high breast density

Tomosynthesis

Digital breast tomosynthesis or 3 D mammography has shown higher sensitivity while maintaining or even increasing specificity compared to mammography in several studies in recent years, especially in women with increased breast density, but not in women with extremely dense breasts since the necessary parenchyma/fat contrast is missing [29] [30] [31] [32] [33] [34] [35]. The radiation dose for 3 D mammography/tomosynthesis, depending on the manufacturer and recording process, is typically slightly more than for a 2 D mammogram, but remains within the dosage limits for 2 D mammography [36].


#

Ultrasound

A number of studies proved that ultrasound can detect cancers in addition to mammography, especially in dense breasts [37] [38] [39] [40] [41] [42]. Depending on the study design and underlying risk prevalence, the number of breast cancers additionally discovered by ultrasound was stated as being up to 4.6/1000 examined women ([Table 1]). Therefore in the early detection guidance from 2008, the S3 guideline for breast cancer already called for the systematic use of ultrasound in mammographically dense breasts (ACR density 3/4) [18]. However, it must be stressed that the demand for ultrasound for ACR 3/4 breasts (evidence level of 3b) refers to general early detection and a transferal to the collective of clients within the mammography screening program (age 50 – 69 years) is only possible on an uncertain evidence base.

Table 1

Studies on ultrasound of the breast as an early detection method for breast cancer.

number of participants (analyses)/ mean age

MG before US; US before MG; doctor/tech

risk

HR/IR/NR

breast density distribution

number of MG lesions

number of US lesions

number of MG&US-detected lesions

NPV without/with US

PPV without/ with US

total number of cancers

number of cancers excl. US+

Δsensitivity with/sensitivity without additional US

number of biopsies per US-detected malignancy (pos. biopsy rate for US-detected Ca)

Bae et al. [33]

106 856 pat./ 47 J. (Ca-Pat.)

100 %/ 0 %; doctor

NR 95 %

ACR 2 – 4 (11/56/33 %)

only US-detected Ca analyzed

356

?

?

?

?

329 Ca (study population)

additional detection rate with US 3.4 Ca/1000 pat., = > suspected Δ 50 %

?

Berg et al. [34]

2637/55 J.

49 %; 51 %; tech

HR/IR (53 % after breast cancer)

5-level (%): 2/11/31/37/19

> C3: 12

> C3: 12

> C3: 8

>C2: 99.2/ 99.6

>C2: 14.7/10.1

40

12

30 %

16.58

Buchberger et al. [35]

6800/49 J.; of these 6113 asympt./49 J.

100 %/ 0 %; doctor

HR/IR/NR (10v. 21 US-detect. Ca in asympt. “high-risk” pat.)

ACR 2 – 4 (768/5236/796)

75

94

66

?/ 99.2 – 100 %[1]

?/ 25.3 – 11.5 %1

103 in 96 pat.

28 in 26 pat.; including 2 “indeterminable lesions”

27 % incl. indeterminate/25 % only malignant classification

12.61 (incl. syst. lesions)

Hooley et al. [36]

14 242 / ?; 935 / 52 J.; 753 asymptomatic, 182 sympt.

Tech

HR 9.3 %; IR 15.9 %; NR 65.7 %

ACR 3 – 4; no further info.

105 BI-RADS 0

55 with 54 subsequent biopsies

0

89.06 %/94.42 %

5.4 – 6.5 % (lesions/per pt)

3

3

100 %

18

Kolb et al. [10]

11 130 / 59.6; of these 5418 US-Pat. / 54.7 J.; of these 4897 asympt. and clin./MG neg.

100 %/ 0 %; Tech

HR/IR 26.5 % der US-pat., 73.5 % NR

ACR 2 – 4

423 biopsies in 393 pat. with 113 Ca in 99 pat.

320 biopsies in 292 pat. with 33 Ca in 31 pat.

?

99.32 %/100 %

35.8 %/20.5 %

146 Ca in 130 pat.

33 Ca in 31 pat.

22.6 %

9.7

Leconte et al. [37]

4236 Pat.; 60.7 J.; 73 % asymptomatic; 24 % post BC therapy; 3 % suspicious symptoms

100 %; doctor

N. D.

ACR 1 – 4; 1/2: MG 20 Ca; US 22 Ca; 3/4: MG 14 Ca; US 22 Ca.

34 Ca

44 Ca

28 Ca

?

?

50

16

20 %

?

Weigel et al [38]

2803 asymptomatic (screening clients)/58 J.

100 %/0 %; doctor

NR 100 %

ACR 1 – 4 (4/44 /49/3 %)

392

8

?

?

20 %/33 %

403

8

2 %

3

1 with/without counting of “indeterminate lesions”;


Ca = breast cancer; Tech = radiographer; HR = high risk; IR = intermediate risk; NR = normal risk; ACR = American College of Radiology.

In the latest guideline recommendations of the Gynecological Oncology Working Group (AGO), ultrasound is recommended as a supplementary measure for dense breasts with an evidence level of 2b and recommendation grade B [43]. In Austrian mammography screening, ultrasound is applied as optional extra imaging directly after mammography in the case of an indication defined by the initial reader (dense breast or unclear results) [44]. Ultrasound has thus become an integral part of Austrian mammography screening.

Conversely, the IGeL (individual health services) monitor rated “ultrasound of the breast for the early detection of cancer in women with unknown breast density” as “unclear” [45]. Interestingly, individual statutory health insurance companies on the other hand promote breast ultrasound for early detection as part of special programs as a reimbursable service [46].

It is important to note the actual definition of the individual health care service. A quote from the IGeL monitor: “IGeLs are all medical services which by law do not belong to the statutory health insurance’s specified service catalog. This includes tasks that are not covered per se in the statutory health insurance area such as certificates or travel vaccinations. To a large extent, IGeLs are medical measures for the prevention, early detection and treatment of diseases, for which an essential prerequisite demanded by law has not been officially established, namely that they conform to the accepted medical standard” [47].

Since an increased cancer detection rate with additional breast sonography is accompanied by a higher biopsy rate, the question of the personal benefit to the individual woman remains open and the cost-benefit ratio for the statutory health insurance is critical. In a risk-adapted or individualized early detection situation, however, the clearly increased sensitivity of ultrasound, which has significantly better availability compared to the above-named methods, in combination with the existing quality assurance measures in Germany (KBV, DEGUM) provides a clear rationale for ultrasound (see also further information in [48] [49]).

The interventional assessment of unclear ultrasound results (which can be performed without delay in Germany, unlike stereotactic, tomosynthetic or even MRI assessment) allows for a significantly shorter delay of diagnosis compared to alternative methods. The mental stress in the waiting period in particular is one of the main arguments in terms of a possible detriment to women as a result of overdiagnosis.


#

Magnetic resonance imaging

MRI of the breasts, which was developed in Germany during the mid-1980 s by W. A. Kaiser and S. H. Heywang, was able to prove its higher sensitivity in comparison to other methods [50]. However, as a result of a possible decrease in specificity, an increased number of non-malignant findings can be classified as requiring clarification, which can lead to additional procedures and unnecessary biopsies. The typical costs of MRI are currently about 10-times higher than typical ultrasound costs and 5-times higher than typical mammography costs. Internationally as well as in Germany, MRI of the breasts is recommended for early detection for women at very high risk (> 20 – 30 % lifetime risk of breast cancer) [51] [52] [53]. Several experts also recommend MRI for women with intermediate risk (15 – 30 %) and dense breasts [8] [54].


#
#

Recommendation for women with dense breasts

The recommendations for evaluation are clear. Here, ultrasound plays the undisputed central role in diagnosis and image-guided assessment using needle biopsy. This can be seen, for example, in the clear data ratios of ultrasound versus stereotactic biopsies, even in mammography screening. In an evaluation report from 2010, 10 691 ultrasound-guided biopsies and 6725 biopsies under X-ray guidance were specified for the initial examinations after primary mammographic abnormality [55]. For the recalled women (PPV I), the cancer rate was 13.9 %. For women who still had a biopsy indication after further assessment including ultrasound, the carcinoma proportion (PPV II) increased by 3.6 times to 50.4 %.It follows that ultrasound, used for the correct indication and with quality-assured application, is obviously able to increase PPV and will not, as some authors would have us believe, decrease the PPV sui generis. Similar experiences seem to have been made in the USA after the introduction of compulsory density notification and consecutive supplementary ultrasound, where reports of a learning curve and declining false-positive results have been published [56] [57].

What can now be recommended to women with dense breasts [ACR density 3/4 and C/D) in the early detection situation (individual prevention or screening)? Given the extensive nationwide experience with ultrasound, good availability, existing quality assurance criteria, the proven breast cancer detection rates with ultrasound, the possibility of timely assessment of a suspicious lesion, the low physical burden on women due to the lack of ionizing radiation and contrast media and last but not least the progressive development of “advanced” ultrasound techniques as well as the ever-improving high frequency B-scan display, ultrasound is preferentially recommended for women with an average risk constellation who are seeking advice if they have dense breasts and wish to have an additional increase in the negative predictive value. The greater the pre-test probability (i. e. the individual risk of the disease at the time of presentation), the more likely it will be – considering the medical constellation as well as the different aspects of German supply reality – that MRI will position itself as the first choice in the early detection strategy.

Needless to say, this recommendation is linked to the fulfilment of qualitative investigator standards and it should always be given to women seeking advice in their search for quality-assured facilities (KBV agreement/DEGUM/DRG qualifications).


#
#

Deutscher Artikel/German Article

  • References

  • 1 Broeders M, Moss S, Nystroem L. EUROSCREEN Working Group et al. The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies. J Med Screen 2012; 19: 14-25
  • 2 Glasziou P, Houssami N. The evidence base for breast cancer screening. Prev Med 2011; 53: 100-102
  • 3 Jones T, Neboori H, Wu H et al. Are breast cancer subtypes prognostic for nodal involvement and associated with clinicopathologic features at presentation in early-stage breast cancer?. Ann Surg Oncol 2013; 20: 2866-2872
  • 4 Goncalves R, Bose R. Using multigene tests to select treatment for early-stage breast cancer. J Natl Compr Canc Netw 2013; 11: 174-182
  • 5 Onega T, Beaber EF, Sprague BL et al. Breast cancer screening in an era of personalized regimens: a conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer 2014; 120: 2955-2964
  • 6 Sickles EA. The use of breast imaging to screen women at high risk for cancer. Radiol Clin North Am 2010; 48: 859-878
  • 7 Boyd NF, Byng JW, Jong RA et al. Quantitative classification of mammographic densities and breast cancer risk: results from the Canadian National Breast Screening Study. J Natl Cancer Inst 1995; 87: 670-675
  • 8 Byrne C, Schairer C, Wolfe J et al. Mammographic features and breast cancer risk: effects with time, age, and menopause status. J Natl Cancer Inst 1995; 87: 1622-1629
  • 9 McCormack VA, dos Santos Silva I. Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. Cancer Epidemiol Biomarkers Prev 2006; 15: 1159-1169
  • 10 Kolb T, Lichy J, Newhouse JH. Comparison of the Performance of Screening Mammography, Physical Examination, and Breast US and Evaluation of Factors that Influence Them: An Analysis of 27825 Patient Evaluations. Radiology 2002; 225: 165-175
  • 11 Wanders JOP, Holland K, Veldhuis WB et al. Effect of volumetric mammographic density on performance of a breast cancer screening program using full-field digital mammography. Insights Imaging 2015; 6: (SS 1802), B-1028, S385
  • 12 http://www.areyoudenseadvocacy.org/dense/ Stand 3.2.2015
  • 13 Gierach GL, Ichikawa L, Kerlikowske K et al. Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium. J Natl Cancer Inst 2012; 104: 1218-1227
  • 14 Chiu SY, Duffy S, Yen AM et al. Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a Swedish mammographic screening. Cancer Epidemiol Biomarkers Prev 2010; 19: 1219-1228
  • 15 Madjar H, Ohlinger R, Mundinger A et al. BI-RADS analoge DEGUM Kriterien von Ultraschallbefunden der Brust – Konsensus des Arbeitskreises Mammasonographie der DEGUM. Ultraschall in Med 2006; 27, 374-379
  • 16 Müller-Schimpfle M für die AG Mammadiagnostik der DRG Konsensustreffen der Kursleiter in der Mammadiagnostik am 5.5.2007 in Frankfurt am Main – Thema: Mikrokalk. Fortschr Röntgenstr 2008; 180: 66-68
  • 17 Müller-Schimpfle MP, Heindel W, Kettritz U et al. Konsensustreffen der Kursleiter in der Mammadiagnostik am 9.5.2009 in Frankfurt am Main – Thema: Herdbefunde. Fortschr Röntgenstr 2010; 182: 671-675
  • 18 Müller-Schimpfle MP, Heindel W, Kettritz U et al. Konsensustreffen der Kursleiter in der Mammadiagnostik am 7.5.2011 in Frankfurt am Main – Magnet-Resonanz-Tomografie der Mamma. Fortschr Röntgenstr 2012; 184: 919-924
  • 19 Müller-Schimpfle M, Heindel W, Kettritz U et al. AG Mamma – Konsensustreffen der Kursleiter in der Mammadiagnostik in Frankfurt am Main – Standards in Technik und Befundung. Senologie – Zeitschrift für Mammadiagnostik und -therapie 2014; 11: 77-82
  • 20 Kassenärztliche Bundesvereinigung. Neufassung der Mammographie-Vereinbarung nach § 135 Abs. 2 SGB V – Vereinbarung von Qualitätssicherungsmaßnahmen nach § 135 Abs. 2 SGB V zur kurativen Mammographie (Mammographie-Vereinbarung). Dtsch Arztebl 2011; 108: A-791/B-643/C-643
  • 21 Schulz KD, Albert US (Herausgeber) Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland. Germering/München: W. Zuckschwerdt Verlag GmbH, Industriestraße 1, D-82110; 2003. ISBN: 3-88603-812-2
  • 22 Albert US (Herausgeber) Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland. 1. Aktualisierung 2008. Germering/München: W. Zuckschwerdt Verlag GmbH, Industriestraße 1, D-82110; ISBN: 978-3-88603-931-9
  • 23 http://www.mammo-programm.de/downloads/ ; zuletzt aufgerufen am 3.2.2015
  • 24 DOKUMENTATION: Deutscher Ärztetag – Entschließungen zum Tagesordnungspunkt II: Prävention. Dtsch Arztebl 2014; 111: A-1088/B-932/C-882
  • 25 Sickles EA, D’Orsi CJ, Bassett LW et al. ACR BI-RADS® Mammography. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston: VA, American College of Radiology; 2013
  • 26 ACOG Committee Opinion no. 593: Management of women with dense breasts diagnosed by mammography. Committee on Gynecologic Practice. Obstet Gynecol 2014; 123: 910-911
  • 27 Mauger B. Special Report: Screening Asymptomatic Women with Dense Breasts and Normal Mammograms for Breast Cancer. TEC Assessment Program Volume 28 No. 15, April 2014
  • 28 Hackelöer BJ, Hille H. Multimodale Brustkrebsfrüherkennung versus isoliertes Mammografiescreening. Frauenarzt 2014; 55; 948-956
  • 29 Skaane P, Bandos AI, Gullien R et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013; 267: 47-56
  • 30 Ciatto S, Houssami N, Bernardi D et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013; 14; 583-589
  • 31 Rose SL, Tidwell AL, Bujnoch LJ et al. Implementation of breast tomosynthesis in a routine screening practice: an observational study. Am J Roentgenol 2013; 200: 1401-1408
  • 32 Haas BM, Kalra V, Geisel J et al. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology 2013; 269: 694-700
  • 33 Conant E, Wan F, Thomas M et al. Implementing digital breast tomosynthesis (DBT) in a screening population: PPV1 as a measure of outcome. Abstract presented at the Radiological Society of North America Scientific Assembly and Annual Meeting, Chicago, IL, USA, December 1–6, 2013. Available from: http://www2.rsna.org/timssnet/rsna/media/pr2013/Conant/abstract/Conant-Tomosynthesis-Abstract-LH.pdf Accessed October 16, 2014
  • 34 Greenberg JS, Javitt MC, Katzen J et al. Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice. Am J Roentgenol 2014; 203: 687-693
  • 35 Friedewald SM, Rafferty EA, Rose SL et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014; 311: 2499-2507
  • 36 van Engen R, Bosmans H, Bouwman R et al. Protocol for the Quality Control of the Physical and Technical Aspects of Digital Breast Tomosynthesis Systems. Draft version 0.15. European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services; January 2014. www.euref.org%2Fdownloads%3Fdownload%3D47%3Aeuref-tomo-protocol-version-015&ei=zagmVZHpN8m8aYPwgIgJ&usg=AFQjCNHH1qbZwswJgPXLQq72B7Fp-Xfrsg ; zuletzt aufgerufen am 9.4.2015
  • 37 Bae MS, Moon WK, Chang JM et al. Breast Cancer Detected with Screening US: Reasons for Nondetection at Mammography. Radiology 2014; 270: 369-377
  • 38 Berg WA, Blume JD, Cormack JB et al. Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. JAMA 2008; 299: 2151-2163
  • 39 Buchberger W, DeKoekkoek-Doll P, Springer P et al. Incidental findings on sonography of the breast: clinical significance and diagnostic workup. Am J Roentgenol 1999; 173: 921-927
  • 40 Hooley RJ, Greenberg KL, Stackhouse RM et al. Screening US in Patients with Mammographically Dense Breasts: Initial Experience with Connecticut Public Act 09-41. Radiology 2012; 265: 59-69
  • 41 Leconte I, Feger C, Galant C et al. Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. Am J Roentgenol 2003; 180: 1675-1679
  • 42 Weigel S, Biesheuvel C, Berkemeyer S et al. Digital mammography screening: how many breast cancers are additionally detected by bilateral ultrasound examination during assessment?. Eur Radiol 2013; 23: 684-691
  • 43 Schreer I, Albert US. Früherkennung und Diagnostik. In: AGO Breast Committee. Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Recommendations 2015. www.ago-online.de ; zuletzt aufgerufen am 09.04.2015
  • 44 http://www.frueh-erkennen.at/Ablauf.html ; zuletzt aufgerufen am 9.4.2015
  • 45 http://www.igel-monitor.de/IGeL_A_Z.php?action=abstract&id=78 , erstellt am 20.3.2013; zuletzt aufgerufen am 8.2.2015
  • 46 http://www.krankenkasseninfo.de/boxentest/vorsorge/krebsvorsorge-ueber-den-gesetzlichen-rahmen-hinaus-27 ; zuletzt aufgerufen am 8.2.2015
  • 47 www.igel-monitor.de/09_FAQ_Liste_final.pdf ; zuletzt aufgerufen am 8.2.2015
  • 48 Hackelöer BJ, Hille H. Multimodale Brustkrebsfrüherkennung versus isoliertes Mammografiescreening. Frauenarzt 2014; 55: 948-956
  • 49 Würstlein R, Degenhardt F, Duda V et al. Evaluation of the Nationwide DEGUM Breast Ultrasound Training Program. Ultraschall in Med 2014; 35: 345-349
  • 50 Lee CH, Dershaw D, Kopans D et al. Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer. J Am Coll Radiol 2010; 7: 18-27
  • 51 Houssami N, Lord SL, Ciatto S. Breast cancer screening: emerging role of new imaging techniques as adjuncts to mammography. MJA 2009; 190: 493-498
  • 52 Lee JM, McMahon PM, Kong CY et al. Cost-effectiveness of Breast MR Imaging and Screen-Film Mammography for Screening BRCA1 Gene Mutation Carriers. Radiology 2010; 254: 793-800
  • 53 Schmutzler R, Schmidt M. Brustkrebsrisiko und Prävention. In: AGO Breast Committee. Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Recommendations 2015. www.ago-online.de ; zuletzt aufgerufen am 09.04.2015
  • 54 American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs . Last Medical Review: 09/10/2014. Last Revised: 9/10/2014. Zuletzt aufgerufen am 10.2.201
  • 55 Malek D, Kääb-Sanyal V, Wegener B. Evaluationsbericht 2010 – Ergebnisse des Mammographie-Screening-Programms in Deutschland. Berlin: Kooperationsgemeinschaft Mammographie; 2014
  • 56 Destounis S, Arieno A, Morgan R. Initial experience with the new york state breast density inform law at a community-based breast center. J Ultrasound Med 2015; 34: 993-1000
  • 57 Weigert J, Steenbergen S. The connecticut experiments second year: ultrasound in the screening of women with dense breasts. Breast J 2015; 21: 175-180

Correspondence

Dr. Markus Peter Mueller-Schimpfle
Klinik für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Frankfurt Höchst
Gotenstraße 6–8
65929 Frankfurt am Main
Germany   
Phone: ++ 49/69/31 06 28 18   
Fax: ++ 49/69/31 06 25 11   

  • References

  • 1 Broeders M, Moss S, Nystroem L. EUROSCREEN Working Group et al. The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies. J Med Screen 2012; 19: 14-25
  • 2 Glasziou P, Houssami N. The evidence base for breast cancer screening. Prev Med 2011; 53: 100-102
  • 3 Jones T, Neboori H, Wu H et al. Are breast cancer subtypes prognostic for nodal involvement and associated with clinicopathologic features at presentation in early-stage breast cancer?. Ann Surg Oncol 2013; 20: 2866-2872
  • 4 Goncalves R, Bose R. Using multigene tests to select treatment for early-stage breast cancer. J Natl Compr Canc Netw 2013; 11: 174-182
  • 5 Onega T, Beaber EF, Sprague BL et al. Breast cancer screening in an era of personalized regimens: a conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer 2014; 120: 2955-2964
  • 6 Sickles EA. The use of breast imaging to screen women at high risk for cancer. Radiol Clin North Am 2010; 48: 859-878
  • 7 Boyd NF, Byng JW, Jong RA et al. Quantitative classification of mammographic densities and breast cancer risk: results from the Canadian National Breast Screening Study. J Natl Cancer Inst 1995; 87: 670-675
  • 8 Byrne C, Schairer C, Wolfe J et al. Mammographic features and breast cancer risk: effects with time, age, and menopause status. J Natl Cancer Inst 1995; 87: 1622-1629
  • 9 McCormack VA, dos Santos Silva I. Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. Cancer Epidemiol Biomarkers Prev 2006; 15: 1159-1169
  • 10 Kolb T, Lichy J, Newhouse JH. Comparison of the Performance of Screening Mammography, Physical Examination, and Breast US and Evaluation of Factors that Influence Them: An Analysis of 27825 Patient Evaluations. Radiology 2002; 225: 165-175
  • 11 Wanders JOP, Holland K, Veldhuis WB et al. Effect of volumetric mammographic density on performance of a breast cancer screening program using full-field digital mammography. Insights Imaging 2015; 6: (SS 1802), B-1028, S385
  • 12 http://www.areyoudenseadvocacy.org/dense/ Stand 3.2.2015
  • 13 Gierach GL, Ichikawa L, Kerlikowske K et al. Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium. J Natl Cancer Inst 2012; 104: 1218-1227
  • 14 Chiu SY, Duffy S, Yen AM et al. Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a Swedish mammographic screening. Cancer Epidemiol Biomarkers Prev 2010; 19: 1219-1228
  • 15 Madjar H, Ohlinger R, Mundinger A et al. BI-RADS analoge DEGUM Kriterien von Ultraschallbefunden der Brust – Konsensus des Arbeitskreises Mammasonographie der DEGUM. Ultraschall in Med 2006; 27, 374-379
  • 16 Müller-Schimpfle M für die AG Mammadiagnostik der DRG Konsensustreffen der Kursleiter in der Mammadiagnostik am 5.5.2007 in Frankfurt am Main – Thema: Mikrokalk. Fortschr Röntgenstr 2008; 180: 66-68
  • 17 Müller-Schimpfle MP, Heindel W, Kettritz U et al. Konsensustreffen der Kursleiter in der Mammadiagnostik am 9.5.2009 in Frankfurt am Main – Thema: Herdbefunde. Fortschr Röntgenstr 2010; 182: 671-675
  • 18 Müller-Schimpfle MP, Heindel W, Kettritz U et al. Konsensustreffen der Kursleiter in der Mammadiagnostik am 7.5.2011 in Frankfurt am Main – Magnet-Resonanz-Tomografie der Mamma. Fortschr Röntgenstr 2012; 184: 919-924
  • 19 Müller-Schimpfle M, Heindel W, Kettritz U et al. AG Mamma – Konsensustreffen der Kursleiter in der Mammadiagnostik in Frankfurt am Main – Standards in Technik und Befundung. Senologie – Zeitschrift für Mammadiagnostik und -therapie 2014; 11: 77-82
  • 20 Kassenärztliche Bundesvereinigung. Neufassung der Mammographie-Vereinbarung nach § 135 Abs. 2 SGB V – Vereinbarung von Qualitätssicherungsmaßnahmen nach § 135 Abs. 2 SGB V zur kurativen Mammographie (Mammographie-Vereinbarung). Dtsch Arztebl 2011; 108: A-791/B-643/C-643
  • 21 Schulz KD, Albert US (Herausgeber) Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland. Germering/München: W. Zuckschwerdt Verlag GmbH, Industriestraße 1, D-82110; 2003. ISBN: 3-88603-812-2
  • 22 Albert US (Herausgeber) Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland. 1. Aktualisierung 2008. Germering/München: W. Zuckschwerdt Verlag GmbH, Industriestraße 1, D-82110; ISBN: 978-3-88603-931-9
  • 23 http://www.mammo-programm.de/downloads/ ; zuletzt aufgerufen am 3.2.2015
  • 24 DOKUMENTATION: Deutscher Ärztetag – Entschließungen zum Tagesordnungspunkt II: Prävention. Dtsch Arztebl 2014; 111: A-1088/B-932/C-882
  • 25 Sickles EA, D’Orsi CJ, Bassett LW et al. ACR BI-RADS® Mammography. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston: VA, American College of Radiology; 2013
  • 26 ACOG Committee Opinion no. 593: Management of women with dense breasts diagnosed by mammography. Committee on Gynecologic Practice. Obstet Gynecol 2014; 123: 910-911
  • 27 Mauger B. Special Report: Screening Asymptomatic Women with Dense Breasts and Normal Mammograms for Breast Cancer. TEC Assessment Program Volume 28 No. 15, April 2014
  • 28 Hackelöer BJ, Hille H. Multimodale Brustkrebsfrüherkennung versus isoliertes Mammografiescreening. Frauenarzt 2014; 55; 948-956
  • 29 Skaane P, Bandos AI, Gullien R et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013; 267: 47-56
  • 30 Ciatto S, Houssami N, Bernardi D et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013; 14; 583-589
  • 31 Rose SL, Tidwell AL, Bujnoch LJ et al. Implementation of breast tomosynthesis in a routine screening practice: an observational study. Am J Roentgenol 2013; 200: 1401-1408
  • 32 Haas BM, Kalra V, Geisel J et al. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology 2013; 269: 694-700
  • 33 Conant E, Wan F, Thomas M et al. Implementing digital breast tomosynthesis (DBT) in a screening population: PPV1 as a measure of outcome. Abstract presented at the Radiological Society of North America Scientific Assembly and Annual Meeting, Chicago, IL, USA, December 1–6, 2013. Available from: http://www2.rsna.org/timssnet/rsna/media/pr2013/Conant/abstract/Conant-Tomosynthesis-Abstract-LH.pdf Accessed October 16, 2014
  • 34 Greenberg JS, Javitt MC, Katzen J et al. Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice. Am J Roentgenol 2014; 203: 687-693
  • 35 Friedewald SM, Rafferty EA, Rose SL et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014; 311: 2499-2507
  • 36 van Engen R, Bosmans H, Bouwman R et al. Protocol for the Quality Control of the Physical and Technical Aspects of Digital Breast Tomosynthesis Systems. Draft version 0.15. European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services; January 2014. www.euref.org%2Fdownloads%3Fdownload%3D47%3Aeuref-tomo-protocol-version-015&ei=zagmVZHpN8m8aYPwgIgJ&usg=AFQjCNHH1qbZwswJgPXLQq72B7Fp-Xfrsg ; zuletzt aufgerufen am 9.4.2015
  • 37 Bae MS, Moon WK, Chang JM et al. Breast Cancer Detected with Screening US: Reasons for Nondetection at Mammography. Radiology 2014; 270: 369-377
  • 38 Berg WA, Blume JD, Cormack JB et al. Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. JAMA 2008; 299: 2151-2163
  • 39 Buchberger W, DeKoekkoek-Doll P, Springer P et al. Incidental findings on sonography of the breast: clinical significance and diagnostic workup. Am J Roentgenol 1999; 173: 921-927
  • 40 Hooley RJ, Greenberg KL, Stackhouse RM et al. Screening US in Patients with Mammographically Dense Breasts: Initial Experience with Connecticut Public Act 09-41. Radiology 2012; 265: 59-69
  • 41 Leconte I, Feger C, Galant C et al. Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. Am J Roentgenol 2003; 180: 1675-1679
  • 42 Weigel S, Biesheuvel C, Berkemeyer S et al. Digital mammography screening: how many breast cancers are additionally detected by bilateral ultrasound examination during assessment?. Eur Radiol 2013; 23: 684-691
  • 43 Schreer I, Albert US. Früherkennung und Diagnostik. In: AGO Breast Committee. Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Recommendations 2015. www.ago-online.de ; zuletzt aufgerufen am 09.04.2015
  • 44 http://www.frueh-erkennen.at/Ablauf.html ; zuletzt aufgerufen am 9.4.2015
  • 45 http://www.igel-monitor.de/IGeL_A_Z.php?action=abstract&id=78 , erstellt am 20.3.2013; zuletzt aufgerufen am 8.2.2015
  • 46 http://www.krankenkasseninfo.de/boxentest/vorsorge/krebsvorsorge-ueber-den-gesetzlichen-rahmen-hinaus-27 ; zuletzt aufgerufen am 8.2.2015
  • 47 www.igel-monitor.de/09_FAQ_Liste_final.pdf ; zuletzt aufgerufen am 8.2.2015
  • 48 Hackelöer BJ, Hille H. Multimodale Brustkrebsfrüherkennung versus isoliertes Mammografiescreening. Frauenarzt 2014; 55: 948-956
  • 49 Würstlein R, Degenhardt F, Duda V et al. Evaluation of the Nationwide DEGUM Breast Ultrasound Training Program. Ultraschall in Med 2014; 35: 345-349
  • 50 Lee CH, Dershaw D, Kopans D et al. Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer. J Am Coll Radiol 2010; 7: 18-27
  • 51 Houssami N, Lord SL, Ciatto S. Breast cancer screening: emerging role of new imaging techniques as adjuncts to mammography. MJA 2009; 190: 493-498
  • 52 Lee JM, McMahon PM, Kong CY et al. Cost-effectiveness of Breast MR Imaging and Screen-Film Mammography for Screening BRCA1 Gene Mutation Carriers. Radiology 2010; 254: 793-800
  • 53 Schmutzler R, Schmidt M. Brustkrebsrisiko und Prävention. In: AGO Breast Committee. Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Recommendations 2015. www.ago-online.de ; zuletzt aufgerufen am 09.04.2015
  • 54 American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs . Last Medical Review: 09/10/2014. Last Revised: 9/10/2014. Zuletzt aufgerufen am 10.2.201
  • 55 Malek D, Kääb-Sanyal V, Wegener B. Evaluationsbericht 2010 – Ergebnisse des Mammographie-Screening-Programms in Deutschland. Berlin: Kooperationsgemeinschaft Mammographie; 2014
  • 56 Destounis S, Arieno A, Morgan R. Initial experience with the new york state breast density inform law at a community-based breast center. J Ultrasound Med 2015; 34: 993-1000
  • 57 Weigert J, Steenbergen S. The connecticut experiments second year: ultrasound in the screening of women with dense breasts. Breast J 2015; 21: 175-180