Breast cancer screening evolves in ‘age of acceleration’
MIAMI — Breast cancer screening is moving away from a generalized, population-based approach to more personalized, risk-based assessment, according to a presenter at Miami Breast Cancer Conference.
“The genomics evolution has greatly impacted the field of breast cancer screening. We now have a better understanding of individual risks and tumors,” Elizabeth A. Morris, MD, FACR, FSBI, FISMRM, chief of breast imaging service at Memorial Sloan Kettering Cancer Center and professor of radiology at Weill Cornell Medical College, said during a presentation. “We are living in an age of acceleration. We are [witnessing] a technological, exponential increase in capabilities. As humans, it is hard for us to adapt to all of these technological changes, but we are going to have to in order to survive in the future.”
A multitude of studies have shown the benefits of screening mammography. Estimates indicate a 60% lower risk for mortality from breast cancer within 10 years and a 47% lower risk for mortality within 20 years, according to Morris.
“We all know that screening mammography works. Women who are screened have a lower risk for death from breast cancer,” Morris said. “However, breast cancer screening is no longer only mammography. There are various novel techniques available today — such as contrast mammography — that have the potential to significantly disrupt the screening space.”
Contrast MRI allows for early detection of biologically relevant breast cancers in a short examination and has become an exceedingly inexpensive technique, Morris said.
“This now opens the door for a test where we can detect early and small cancers, with no increases in false-positives and with improvements in pricing,” she said.
Morris also discussed challenges associated with screening, including overdiagnosis.
“Screening is not perfect and there is the potential for overdiagnosis. Of note, this is something that is most often related to age,” Morris said. “Research has shown that it is less likely for a cancer to be overdiagnosed in a 40-year-old patient, whereas overdiagnosis is more common in an 80-year-old patient. This is important for clinicians to realize when we are thinking about techniques for breast cancer screening.”
Another challenge is the need for better tools to detect cancers in women with dense breasts.
“Women with dense breasts have a higher risk for breast cancer, which is masked on mammogram in these women,” Morris said. “So, while mammography works for most women, those with dense breasts have more interval breast cancers. Many of these cancers are already metastatic when they are picked up at screening. We now know that women with dense breasts need at least ultrasound in addition to mammography.”
Many trials are underway examining new screening techniques among prospective cohorts with risk-adaptive screening regimens.
The multicenter WISDOM trial is comparing risk-based vs. annual screening for 100,000 women aged 40 to 74 years treated within the Athena Breast Health Network in California and the Midwest. For this trial, researchers will use the Breast Cancer Surveillance Consortium model due to the accuracy associated with it, ease of implementation, large multiethnic target population, and the incorporation of ethnicity and breast density as risk factors.
“We now have so many different options for breast cancer screening and because of this, American women appear ready to leave population-based screening and go with a more personalized approach,” Morris said. – by Jennifer Southall
Morris EA. The future of screening: Precision vs. population. Presented at: Miami Breast Cancer Conference; March 7-10, 2019; Miami.
Disclosure: Morris reports research funding from GRAIL, General Electric, Hologic and Medtronic, as well as board/committee service for Medscape.