Performance of Supplemental Imaging Modalities for Breast Cancer in Women With Dense Breasts: Findings From an Umbrella Review and Primary Studies Analysis

Breast cancer screening performance of supplemental imaging modalities by breast density and breast cancer risk has not been widely studied, and the optimal choice of modality for women with dense breasts remains unclear in clinical practice and guidelines. This systematic review aimed to assess breast cancer screening performance of supplemental imaging modalities for women with dense breasts, by breast cancer risk. Systematic reviews (SRs) in 2000 to 2021, and primary studies in 2019 to 2021, on outcomes of supplemental screening modalities (digital breast tomography [DBT], MRI (full/abbreviated protocol), contrast enhanced mammography (CEM), ultrasound (hand-held [HHUS]/automated [ABUS]) in women with dense breasts (BI-RADS C&D) were identified. None of the SRs analyzed outcomes by cancer risk. Meta-analysis of the primary studies was not feasible due to lack of studies (MRI, CEM, DBT) or methodological heterogeneity (ultrasound); therefore, findings were summarized narratively. For average risk, a single MRI trial reported a superior screening performance (higher cancer detection rate [CDR] and lower interval cancer rate [ICR]) compared to HHUS, ABUS and DBT. For intermediate risk, ultrasound was the only modality assessed, but accuracy estimates ranged widely. For mixed risk, a single CEM study reported the highest CDR, but included a high proportion of women with intermediate risk. This systematic review does not allow a complete comparison of supplemental screening modalities for dense breast populations by breast cancer risk. However, the data suggest that MRI and CEM might generally offer superior screening performance versus other modalities. Further studies of screening modalities are urgently required.