This year marks the 30^th anniversary of the Breast Screening Programme in the UK and, to mark the occasion, the Royal College of Radiologists has published a series of reviews articles in its journal Clinical Radiology. Edited by Nishma Sharma, secretary of the British Society of Breast Radiology, the five papers covered personalised screening, breast density, tomosynthesis, overdiagnosis, and performance metrics. The authors were asked to consider the challenge of describing current practice and the future directions of breast imaging.

Fiona Gilbert and Ayla Selamoglu from Cambridge posed the question: “Personalised screening: is this the way forward?” They covered two main areas: (1) women with different risk profiles of developing breast cancer and how to identify them; and (2) what imaging technologies should be implemented, and how often, to identify aggressive cancers. The authors recognised that in women with heterogeneously dense breast tissue, supplemental screening with digital breast tomosynthesis (DBT), automated breast ultrasound (ABUS), contrast-enhanced mammography, or abbreviated magnetic resonance imaging (MRI) should be considered. They also acknowledged the cost-effectiveness of these techniques should be investigated.

Sarah Vinnicombe from Dundee asked: “Breast density: why all the fuss?” Her paper is undoubtedly one of the most comprehensive reviews undertaken on this topic, running to 24 pages and almost 250 cited references. The author identified two reasons why breast density was important: (1) a reduction in the sensitivity of standard mammography to detect breast cancer; and (2) breast density is itself a risk factor for breast cancer. She concluded that mammographic density could provide a major step towards risk-adjusted and personalised breast cancer prevention, imaging and treatment. The image below (© Dr Wendie Berg) illustrates a fatty breast (A) through to an extremely dense breast (D).

Michael Michell and Bhavna Batoni from London considered the “Role of tomosynthesis in breast imaging going forward” and reviewed the most recent developments in DBT technology, clinical applications, and assessment of its usefulness in breast screening. In many of the trials there was an increase in the detection of invasive cancer and a reduction in recall rates, but ongoing clinical trials were needed to evaluate the implications of utilising DBT in routine screening.

Matthew Wallis from Cambridge asked: “How do we manage overdiagnosis/overtreatment in breast screening?” and acknowledged that there was a need to identify breast cancer patients who could avoid surgery and be offered active monitoring. Finally, Sue Cohen and colleagues from London considered the role of performance metrics and suggested these had improved the national screening programme over the past three decades, although there was still the need for transparency and a duty of candour.