Two weeks ago, the European Society of Radiology hosted an online webinar entitled “Breast cancer screening: the updated EU Council recommendations and their impact on clinical practice.” The moderator was Michael Fuchsjäger, professor of radiology at the Medical University of Graz in Austria, while the two speakers included Dr Ritse Mann (seen right) from Nijmegen who is also the current chair of the European Society of Breast Imaging (EUSOBI), and Dr Caroline Drukker (seen below left), a breast surgeon from Amsterdam. This was an opportune time for Europeans to consider their own position and how it might differ from the American approach to breast screening.
Mann pointed out that he recommended giving serious consideration to the implementation of functional imaging. He emphasised that full-field digital mammography (FFDM) has led to a 20% reduction in mortality, and this number increased to 40% for those women who participated in the screening programme. He commented, “The idea behind screening is quite simple: we try to find cancers that are smaller than when they appear clinically … and prevent metastatic spread. If we find cancers earlier, that gain in survival gets better.”
Mann said it should be possible to solve breast cancer mortality in the screened population if the Netherlands were to adopt other imaging modalities in addition to FFDM. The most effective modalities would use a contrast medium, including contrast-enhanced mammography, and MRI. He pointed out that whereas FFDM yields 6 cancers per 1,000 women screened, contrast MRI finds an additional 15 to 20 cancers for women whose mammograms are negative. To be sure, this is an impressive increase.
To those who might suggest that MRI is too expensive to be used as a routine screening modality, Mann argued that MRI is affordable since it costs about €75,000 per life saved, or €11,500 per QALY (quality-adjusted life year). He compared this latter cost with the country’s willingness to spend €80,000 per QALY for therapeutic treatment. His fellow panellist, Drukker, acknowledged that there was a need to determine just who should be eligible for MRI screening.
It seems reasonable to ask: What impact should these machinations about breast screening in the USA and Europe have on the lives of women in the developing world who have suffered – and continue to suffer – a high burden of the disease because their cancer is often detected too late? The reality is that FFDM, digital breast tomosynthesis (DBT), and MRI are simply too expensive to be deployed on a widespread basis in developing countries. Which of course begs the question: What about ultrasound combined with AI?