Bolstering Breast Cancer Awareness: October and Year-Round

For 40 years, Breast Cancer Awareness Month has helped raise national awareness of breast cancer and the importance of maintaining breast health. During that time, early detection and advancements in treatment options have saved more than half a million lives. The Bulletin spoke with the ACR Commission on Breast Imaging Chair Stamatia “Toula” Destounis, MD, FACR, FSBI, FAIUM, to get her thoughts on the direction of screening in today’s healthcare landscape and the many moving parts of ensuring early detection. Destounis participated in a virtual congressional briefing earlier this year on the importance of detecting breast cancer early — with the goal of educating congressional staff and lawmakers about the critical need to advance policies that ensure all women in the United States have equal and full access to breast imaging healthcare services.

What is new in screening mammography?

Screening mammography coverage continues to evolve, with new legislation at both state and federal levels expanding insurance coverage, so patients can access diagnostic and supplemental imaging without cost-sharing. In addition, imaging technology continues to advance, with AI in the spotlight. The FDA recently approved the first tool to predict five-year breast cancer risk from routine mammograms. We know that AI has the potential to reduce missed cancers and unnecessary recalls and can aid radiologists by acting as a second reader, bolster clinical workflow and mainstream many of the tasks related to patient scheduling, imaging, radiology reports and even education. Clinical research has also continued with newer technologies such as contrast-enhanced mammography and abbreviated MRI that have been shown to detect more breast cancers when compared to mammography alone. There is evidence supporting these imaging modalities in screening women with dense breasts and other breast cancer risk factors, including family history and genetic mutations.

Do you think the public outreach and education around Breast Cancer Awareness Month each October has been effective?

It has certainly helped. And I believe this is an important October as we, the breast radiologists, have advocated for so many years for annual screening for patients at average risk beginning at age 40. We have experienced significant challenges in the past from many organizations or panels who disagree with ACR recommendations. However, this year we are encouraged by groups such as the U.S. Preventive Services Task Force (USPSTF) revising its recommendations to align with the College’s position that 40 is the age to begin screening. I think the USPSTF — and other groups who are beginning to get on board — have realized that by delaying the recommended age, they are missing many patients who may be at higher risk, such as patients from minority backgrounds, patients with dense breast tissue and others.

What are initial breast cancer risk assessments and why do they matter?

An initial breast cancer risk assessment is critical for identifying women who may benefit from earlier or supplemental screening. Risk factors include age, family history, breast density, personal health history and genetic predispositions (for example, BRCA1/2 mutations). National guidelines, such as those put forward by ACR, increasingly recommend formal risk assessment by age 25, so women at elevated risk can be offered the right screening strategies sooner. While breast cancer is more common after age 40, the incidence in younger women has been rising modestly over the last several years, and cancers in this age group are often more aggressive and diagnosed at later stages. This underscores why risk assessment should not wait until the traditional screening age.

Further, breast cancer affects women across all racial and ethnic groups, with patterns of incidence differing. Black women are more likely to be diagnosed at younger ages and are nearly twice as likely to die from the disease compared to White women. Black women have much higher rates of aggressive subtypes, such as triple-negative breast cancer. This also highlights why all women need to undergo risk assessment early. Individualized risk assessment for every patient is incredibly important, rather than a one-size-fits-all approach. This allows us to better tailor screening recommendations to the individual, helping to ensure early detection and improved outcomes for all women.

How important is supplemental screening and keeping lines of communication open following initial screening mammography?

For some women — especially those with dense breast tissue or other high-risk factors — supplemental screening with ultrasound, MRI or contrast-enhanced mammography may be recommended after an initial mammogram. It is important to reiterate to these women that the additional imaging that is recommended is due to having dense tissue or being at higher risk — not because of a finding from their initial mammogram. Supplemental screening is offered because dense breast tissue can obscure cancers and because these women benefit from more sensitive tools to detect breast cancers mammography might miss.

In addition, some patients may be called back for additional imaging after their initial mammogram if the radiologist identifies something that needs a closer look. Being called back for more imaging is common and usually means more clarity is needed, not that cancer has been found. Keeping communication open, explaining next steps clearly and encouraging patient questions help reduce anxiety and hopefully lead to timely follow-up.

Do patients’ PCPs have a role in educating patients about supplemental screening?

When PCPs and other frontline healthcare professionals actively educate patients about supplemental breast screening, it can make a big difference. Many women don’t realize dense breast tissue both raises breast cancer risk and makes cancers harder to identify on mammograms. Others may be unaware additional tools exist and may be covered by insurance in certain situations. Involvement of the PCP helps shift patient understanding of supplemental screening, from being seen as optional or confusing to being understood as an important next step in breast cancer screening and early detection.

Read part one of this month’s Board of Chancellors column by Debra L. Monticciolo, MD, FACR, on early detection of breast cancer through screening.

Interviewed by Chad Hudnall, senior writer, ACR Press