Breast cancer screening controversies: who, when, why, and how? Alison Chetlen ⁎ , 1 , Julie Mack 2, 3 , Tiffany Chan 3, 4 Penn State Milton S. Hershey Medical Center, Penn State Hershey Breast Imaging, Department of Radiology, EC 008, 30 Hope Drive, Suite 1800, Hershey, PA, 17033-0859 abstract article info Article history: Received 28 March 2015 Accepted 26 May 2015 Keywords: Breast cancer screening Mammography Tomosynthesis Automated whole-breast ultrasound Magnetic resonance imaging Mammographic screening is effective in reducing mortality from breast cancer. The issue is not whether mam- mography is effective, but whether the false positive rate and false negative rates can be reduced. This review will discuss controversies including the reduction in breast cancer mortality, overdiagnosis, the ideal screening candidate, and the optimal imaging modality for breast cancer screening. The article will compare and contrast screening mammography, tomosynthesis, whole-breast screening ultrasound, magnetic resonance imaging, and molecular breast imaging. Though supplemental imaging modalities are being utilized to improve breast cancer diagnosis, mammography still remains the gold standard for breast cancer screening. © 2015 Elsevier Inc. All rights reserved. The menu of available options for breast cancer screening continues to expand. Questions arise regarding why screen, when to screen, who to screen, and how to screen. Breast cancer is the second most common cancer in the world and by far, the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers) [1]. Breast cancer ranks as the fifth cause of death from cancer overall, and while it is the most frequent cause of cancer death in women in less developed regions, it is now the second cause of cancer death in more developed regions after lung cancer [1]. It is accepted that screening with mammography prevents deaths from breast cancer, although debate continues about the absolute size of the mortality benefit conferred and the concomitant risks associated with screening [2–6]. To reduce mortality, screening must detect poten- tially life-threatening disease at an earlier, more curable stage [7]. Effec- tive screening programs therefore should both increase the incidence of cancer detected at an early stage as well as decrease the incidence of cancer presenting at a late stage [7]. However, to be effective in reducing mortality in the population, the proportion of the population screened must remain high. One of the factors limiting success of any screening program is low compliance. The primary factor limiting compliance with screening mammogra- phy is low health literacy. Health literacy represents the degree to which individuals are able to obtain, process, and understand the basics of medical information in order to make necessary health decisions. Socioeconomic factors such as ethnicity, education, income, or employ- ment, are also significant factors in whether or not patients undergo screening [8]. Given that patient compliance with mammography is less than 50%, efforts to increase health literacy are paramount [9]. Though mammography remains the gold standard for initial screening exams to detect breast cancer, limitations exist. Mammography has an overall sensitivity of 85%; however, when a patient has dense breasts, the sensitivity decreases to 68% [10]. This is relevant for 50% of American women, who fall into the category of having dense breast tissue [11]. In addition, critics point to the low specificity of an ab- normal screening mammogram stating that many biopsies per- formed for an abnormal mammogram show no evidence of cancer and lead to unnecessary anxiety and high cost [12]. Proponents for mammography screening agree that an abnormal screening mam- mogram does not frequently lead to a cancer diagnosis, but point out that less than 10% of patients require additional views for further clarification, and less than 2% of women screened undergo biopsies (30–40% of which show breast cancer) [13]. A number of observational studies have claimed to find low rates of benefit in terms of reducing mortality rates or late-stage disease and high rates of overdiagnosis [7,14] and have stimulated debate in the media [15]. Therefore, supplemental imaging modalities are being utilized to improve breast cancer diagnosis. 1. Reduction in breast cancer mortality Randomized controlled trials have consistently shown a reduction in mortality in patients screening with mammography [16]. Despite this, recent authors claim screening mammography has only marginally Clinical Imaging 40 (2016) 279–282 ⁎ Corresponding author. Penn State Milton S. Hershey Medical Center, Penn State Hershey Breast Imaging, Department of Radiology, EC 008, 30 Hope Drive, Suite 1800, Hershey, PA, 17033–0859. Tel.: +1-717-531-1495; fax: +1-717-531-4335. E-mail addresses: achetlen@hmc.psu.edu (A. Chetlen), jmack@hmc.psu.edu (J. Mack), tchan@hmc.psu.edu (T. Chan). 1 This author worked as a research consultant for Siemens in November–December 2014 during a reader study for breast tomosynthesis for FDA approval. This relationship has no bearing on the content of this manuscript. 2 Tel.: +1-717-531-6521. 3 This author has no conflicts of interest to disclose. 4 Tel.: +1-717-531-0000. http://dx.doi.org/10.1016/j.clinimag.2015.05.017 0899-7071/© 2015 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Clinical Imaging journal homepage: http://www.clinicalimaging.org