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Breast Cancer Screening: The Paradigm Shifts (Finally)

      See Related Article p. 472
      The seemingly endless and often overwrought debate about the utility of screening mammography may finally be drawing to a close. We may at last be moving beyond the standard paradigm of mass screening by mammography alone, which has had, at best, marginal success in most developed countries, to a tailored approach using a variety of methodologies that take into account pertinent patient characteristics.
      The problem, of course, is that mammography alone is not a very good screening modality and has strikingly variable false positive, false negative, specificity, and efficacy rates, depending on what you read and who you believe. Worldwide, organizational recommendations for screening mammography are, ahem, all over the map, and the days of simple repetitive yearly or biannual mammograms for every living woman over some arbitrary age may be over soon.
      In this month's “Imaging for the Clinician” article, Drukteinis et al
      • Drukteinis J.S.
      • Mooney B.P.
      • Flowers C.I.
      • Gatenby R.A.
      Beyond mammography: new frontiers in breast cancer screening.
      show that breast cancer screening is about to evolve into a personalized, patient-centered program that includes both new technologies and new forms of risk stratification. As they point out, there will likely be no new whiz-bang technology to replace mammography; rather, innovative patient-specific approaches that incorporate new adjunctive and complementary technologies into overall breast cancer screening will improve specificity and sensitivity, reduce radiation exposure, and remove a significant amount of anxiety from the lives of our patients. No small feat.
      So what does this mean for the practicing clinician? It means a whole new ball game. It means you can't just look at the patient's chart and order a mammogram when a computer-generated flag pops up saying it's time. It means understanding fairly complex risk stratification, the indications for these new technologies, and the clinical context for various imaging strategies. As all clinicians know, women are increasingly knowledgeable, are appropriately demanding the best breast care possible, and will be in your office or clinic with as much or perhaps more information than you have on the subject. Even more, screening strategies have become highly politicized, and as Drukteinis et al point out, many states are passing legislation mandating early algorithmic aspects of such care (eg, breast density risk stratification). I'm not a big fan of nonprofessionals telling clinicians how to practice, but that is now the reality, and don't expect it to go away any time soon.
      Clearly, clinicians cannot all become experts in the intricacies of these newly emerging but not yet formalized imaging protocols. Which brings me to the critical point beyond the important concepts discussed in this article: There will need to be a much closer working relationship between breast imagers and clinicians so that all women receive the optimal breast cancer screening that they individually require based on their genetic, phenotypic, and clinical profiles.
      Yes, things just got a bit more complex, but that's life. The development of a personalized, individual patient-centered approach to breast cancer screening mirrors the evolution of similar strategies in other aspects of medicine, particularly in the area of pharmaceuticals. Perhaps the motto of 21st century medicine will be: “One size doesn't fit all.” And that will benefit all of us.

      Reference

        • Drukteinis J.S.
        • Mooney B.P.
        • Flowers C.I.
        • Gatenby R.A.
        Beyond mammography: new frontiers in breast cancer screening.
        Am J Med. 2013; 126: 472-479