Cochrane 2023: Is Ultrasonography Plus Mammography Superior to Mammography Alone in Average Risk Women?
BACKGROUND AND PURPOSE:
- Glechner et al. (Cochrane Database of Systematic Reviews, 2023) assessed the comparative effectiveness and safety of mammography in combination with breast ultrasonography vs mammography alone for breast cancer screening for women at average risk of breast cancer
METHODS:
- Systematic review and meta-analysis
- Inclusion criteria
- Randomized controlled trials and controlled non-randomized studies of women at average risk of breast cancer between the ages of 40 and 75
- Studies were also included if 80% of the population met the age and breast cancer risk inclusion criteria
- Study design
- GRADE criteria were used to assess quality of evidence
- Random-effects meta-analysis was used
- Primary outcome
- Breast cancer detection
- Breast cancer mortality
RESULTS:
- 8 studies | 209,207 women
- Follow-up 1 to 3 years | Dense breasts: 48 to 100% of women in included studies
- None of the studies assessed whether mammography screening in combination with ultrasonography led to lower mortality from breast cancer or all-cause mortality
- Screening with a combination of mammography and ultrasonography detects more breast cancer than mammography alone
- Additional ultrasonography: 5 detected per 1000
- Mammography alone: 3 detected per 1000
- Risk ratio (RR) 1.54 (95% CI, 1.22 to 1.94)
- 1 trial | High-certainty evidence
- The percentage of invasive tumors was similar between the groups
- Additional ultrasonography: 69.6%
- Mammography alone: 73.5%
- RR 0.95 (95% CI, 0.82 to 1.09)
- Low-certainty evidence
- Positive lymph node status was detected less frequently in women with invasive cancer who underwent mammography screening and ultrasonography
- Additional ultrasonography: 18%
- Mammography alone: 34%
- RR 0.53 (95% Ci, 0.33 to 0.86)
- Moderate-certainty evidence
- interval carcinomas occurred less frequently in the group screened by mammography and ultrasonography
- Additional ultrasonography: 5 per 10,000 women
- Mammography alone: 10 per 10,000 women
- RR 0.50 (95% CI, 0.29 to 0.89)
- High-certainty evidence
- False-negative results were less common when ultrasonography was used in addition to mammography
- Additional ultrasonography: 9%
- Mammography alone: 23%
- RR 0.39 (95% CI, 0.23 to 0.66)
- Moderate-certainty evidence
- False-positive results were more common in the group with additional ultrasonography
- RR 1.43 (95% CI, 1.37 to 1.50)
- High-certainty evidence
- Compared to mammography alone, for every 1000 women participating in screening with a combination of mammography and ultrasonography, 27 more women will have a biopsy
- RR 2.49 (95% CI, 2.28 to 2.72)
- High-certainty evidence
Breast Density
- Secondary analysis of J-START trial
- 19,213 women
- In women with dense breasts, the combination of mammography and ultrasonography detected 3 more cancer cases per 1000 women screened
- RR 1.65 (95% CI, 1.0 to 2.72)
- High-certainty evidence
- Meta-analysis of three cohort studies showed similar findings in women with dense breasts
- RR 1.78 (95% CI, 1.23 to 2.56)
- Moderate-certainty evidence
- In women with non-dense breasts, there were more cancer cases detected when adding ultrasound to mammography screening
- RR 1.93 (95% CI, 1.01 to 3.68)
- Moderate-certainty evidence
- However, meta-analysis of two cohort studies did not support this finding
- RR 1.13 (95% CI, 0.85 to 1.49)
- Low-certainty evidence
CONCLUSION:
- Based on one quality study, adding ultrasonography to mammography results in more screening‐detected breast cancer cases among average risk women
- There were higher false-positives and more biopsies with the addition of ultrasonography
- No studies addressed mortality
The authors state
For women with dense breasts, cohort studies more in line with real‐life clinical practice confirmed this finding, whilst cohort studies for women with non‐dense breasts showed no statistically significant difference between the two screening interventions
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