Breast Imaging: Basics and Beyond

Breast Imaging: Basics and Beyond

Noor Ahmed Al-Khori, MD
Consultant Physician -RadiologySidra Medicine
Assistant Professor of Clinical Radiology
Weill Cornell Medicine-Qatar

Although the incidence of breast cancer(BC) is lower in low and middle income countries relative to the incidence in high income countries​[1]​, evidence shows that BC is rising in incidence worldwide​[2]​. The rise in incidence has been attributed to urban development, reduced and delayed fertility, and increased “Westernization” of lifestyle​[1]​. 
Many studies have shown that Arab countries had a higher incidence of BC in younger females (20-44 years of age)​[3]​.Similar observations are noted in China​[4]​,Korea​[5]​, and India​[1]​. While other studies have attributed this observation to the fact that the Arab region has a much younger population​[6]​, others have reported age-adjusted standardized incidence rates varying from 10-50 cases per 100,000 women per year, with up to 50% of cases in women younger than 50 years ​[7]​.
In 2015, BC was the most commonly diagnosed cancer among females in Qatar, representing 87% of all malignant cancers in females of all nationalities​[12]​.Compared to other countries in the MENA region, Qatar has one of the highest BC incidence and mortality rates​[13], [14]​. 
Screening Programs and Guidelines
A meta-analysis of 11 “high quality” randomized clinical trials (RCTs) with 13 years follow-up showed a 20% reduction in breast cancer mortality in women invited for screening ​[26]. Over the past few decades, many countries have established centralized national screening programs​[15]​. Countries differ in the guidelines of their screening programs, specifically, in the age range of the target population and in the screening interval. The current guideline in Qatar recommends screening of all women from the ages of 45-69 every 3 years​[17]​. Long-term, high-quality data will be required to assess the appropriateness of this screening guideline for the women of Qatar. 

The Role of Breast Imaging
Breast imaging is used to detect early-stage disease (screening), evaluate symptomatic abnormalities (diagnostic), and to followup women who have already received treatment for a breast concern. 
The main modalities used in the evaluation of the breast are mammography, ultrasound and MRI. An image-guided biopsy can be performed using any modality that allows best visualization of the lesion or offers the best method of obtaining an adequate tissue sample. New advances in breast imaging include digital breast tomosynthesis (3-D mammography), automated breast ultrasound, abbreviated MRI, and positron-emission mammography (PEM). 

The Value of BIRADS
BIRADS stands for Breast Imaging Reporting and Data System, and comprises a specific lexicon used to describe breast findings on imaging. It enables clear and consistent communication among breast specialists, and determines patient management. 

Benefits vs. Harms
Harms​ of screening include pain, anxiety, false positive/negative results, morbidity related to surgery or radiation[28​].​ Harms also encompass overdiagnosis, which represents the diagnosis of cancer that would have never caused symptoms or resulted in death [26​].​  

Future Directions
Given the harms and downsides to imaging, some insist that the age at which to begin screening and the frequency of screening should be personalized in accordance to a woman’s risk. There is still much to learn about the natural history of breast cancer and the role of risk factors. Genomics plays a role in determining genetic mutations which increase a woman’s risk, but this is also an area of active discovery. 
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