Personalizing breast cancer screening in the era of precision medicine

Mammography screening is generally the recommended exam for detecting breast cancer in women. Though it has effectively reduced breast cancer mortality in some patient groups,[1] a one-size-fits-all approach to mammography might not be best suited for all patients. Not all women have the same risk for the same type of breast cancer as various individual factors can increase it. These specific factors may include breast tissue density or the patient’s family history of breast cancer.

With a goal of more personalized healthcare and better outcomes, breast cancer screening is evolving toward new approaches that assess each woman’s risk and lifestyle factors.

At the same time, inequities in access to healthcare and the latest treatments mean that too many women die of breast cancer who otherwise might not. This includes disproportionate numbers of socially and economically disadvantaged populations and many at elevated risk for cancer due to inherited genetic profiles. It is an unfortunate reality that women in minority populations, such as African American women when compared to white women, are 72 percent more likely to be diagnosed with invasive breast cancer, 58 percent more likely to be diagnosed with advanced-stage disease, and 127 percent more likely to die from breast cancer—all before age 50.[2] Additionally, for women dealing with limited income, insurance gaps, child care, or transportation issues, pursuing and paying for screening exams can be challenging.

Evolving the approach to breast cancer screening

New, sophisticated approaches to cancer screening can aggregate data from genetic profiles, blood work, environmental factors, family history, and personal health data to make breast cancer screening precise and more effective.

Concurrently, industry partners, health systems, and patient advocacy groups are working to improve access to screening—from using more accessible screening techniques to detect breast cancer at the earliest stages to coordinating screening and diagnostic efforts to reduce the time from screening to diagnosis and treatment.

Industry partners like GE HealthCare are committed to innovating breast screening to support earlier detection of breast cancer and improved access for patients.

“The vision is to provide the clinician with the information to inform screening decisions so every patient can get a screening recommendation optimized for them personally, and not for a group of people similar to them,” said Andy DeLaO, Chief Strategy and Marketing Officer at GE HealthCare. “Based on an analysis of a multitude of data, healthcare practitioners will have the insights needed to plan and order the most effective screening test for each individual patient.”

Updating breast cancer screening guidelines for a data-driven future

There is an opportunity to improve breast cancer screening guidelines. Screening for breast cancer has been evaluated by randomized trials for over five decades and recommended by major guideline groups for over three decades.[3] Modern mammography methods were developed late in the 1960s and were first officially recommended by the American Cancer Society (ACS) in 1976. Mammograms continue to be the most reliable way to screen for breast cancer.[4]

Data has always been an important factor in breast cancer screening. Demographics such as age and population data are used to understand breast cancer incidence and prevalence. With this data, randomized trials helped to build the models that are the basis for recommended screening guidelines by organizations such as the ACS and by other organizations around the globe. Breast cancer screening guidelines provide valuable tools for clinical decision-making as providers can base treatment recommendations on available evidence.

“Breast cancer screening has historically been a population-based methodology,” said DeLaO. “The recommendations are based on a woman’s age and may consider her ethnicity and family history. Was there someone else in their immediate family, their mother or sister, that had breast cancer?? These types of variables are built into the sets of guidelines that are available.”

Unfortunately, little information is known about how many countries have issued breast cancer screening guidelines, so differences among existing guidelines can be inconsistent.[5] Further, organizations that do maintain guidelines and recommendations do not all agree on when to begin screening mammograms and how often to repeat them.

However, organizations do release updates to their breast cancer screening guidelines regularly, and when new data or technology is introduced that may impact existing guidelines. For example, newer technologies, such as 3D tomosynthesis, are now used in breast cancer screening in many countries. Because this technology can potentially replace the originally evaluated screening tests, healthcare organizations and clinicians need supporting evidence of its effectiveness.

Evaluating and addressing the cause of the occurrence and frequency of false-positive screening test results might also fuel a change to breast cancer screening recommendations—as could addressing the emergence of overdiagnosis. For example, evidence shows that women with extremely dense breast tissue were almost two times more likely to have a false-positive mammogram than women with fatty breast tissue.[6] Experts understand from published data that the sensitivity of mammography in identifying breast cancer is reduced for women with dense breasts.[7]

Several supplemental screening tests like automated breast ultrasound are available for women with dense breast tissue, but no established guidelines exist to direct healthcare practitioners in recommending the preferred supplemental screening test.[8] A more tailored approach that considers the patient’s mammographic breast density and lifetime breast cancer risk can guide breast cancer screening strategies that are more comprehensive and effective overall.

Reducing delays to diagnosis and treatment with improved access to care

Additional changes are needed to address the gaps in breast cancer screening due to disparities in care. Increased outreach and education efforts are underway. Starting education with youth, preparing educational materials in clear language, and making them available in multiple languages can help. Between organizing mobile mammography units in underserved communities or funding diagnostic and screening exams for women who otherwise cannot afford them, industry partners, health systems, and patient advocates are helping more patients connect with improved access to breast cancer screening. These groups focus on getting patients the education and information they need, and, in some cases, assist women in accessing care if they are experiencing treatment challenges due to inconsistent childcare, limited time allowed away from work, or transportation.

Delays in breast cancer diagnosis and treatment have been recorded across patient subpopulations and are associated with adverse outcomes.[9],[10] Delayed time to treatment is a significant area where racial disparity persists, as highlighted in a study that reported how women of color waited nearly 17 days longer for treatment initiation compared with white women.[11]

To reduce these delays and provide all women with comprehensive breast care, organizations like GE HealthCare are providing counsel, new care pathway approaches, and algorithms to breast clinics to implement a highly coordinated and methodical patient journey, from appointment to diagnosis and treatment plan. GE HealthCare’s One-stop™ Clinic for breast care is a multi-modality approach that creates a highly coordinated patient journey—from the initial appointment to diagnosis to treatment plan and beyond—in one location and with one treatment team, often in a single day. This solution aims to reduce the time between abnormal screening results and a confirmed cancer diagnosis to develop a treatment plan accordingly.

Having the entire scope of services completed in one day can be helpful to those women who may have difficulty getting time off work or arranging childcare or may not want to return for follow-up exams after a suspicious mammogram.

Identifying the right screening tool for the right patient

The strongest patient risk factors for breast cancer include age and genetic mutations;[12] these factors outweigh other factors such as reproductive history, family history, and breast density. Even though breast density is a lower risk, it is more common in the general population,[13] and there are variations in the proportion of women with dense breast tissue. Directing these patients to screening exams better suited to image their breast tissue is a step in the right direction.

“We know in the US about 40 percent of women have dense breast tissue,” said DeLaO. “However, we also know that in countries such as China and Japan, there’s a higher proportion of women that have dense tissue. In those parts of the world, clinicians may opt to use breast ultrasound as an alternative screening exam.”

As breast cancer screening evolves, more data can be included to stratify patient risk, and could potentially expand the selection of primary screening tools so that clinicians would e able to select the most effective screening tool for their patients. Over the last several years, multiple imaging modalities have been introduced as supplemental screening tools for women with increased risk of breast cancer, including women with dense breasts.[14]

Magnetic resonance imaging (MRI) is considered one of the most sensitive imaging modality for detecting breast cancer; however, it has low specificity, requires intravenous gadolinium injection, and is associated with a higher false-positive rate and higher costs. Even though it is considered an effective tool for women with high risk, there is little evidence to support MRI for women with dense breasts and no other risk factors.[15]

Automated whole breast ultrasound (ABUS) was approved as a new supplemental screening modality by the FDA in 2012, and early studies demonstrate promise for ABUS for detecting additional cancers.[16]

The future of breast cancer screening and early detection

Artificial intelligence (AI) is having a profound impact on many areas of healthcare—and breast imaging and breast cancer detection are no exception. AI algorithms for interpreting mammograms are already improving the effectiveness of population breast cancer screening programs. AI’s ability to detect cancers without overdiagnosis is key to its adoption into daily clinical practice.

Developments are aiming to aggregate data from multiple sources to inform the optimal breast cancer screening experience for each patient. Electronic health records already hold baseline data from prior screenings, including dense breast information, vital patient health histories, and family health histories.

“Progress in personalizing breast cancer screening is moving at lightning speed,” noted DeLaO. “All of the relevant existing data can be aggregated and combined with new datasets, such as social determinants of health, via AI and software. My question is: Can we now add genetic histories and genetic profiling with less invasive tests such as a lab or blood test? As an industry partner, it will be up to us to provide the platform to house this data and provide analytics and insights that will help to inform patients’ and clinicians’ decisions about breast cancer screening, making common questions easier such as, ‘Should I really start screening someone at age 40?? Or because of her or his risk factors and history, should I start at 36?’”

Until that time, clinicians continue to rely on screening mammography as the primary screening tool, supporting breast cancer detection at the earliest stage possible. Efforts continue to improve access to breast cancer screenings and care and to improve patient health outcomes for the long term. AThis work supports providing personalized care for each individual.

Learn more about GE HealthCare’s breast care solutions.

Read more about personalized breast care.

 

DISCLAIMER

Not all products or features are available in all geographies. Check with your local GE HealthCare representative for availability in your country.

 

REFERNECES

[1] Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2016 Feb 16;164(4):244-55. doi: 10.7326/M15-0969. Epub 2016 Jan 12. PMID: 26756588.

[2] https://www.acr.org/Practice-Management-Quality-Informatics/Imaging-3/Case-Studies/Patient-Engagement/Improving-Access-for-Women

[3] https://academic.oup.com/epirev/article/33/1/165/488909

[4] https://www.cancer.org/treatment/understanding-your-diagnosis/history-of-cancer/screening-early-detection.html

[5] https://www.sciencedirect.com/science/article/pii/S0960977622000765#

[6] Lehman CD, White E, Peacock S, Drucker MJ, Urban N. Effect of age and breast density on screening mammograms with false-positive findings. AJR Am J Roentgenol. 1999 Dec;173(6):1651-5. doi: 10.2214/ajr.173.6.10584815. PMID: 10584815.

[7] Vegunta S, Kling JM, Patel BK. Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals. Mayo Clin Proc. 2021 Nov;96(11):2891-2904. doi: 10.1016/j.mayocp.2021.06.001. Epub 2021 Oct 19. PMID: 34686363.

[8] Vegunta S, Kling JM, Patel BK. Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals. Mayo Clin Proc. 2021 Nov;96(11):2891-2904. doi: 10.1016/j.mayocp.2021.06.001. Epub 2021 Oct 19. PMID: 34686363.

[9] Bleicher RJ, Ruth K, Sigurdson ER, et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol 2016;2:330-9.

[10] Gagliato DeM, Gonzalez-Angulo AM, Lei X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol 2014;32:735-44.

[11] Selove R, Kilbourne B, Fadden MK, et al. Time from screening mammography to biopsy and from biopsy to breast cancer treatment among black and white, women Medicare beneficiaries not participating in a health maintenance organization. Women’s Health Issues 2016;26:642-7.

[12] https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#

[13] Lee CI, Chen LE, Elmore JG. Risk-based Breast Cancer Screening: Implications of Breast Density. Med Clin North Am. 2017 Jul;101(4):725-741. doi: 10.1016/j.mcna.2017.03.005. PMID: 28577623; PMCID: PMC5458625.

[14] Lee CI, Chen LE, Elmore JG. Risk-based Breast Cancer Screening: Implications of Breast Density. Med Clin North Am. 2017 Jul;101(4):725-741. doi: 10.1016/j.mcna.2017.03.005. PMID: 28577623; PMCID: PMC5458625.

[15] Lee CI, Chen LE, Elmore JG. Risk-based Breast Cancer Screening: Implications of Breast Density. Med Clin North Am. 2017 Jul;101(4):725-741. doi: 10.1016/j.mcna.2017.03.005. PMID: 28577623; PMCID: PMC5458625.

[16] Kelly KM, Dean J, Comulada WS, Lee SJ. Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts. Eur Radiol. 2010;20(3):734–742. [PMC free article] [PubMed] [Google Scholar] [Ref list]

Breast cancer screening

Health screenings

Mammography, mammograms

Precision imaging / Precision medicine

Patient experience