EARLY BREAST CANCER DETECTION – NO COMPROMISE WITH 3D MAMMOGRAPHY

13rd September 2022, NIA Diagnostic Imaging

Mammography remains the gold standard imaging technique in early-stage breast cancer diagnosis. It forms part of the triple test approach to the investigation of new breast symptoms. (Cancer Australia 2021). In the past, there used to be limitations with conventional mammography’s sensitivity and specificity in detecting abnormalities in young female breasts due to the patients’ mostly dense breast tissues. This has now been greatly improved with the use of digital breast tomosynthesis or also called 3D mammography technique.

Digital breast tomosynthesis allows radiologists to view breast images in multiple layers or slices of otherwise overlapping breast tissues, which enables not only higher cancer detection rate, but also more confident characterisations of benign lesions. In fact, results from Friedewald et al. (2014)’s study has found an average of 20-65% increase in invasive breast cancers detected per 1000 screening exams in women receiving the combined 2D and 3D mammograms acquired with the Hologic® 3D Mammography™ system, as compared with those receiving 2D mammogram alone.

The use of digital breast tomosynthesis also accounts for up to 40% reduction in recalls compared with the conventional 2D mammography alone. Subsequently, one can say that 3D mammogram helps speed up reporting process and avoid long result waiting time, which in turn may reduce patient’s anxiety. From the managing clinician’s point of view, the prompt availability of imaging results means that core biopsy and/or fine needle aspiration (FNA) of breast lesions can be requested without delay, facilitating disease diagnosis and treatment plan. Overall, breast imaging using 3D mammogram +/- ultrasound in all age groups have proven to be very effective tools in breast cancer diagnosis, particularly in (young) women with dense breasts.

This state-of-the-art technology, powered by Hologic® the global industry leader in breast heath, is readily available at NIA Diagnostic Imaging. With a team of experienced mammographers, sonographers and radiologists on site, NIA Diagnostic Imaging can collaborate with the managing clinicians to deliver a seamless diagnosis journey for patients, from 3D mammography, ultrasound to imaging guided biopsy.

Mammography is just one facet of the triple test approach to the diagnosis.

According to Cancer Australia, breast cancer is the second most commonly diagnosed cancer in Australia in 2022. Approximately 57 Australians (both females and males) are diagnosed each and every day, which equates to over 20,000 breast cancer cases each year. (National Breast Cancer Foundation, 2022). About 1 in 600 men are diagnosed with breast cancer in their lifetime and about 1 in 7 women are diagnosed in their lifetime. As age is one of the risk factors, women between the ages of 50-74 are currently being invited for annual screening mammograms. However, it is also worth noted that around 1000 young women are diagnosed with breast cancer each year, equivalent to about 3 young women each day. Statistics has shown that in 2022, approximately one woman under the age of 40 is expected to die each week from breast cancer. (National Breast Cancer Foundation, 2022) This highlights the importance of accurate and early breast cancer diagnosis in young female patients in order to improve their prognosis.

References:

Cancer Australia 2022, Breast Cancer, viewed 10 September 2022, https://www.canceraustralia.gov.au/cancer-types/breast-cancer/statistics
National Breast Cancer Foundation 2022, Breast Cancer Stats, viewed 10 September 2022, https://nbcf.org.au/about-breast-cancer/breast-cancer-stats/#:~:text=Around%201000%20young%20women%20are,each%20week%20from%20breast%20cancer
Cancer Australia 2022, The Investigation of A New Breast Symptom, A Guide for General Practitioners, viewed 10 September 2022, https://www.canceraustralia.gov.au/sites/default/files/publications/investigation-new-breast-symptom-guide-general-practitioners/pdf/investigation-of-a-new-breast-symptom-a-guide-for-general-practitioners.pdf
Friedewald SM et al. 2014, ‘Breast cancer screening using tomosynthesis in combination with digital mammography’, JAMA vol 311, no. 24. pp.2499-2507.
Finding Value in Digital Breast Tomosynthesis 2017, Imaging Technology News, viewed 10 September 2022, https://www.itnonline.com/article/finding-value-digital-breast-tomosynthesis

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”