8/11/2019 Screening for Early Detection of Breast Cancer- Overdiagnosis Versus Suboptimal Patient Management

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OPINION: Screening for Early Detection of Breast Cancer Gur and Sumkin

328  radiology.rsna.org n  Radiology: Volume 268: Number 2—August 2013

mal use or misuse of correct informationthrough information overloading and/or

the introduction of noise that does notcarry additional diagnostic information isprimarily a human factor that can andshould eventually be overcome by profes-sionals. Once a decision to screen ismade, the role of radiology in screeningfor early detection of disease has beenand needs to remain diligence in detectingand correctly diagnosing all depicted ab-normalities at the earliest stage possible.What follows is the role of other spe-cialties, preferably with appropriate andvaluable input from radiologists as active

participants, in deciding how best to usethe provided information.In our opinion, there is no such thing

as overdiagnosis, there is only correct,partially correct, or incorrect diagnosis.If abnormal findings are diagnosed cor-rectly, there is only optimally managed,suboptimally managed, mismanaged, andpossibly overtreated disease. Society as awhole, together with everyone involved inmaking these clinical managementdecisions, including radiologists, has todetermine and agree on the most effec-tive and efficacious management path. If

some of the findings are not consideredindicative of a clinically important diseaseor are indicative of a disease that is bet-ter left alone at the time of diagnosis, it isreasonable and should be acceptable toleave the disease alone, as long as the in-formation provided by radiologists is ac-curate and complete. Eventually, this ap-proach may very well result in decisionsnot to treat the disease but rather to fol-low specific reported findings until andunless there is a change in these findingsover time that necessitates treatment, ashighlighted by Bleyer and Welch (eg,

grade 1 ductal carcinoma in situ). Radiol-ogists should be encouraged by all to lookmore and find more, as this work is at thecore of generating accurate and completedescriptions of abnormal findings in pa-tients and would hopefully constitutevaluable information. Radiologists shouldnot intentionally hide in the sand to avoidfinding some abnormalities, despite theconcerns expressed by our colleaguesabout additional findings that requiredadditional biopsies or surgical interven-tions for largely benign disease. Radiolo-

gists should always focus on finding allabnormalities and classifying them cor-

rectly, and they should encourage appro-priate management rather than not lookand thereby not find!

In other areas of radiology (eg, bonesand chest) there are well-recognized“leave-me-alone” lesions. While there aresome abnormalities of this type in breastimaging, the problem is that there areperhaps some lesions for which the infor-mation needed to optimally guide appro-priate management does not exist. To ourknowledge, there are currently no ac-cepted criteria or guidelines for many

types of abnormalities depicted in thebreast to determine which detected ab-normality may indeed constitute an over-diagnosis, a population-based term, whenapplied to findings within an individualexamination. The current controversysurrounding the treatment of lobular neo-plasia is but one example. At the sametime, whenever possible, radiologistsshould be active participants in manage-ment decisions or, at a minimum, be ac-tive consultants to those who make them.We should strive to be at the table when-ever possible, as we cannot fully blame

our colleagues for suboptimal use of infor-mation we provide if we are not activelytrying to be participants in this process.

How much looking radiology can af-ford, is expected, or perhaps is even di-rected to do will eventually be deter-mined by policymakers, as the cost ofimaging-based screening of large popula-tions is substantial. However, radiologistsshould never shy away from finding andcorrectly characterizing as much as pos-sible as early as possible. There shouldnot be any doubt that the overall objec-tive of a screening program is to first and

foremost detect, correctly diagnose, andappropriately treat early preclinical can-cers that, if left alone, would become life-threatening cancers. Interestingly, all re-cently proposed imaging approaches toscreening (either primary or supplemen-tal screening) attempt to at least partiallyaddress this issue, namely, improving de-tection and diagnosis of invasive node-negative and node-positive nonmetasta-sized cancers (2,3). A second majorobjective should be to identify women athigher than average risk for developing

these cancers and to develop an appro-priate and hopefully optimal personalized

management plan for them. This includesall risk factors, such as personal history,genetic disposition, breast density andthe like, as well as depicted abnormality–related risk factors (eg, calcification clus-ters and asymmetry). Because none ofthe currently available technologies areperfect in this regard and because futureapproaches, such as cellular, molecular,and/or genetic profiling, are not likely tobe perfect either, we are bound to dowhatever we can to progress towardachieving these objectives as best we can.

Eventually, under a truly optimal individ-ualized health care delivery system,some, if not many, of the imaging-basedfindings will become important as riskfactors or modifiers for future follow-upprotocols.

Most importantly, we must ensurethat overtreatment rather than so-calledoverdiagnosis is addressed by medicineand society as a whole. Until there arevalidated and accepted alternatives toimaging-based screening, as imagersfinding these lesions, we are doing ex-actly what we are supposed to do and

exactly what women expect us to do.

Disclosures of Conflicts of Interest: D.G. Finan-cial activities related to the present article: none todisclose. Financial activities not related to the pre-sent article: none to disclose. Other relationships:is currently employed by Hologic. J.H.S. Financialactivities related to the present article: none todisclose. Financial activities not related to the pre-sent article: provided expert testimony for Mosca-rino and Treu; institution received grants fromHologic; developed educational presentations forthe International Institute for Continuing MedicalEducation (iiCME) and the International Centerfor Postgraduate Medical Education (ICPME).Other relationships: none to disclose.

References

 1. Bleyer A, Welch HG. Effect of three decades ofscreening mammography on breast-cancer inci-

dence. N Engl J Med 2012;367(21):1998–2005.

 2. Berg WA, Zhang Z, Lehrer D, et al. Detection of

breast cancer with addition of annual screening

ultrasound or a single screening MRI to mam-

mography in women with elevated breast cancer

risk. JAMA 2012;307(13):1394–1404.

 3. Skaane P, Bandos AI, Gullien R, et al. Compar-

ison of digital mammography alone and digital

mammography plus tomosynthesis in a popula-

tion-based screening program. Radiology

2013;267(1):47–56.