Supplemental imaging modalities for breast cancer screening in women with dense breasts: A systematic review with economic considerations

BACKGROUND: Underdiagnosis of breast cancer is a concern for women with dense breasts. This systematic review and meta-analysis evaluates the performance and cost-effectiveness of supplementary imaging modalities plus standard mammography, versus mammography alone, for detecting breast cancer in women with dense breasts. METHODS: We searched MEDLINE, Embase, Scopus, Cochrane Database, Web of Science, and CENTRAL for English-language studies published January 2014 to November 2024. Eligible studies compared the performance of a supplementary imaging modality with standard mammography in terms of cancer detection rate (CDR) in women with dense breasts undergoing screening. Risk of bias was assessed using QUADAS-2/QUADAS-C. Screening, data extraction, and quality assessment was conducted by one reviewer and checked by a second reviewer. PROSPERO: CRD42024550250. RESULTS: Out of 1740 search results, 36 studies met the inclusion criteria. Versus mammography alone, magnetic resonance imaging (MRI) identified 18·92 (95 % CI 15·41-22·43) additional cancers per 1000 screenings while digital breast tomosynthesis (DBT), automated breast ultrasound (ABUS), and handheld ultrasound (HHUS) detected 1·69 (95 % CI 0·81-2·58), 2·3 (95 % CI 1·28-3·33), and 2·57 (95 % CI 0·99-4·14) additional cancers, respectively. One study of contrast-enhanced mammography (CEM) reported a CDR comparable to MRI. Economic modelling studies revealed heterogeneous results, with MRI showing potential under specific model assumptions. CONCLUDING STATEMENT: Standard mammography often fails to detect cancers in women with dense breasts. Supplementary MRI provides better detection than DBT, ABUS, and HHUS. CEM seems comparable to MRI, based on limited evidence. These findings should be considered in future screening policy reviews for women with dense breasts.