The current status of risk-stratified breast screening

• Published in: British journal of cancer 2022-03, Vol.126 (4), p.533-550
• Main Authors: Clift, Ash Kieran, Dodwell, David, Lord, Simon, Petrou, Stavros, Brady, Sir Michael, Collins, Gary S., Hippisley-Cox, Julia
• Format: Article
• Language: English
• Subjects: 692/4028/67/1347; 692/699/67/2324; Age; Biomedical and Life Sciences; Biomedicine; Breast cancer; Breast Neoplasms - diagnostic imaging; Breast Neoplasms - genetics; Cancer Research; Clinical Decision-Making; Clinical trials; Drug Resistance; Early Detection of Cancer; Epidemiology; Female; Genetic Predisposition to Disease - genetics; Humans; Mammography; Mammography - methods; Molecular Medicine; Morbidity; Oncology; Practice Guidelines as Topic; Prediction models; Qualitative research; Retrospective Studies; Review; Review Article; Risk assessment; Sensitivity and Specificity
• ISSN: 0007-0920; 1532-1827
• DOI: 10.1038/s41416-021-01550-3

Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.