title: Comparison of digital screening mammography and screen-film mammography in the early detection of clinically relevant cancers: a multicenter study.
abstract: OBJECTIVE
  To compare screen-film mammography with digital mammography in a breast cancer screening program, with a focus on the clinical relevance of detected cancers.
  
  
  METHODS
  The study was approved by the regional medical ethics review board. Informed consent was not required. Before the nationwide transition to digital mammography in the Dutch biennial screening program, the performance of digital mammography was studied in three screening regions. For initial screening examinations, mediolateral oblique and craniocaudal views were obtained of each breast. In subsequent examinations, the mediolateral oblique view was standard. A craniocaudal view was added if indicated. Screening outcomes obtained with screen-film mammography and digital mammography, including radiologic and pathologic characteristics, were compared for initial and subsequent examinations.
  
  
  RESULTS
  A total of 1,198,493 screening examinations were performed between 2003 and 2007. Recall was indicated in 18 896 cases (screen-film mammography: 2.6% at initial examinations, 1.3% at subsequent examinations; digital mammography: 4.4% at initial examinations, 2.1% at subsequent examinations; P < .001 for both). Breast cancer was diagnosed in 6410 women (detection rate per 1000 women with screen-film mammography: 5.6 at initial examinations, 5.2 at subsequent examinations; detection rate per 1000 women with digital mammography: 6.8 at initial examinations, 6.1 at subsequent examinations; P = .02 and P < .001, respectively). Digital mammography depicted significantly more ductal carcinoma in situ (DCIS) lesions, irrespective of screening round. Invasive carcinoma was detected significantly more often in subsequent examinations, particularly when associated with microcalcifications (P = .047). The distribution of the histopathologic differentiation grades for DCIS and invasive carcinoma were similar with both modalities. However, with digital mammography more high-grade DCIS lesions were detected at subsequent examinations (P = .013).
  
  
  CONCLUSIONS
  In a population-based breast screening program, the performance of digital mammography in the detection of DCIS and invasive carcinoma was substantially better than that of screen-film mammography. There is no sign of an increase in detection of low-grade DCIS lesions-indicative of possible overdiagnosis-with digital breast cancer screening. Rather, digital mammography appears to add to the detection of high-grade DCIS.
authors.affiliation: National Expert and Training Centre for Breast Cancer Screening, PO Box 6873, 6503 GJ Nijmegen, the Netherlands. a.bluekens@lrcb.umcn.nl
authors.forename: Adriana M J
authors.initials: AM
authors.lastname: Bluekens
authors.forename: Roland
authors.initials: R
authors.lastname: Holland
authors.forename: Nico
authors.initials: N
authors.lastname: Karssemeijer
authors.forename: Mireille J M
authors.initials: MJ
authors.lastname: Broeders
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: den Heeten
mesh_terms: D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000453:epidemiology; D016009:Chi-Square Distribution; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D008327:Mammography / Q000379:methods*; D008403:Mass Screening; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011856:Radiographic Image Enhancement; D011857:Radiographic Image Interpretation, Computer-Assisted; D014963:X-Ray Intensifying Screens