Breast Imaging| Volume 55, P119-125, May 2019

Double reading of automated breast ultrasound with digital mammography or digital breast tomosynthesis for breast cancer screening


      • Adding ABUS increased recall rates for FFDM and DBT.
      • Most ABUS recalls were for masses, which were all benign at biopsy or follow up.
      • Independent double reading of new ABUS may reduce recalls during ABUS adoption.



      To evaluate the impact of double reading automated breast ultrasound (ABUS) when added to full field digital mammography (FFDM) or digital breast tomosynthesis (DBT) for breast cancer screening.


      From April 2014 to June 2015, 124 women with dense breasts and intermediate to high breast cancer risk were recruited for screening with FFDM, DBT, and ABUS. Readers used FFDM and DBT in clinical practice and received ABUS training prior to study initiation. FFDM or DBT were first interpreted alone by two independent readers and then with ABUS. All recalled women underwent diagnostic workup with at least one year of follow-up. Recall rates were compared using the sign test; differences in outcomes were evaluated using Fisher's exact test.


      Of 121 women with complete follow-up, all had family (35.5%) or personal (20.7%) history of breast cancer, or both (43.8%). Twenty-four women (19.8%) were recalled by at least one modality. Recalls increased from 5.0% to 13.2% (p = 0.002) when ABUS was added to FFDM and from 3.3% to 10.7% (p = 0.004) when ABUS was added to DBT. Findings recalled by both readers were more likely to result in a recommendation for short term follow-up imaging or tissue biopsy compared to findings recalled by only one reader (100% vs. 42.1%, p = 0.041). The cancer detection rate was 8.3 per 1000 screens (1/121); mode of detection: FFDM and DBT.


      Adding ABUS significantly increased the recall rate of both FFDM and DBT screening. Double reading of ABUS during early phase adoption may reduce false positive recalls.


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        • Boyd N.F.
        • Guo H.
        • Martin L.J.
        • Sun L.
        • Stone J.
        • Fishell E.
        • et al.
        Mammographic density and the risk and detection of breast cancer.
        N Engl J Med. 2007; 356: 227-236
        • Mandelson M.T.
        • Oestreicher N.
        • Porter P.L.
        • White D.
        • Finder C.A.
        • Taplin S.H.
        • et al.
        Breast density as a predictor of mammographic detection: comparison of interval- and screen-detected cancers.
        J Natl Cancer Inst. 2000; 92: 1081-1087
      1. Legislation and regulations for dense breast.
        (Available from:) ([Last updated June 15, 2018])
        • Dehkordy S.F.
        • Carlos R.C.
        Dense breast legislation in the United States: state of the states.
        J Am Coll Radiol. 2013; 10: 899-902
        • Kressin N.R.
        • Gunn C.M.
        • Battaglia T.A.
        Content, readability, and understandability of dense breast notifications by state.
        JAMA. 2016; 315: 1786-1788
        • Horny M.
        • Cohen A.B.
        • Duszak Jr., R.
        • Christiansen C.L.
        • Shwartz M.
        • Burgess Jr., J.F.
        Dense breast notification laws: impact on downstream imaging after screening mammography.
        Med Care Res Rev. 2018; ([Jan 1, Epub ahead of print])1077558717751941
        • Sanders L.M.
        • King A.B.
        • Goodman K.S.
        Impact of the New Jersey breast density law on imaging and intervention volumes and breast cancer diagnosis.
        J Am Coll Radiol. 2016; 13: 1189-1194
        • Vourtsis A.
        • Kachulis A.
        The performance of 3D ABUS versus HHUS in the visualisation and BI-RADS characterisation of breast lesions in a large cohort of 1,886 women.
        Eur Radiol. 2018; 28: 592-601
        • Berg W.A.
        • Blume J.D.
        • Cormack J.B.
        • Mendelson E.B.
        • Lehrer D.
        • Bohm-Velez M.
        • et al.
        Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer.
        JAMA. 2008; 299: 2151-2163
        • Corsetti V.
        • Houssami N.
        • Ferrari A.
        • Ghirardi M.
        • Bellarosa S.
        • Angelini O.
        • et al.
        Breast screening with ultrasound in women with mammography-negative dense breasts: evidence on incremental cancer detection and false positives, and associated cost.
        Eur J Cancer. 2008; 44: 539-544
        • Hooley R.J.
        • Greenberg K.L.
        • Stackhouse R.M.
        • Geisel J.L.
        • Butler R.S.
        • Philpotts L.E.
        Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41.
        Radiology. 2012; 265: 59-69
        • Tagliafico A.S.
        • Calabrese M.
        • Mariscotti G.
        • Durando M.
        • Tosto S.
        • Monetti F.
        • et al.
        Adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts: interim report of a prospective comparative trial.
        J Clin Oncol. 2016; 34: 1882-1888
        • Melnikow J.
        • Fenton J.J.
        • Whitlock E.P.
        • Miglioretti D.L.
        • Weyrich M.S.
        • Thompson J.H.
        • et al.
        Supplemental screening for breast cancer in women with dense breasts: a systematic review for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2016; 164: 268-278
        • Maier A.
        • Heil J.
        • Lauer A.
        • Harcos A.
        • Schaefgen B.
        • von Au A.
        • et al.
        Inter-rater reliability and double reading analysis of an automated three-dimensional breast ultrasound system: comparison of two independent examiners.
        Arch Gynecol Obstet. 2017; 296: 571-582
        • Saslow D.
        • Boetes C.
        • Burke W.
        • Harms S.
        • Leach M.O.
        • Lehman C.D.
        • et al.
        American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography.
        CA Cancer J Clin. 2007; 57: 75-89
      2. Cancer Surveillance System.
        (Available from:)
        • Brem R.F.
        • Tabar L.
        • Duffy S.W.
        • Inciardi M.F.
        • Guingrich J.A.
        • Hashimoto B.E.
        • et al.
        Assessing improvement in detection of breast cancer with three-dimensional automated breast US in women with dense breast tissue: the SomoInsight Study.
        Radiology. 2015; 274: 663-673
        • Giuliano V.
        • Giuliano C.
        Improved breast cancer detection in asymptomatic women using 3D-automated breast ultrasound in mammographically dense breasts.
        Clin Imaging. 2013; 37: 480-486
        • Kelly K.M.
        • Dean J.
        • Comulada W.S.
        • Lee S.J.
        Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts.
        Eur Radiol. 2010; 20: 734-742
        • Wilczek B.
        • Wilczek H.E.
        • Rasouliyan L.
        • Leifland K.
        Adding 3D automated breast ultrasound to mammography screening in women with heterogeneously and extremely dense breasts: report from a hospital-based, high-volume, single-center breast cancer screening program.
        Eur J Radiol. 2016; 85: 1554-1563
        • Skaane P.
        • Bandos A.I.
        • Eben E.B.
        • Jebsen I.N.
        • Krager M.
        • Haakenaasen U.
        • et al.
        Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images.
        Radiology. 2014; 271: 655-663
        • Svahn T.M.
        • Houssami N.
        • Sechopoulos I.
        • Mattsson S.
        Review of radiation dose estimates in digital breast tomosynthesis relative to those in two-view full-field digital mammography.
        Breast. 2015; 24: 93-99
        • Zuckerman S.P.
        • Conant E.F.
        • Keller B.M.
        • Maidment A.D.
        • Barufaldi B.
        • Weinstein S.P.
        • et al.
        Implementation of synthesized two-dimensional mammography in a population-based digital breast tomosynthesis screening program.
        Radiology. 2016; 281: 730-736
        • Zuley M.L.
        • Guo B.
        • Catullo V.J.
        • Chough D.M.
        • Kelly A.E.
        • Lu A.H.
        • et al.
        Comparison of two-dimensional synthesized mammograms versus original digital mammograms alone and in combination with tomosynthesis images.
        Radiology. 2014; 271: 664-671
        • Caumo F.
        • Zorzi M.
        • Brunelli S.
        • Romanucci G.
        • Rella R.
        • Cugola L.
        • et al.
        Digital breast tomosynthesis with synthesized two-dimensional images versus full-field digital mammography for population screening: outcomes from the Verona Screening Program.
        Radiology. 2018; 287: 37-46
        • Arleo E.K.
        • Saleh M.
        • Ionescu D.
        • Drotman M.
        • Min R.J.
        • Hentel K.
        Recall rate of screening ultrasound with automated breast volumetric scanning (ABVS) in women with dense breasts: a first quarter experience.
        Clin Imaging. 2014; 38: 439-444
        • Schaefgen B.
        • Heil J.
        • Barr R.G.
        • Radicke M.
        • Harcos A.
        • Gomez C.
        • et al.
        Initial results of the FUSION-X-US prototype combining 3D automated breast ultrasound and digital breast tomosynthesis.
        Eur Radiol. 2018; 28: 2499-2506
        • Sprague B.L.
        • Stout N.K.
        • Schechter C.
        • van Ravesteyn N.T.
        • Cevik M.
        • Alagoz O.
        • et al.
        Benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts.
        Ann Intern Med. 2015; 162: 157-166