Considerations in Breast cancer screening, density and supplemental imaging in average-risk women

Breast cancer remains a prevalent health concern, affecting approximately one in eight women during their lifetime. While screening mammography has significantly reduced mortality through early detection, its sensitivity is compromised in women with dense breast tissue-a factor that not only increases cancer risk but also obscures malignancies on imaging. Digital breast tomosynthesis has enhanced screening capabilities over traditional 2D mammography, yet limitations persist for dense breasts. In response, recent US federal legislation mandates that mammography lay summaries inform patients about the implications of breast density, including reduced detection rates and elevated risk. Additionally, insurance coverage for supplemental imaging is expanding across the United States. Supplemental screening modalities such as magnetic resonance imaging, whole-breast ultrasound, contrast-enhanced mammography, and molecular breast imaging offer improved detection in dense tissue, but guidance for average-risk women remains unclear. This lack of consensus can lead to confusion among patients and providers. This article aims to equip clinicians with a comprehensive understanding of breast density's impact on screening efficacy, the available supplemental imaging options, and current societal recommendations. By clarifying these considerations, clinicians can better navigate shared decision-making with average-risk patients regarding breast cancer screening.