Contrast-Enhanced Mammography Shows Promise as MRI Alternative for Women with Dense Breasts

Contrast-enhanced mammography (CEM) may serve as an effective substitute for breast MRI in women with dense breast tissue who need additional screening beyond standard digital breast tomosynthesis (DBT).

Findings from an ongoing clinical trial, published this week in Radiology, suggest that CEM could significantly improve breast cancer detection in cases where MRI—the current gold standard for supplemental screening in dense breasts—is not accessible or feasible for certain patients.

“Relative to the number of women who may benefit from screening MRI, there is a shortage of equipment/capacity,” wrote principal investigator Wendie Berg, MD, PhD, professor of radiology at the University of Pittsburgh School of Medicine, and her co-authors. “Further, nearly half of women cannot have an MRI for medical or other reasons, such as claustrophobia, implanted devices, body habitus, or cost (deductible and copay apply even with the new legislation). Contrast-enhanced mammography appears to have similar performance to MRI but has not been widely validated, particularly for screening.”

In the study, researchers enrolled 601 women who had previously undergone DBT and were eligible for breast MRI. Instead, they received a CEM exam. Two radiologists interpreted the images—one began with DBT, the other with CEM.

The researchers then evaluated differences in cancer detection rates, recall-related false positives, positive predictive value of biopsies, and the area under the receiver operating characteristic curve (AUC) for each modality.

Among the 601 participants, 12 women were diagnosed with 16 malignant lesions. Of these, five lesions were detected by the reader who started with DBT, and one was caught by the reader who began with CEM. The remaining six cancers were found only on CEM—five of which were invasive, node-negative, with a median tumor size of 0.7 cm; three of these were lobular carcinomas.

The combination of DBT and CEM led to a 13.4% increase in false-positive recalls for the first reader compared to DBT alone. However, this pairing also improved the AUC from 0.73 to 0.92, demonstrating CEM’s potential as a high-performing alternative to MRI.

“A significant increase in the detection of early-stage breast cancer was achieved using CEM after DBT. Despite substantially increasing the [false-positive rate], adding CEM to DBT improved the overall AUC by 0.19,” the authors concluded.