Should tailored screening with hand-held ultrasound based on high mammographic breast density, in addition to mammography, vs. mammography alone be used for early detection of breast cancer in asymptomatic women?

The conditional recommendation (rather than strong) against tailored screening with hand-held ultrasound (HHUS) in addition to mammography screening over mammography screening alone in women with high mammographic breast density, in the context of an organised screening programme, is the result of a balance of the health effects that does not favour either the intervention nor the comparison, in the context of low certainty in the evidence about these effects, and the large resource (cost) associated with HHUS. There is an improved detection rate of HHUS plus mammography over mammography alone, however, this improvement is smaller as compared to alternative imaging modalities such as DBT (see recommendation for this intervention) although no direct comparison of HHUS and DBT was made.

In settings that are not already using HHUS in tailored screening, it is likely not useful to implement this for screening programmes

• If resources and implementation are not a concern, or where HHUS has already been implemented, countries may decide to keep HHUS-based screening programmes.
• The GDG members felt that information and education for women about mammographic breast density is critical. The opinion of women regarding HHUS depends on the quality of the information provided to them with regards to the evidence behind this modality for tailored screening, including the information concerning the limitations or uncertainty about the effects of HHUS and inter-operator variability.
• The GDG expressed concern about the quality assurance for HHUS in contexts where training is variable and screening is opportunistic and not organised.
• No new technology would likely be necessary in most settings, although some institutions may not have the ultrasound equipment which fulfils the requirements for performing breast ultrasound.
• There are additional training requirements for radiologists performing HHUS.
• Pressure to implement HHUS exists, which may have to be considered with regards to the conditional recommendation against based on the evidence reviewed by the GDG.

Quality assurance of HHUS appears challenging to conduct or implement. In settings where they decide to implement HHUS, the GDG recommends consideration be given to quality assurance of HHUS.