Updated Relevance of Mammographic Screening Modalities in Women Previously Treated with Chest Irradiation for Hodgkin Disease

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REVIEWS AND COMMENTARY n OpiniOn
Radiology: Volume 265: Number 3—December 2012 n radiology.rsna.org 669
1 From the Department of Radiology, Hospices Civils de
Lyon, Centre Hospitalier Lyon Sud, 165 Chemin du Grand
Revoyet, 69495 Pierre Bénite, France (C.C., M.C., P.J.V.);
Radiation Epidemiology Group, INSERM U1018, Villejuif,
France (F.d.V.); Institut Gustave Roussy, Villejuif, France
(F.d.V.); Université Paris-Sud, Villejuif, France (F.d.V.); CRAN
UMR 7039 Université de Lorraine-CNRS, Vandoeuvre-les-
Nancy, France (A.N.); INSERM CR-U1052, Groupe de
Radiobiologie, Centre de Recherche en Cancérologie de
Lyon, Lyon, France (C.D., N.F.); and Université Lyon 1,
Faculté de Médecine Lyon Sud Charles Mérieux, Oullins,
France (P.J.V.). Received May 9, 2012; revision requested
June 8; revision received June 13; accepted July 12; final
version accepted July 24. Address correspondence to
C.C. (e-mail: catherine.colin01@chu-lyon.fr).
q RSNA, 2012
The high incidence of second cancers
and other health problems affecting
survivors induced clinical practice
guidelines for the long-term follow-up
care of childhood cancer survivors. It is
well known that women treated with
chest radiation for a pediatric or young
adult cancer are at substantially in-
creased risk of breast cancer. Evidence
for this risk comes from studies of fe-
male Hodgkin lymphoma survivors
(1,2). In 2008 and 2010, the Children’s
Oncology Group updated the guidelines
to include adjunct breast magnetic reso-
nance (MR) imaging with the recom-
mended annual screening mammogra-
phy, with mammography starting at 25
years of age or 8 years after radiation
therapy (Table 1). The recommendation
for annual MR imaging was consistent
with guidelines from the American Can-
cer Society, United Kingdom Depart-
ment of Health, and European Society of
Breast Cancer Specialists (5–7). In
2004, a North American study (9) found
that, despite the guideline recommenda-
tion that survivors of childhood cancer
treated with chest radiation undergo an-
nual screening for breast cancer, most
women and their clinicians were not
aware of this risk and the screening rec-
ommendations. More recently, a study
evaluating breast cancer surveillance
practices in a North American cohort
highlighted that 63.5% of those aged
25–39 years and 23.5% of those aged
40–50 years had not undergone mam-
mography screen ing in the previous 2
years (10). There was not a lack of med-
ical contact among participants, because
92% reported a clinical breast examina-
tion within the previous 2 years. It is
possible that patients and clinicians are
anxious about the use of irradiation
screening investigations in these young
patients, who are already at high risk of
radiation-induced breast cancer and
most likely carry a substantial radiation-
induced genomic instability in mammary
epithelium owing to radiation therapy.
Delivered dose and specific low-
dose effects are main concerns in radio-
logic breast imaging. Ionizing radia-
tion is a known mutagen and an
established breast carcinogen. Because
of both the high spontaneous rate of
breast cancer in the general population
and the high multiplicative risk in-
duced by breast radiation exposure,
breast is the most radiation-sensitive
organ in the human body (11). Radia-
tion at a young age is associated with
longer latency times for breast cancer
because radiation-induced breast
cancer appears when the normal tu-
mor incidence is seen. Knowledge in
the field of radiation-induced breast
cancer has been investigated by sev-
eral important cohorts (12,13). In
2008, de Vathaire and Chapitre (14)
conducted a French review in the gen-
eral population to determine the impor-
tance of the risk of breast cancer after
irradiation. The risk of radiation-in-
duced breast cancer was very impor-
tant if patients were younger than 20
years at irradiation and proved before
age 40 years. Authors concluded that
diagnostic chest irradiation or radia-
tion therapy for benign or malignant
diseases increases the risk of breast
cancer for cumulative doses as low as
130 mGy. In addition, breast is the only
organ for which there is no decrease
of radiation-induced risk of breast can-
cer when increasing the number of frac-
tions for a same total dose (14,15). The
risk decreased substantially with age
of exposure to ionizing radiation (11).
Many studies support the linearity of
the radiation dose response for breast
cancer (12,14–16).
Catherine Colin, MD, PhD
Florent de Vathaire, PhD
Alain Noël, PhD
Mathilde Charlot, MD
Clément Devic, BSc
Nicolas Foray, PhD
Pierre-Jean Valette, MD, PhD
Updated Relevance of
Mammographic Screening
Modalities in Women Previously
Treated with Chest Irradiation
for Hodgkin Disease1
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OPINION: Mammographic Screening Modalities in Women Previously Treated for Hodgkin Disease Colin et al
670 radiology.rsna.org n Radiology: Volume 265: Number 3—December 2012
Published online
10.1148/radiol.12120794 Content code:
Radiology 2012; 265:669–676
Conflicts of interest are listed at the end of this article.
Table 2
Breast Cancer Screening Studies in Women Treated with Chest Radiation for Hodgkin or Non–Hodgkin Lymphoma
Study and Year Screening Modality No. in Cohort Median Patient Age (y)*
Median Chest
Radiation Dose (Gy)* Years of Study
Prevalent and Incident
Breast Cancer†
Diller et al, 2002 (20) Mammography 90 38 (24–51) 37.5 (30.0–41.5) 1995–1999 2 DCIS, 10 IDC
Kwong et al, 2008 (21) Mammography 115 41 (25–55) Not reported 2002 2 DCIS, 2 IDC
Lee et al, 2008 (22) Mammography, MR imaging,
ultrasonography
115 35 (24–55) 35 (15–60) 1997–2006 5 DCIS, 7 IDC
Sung et al, 2011 (23) Mammography, MR imaging 91 42 (18–62) 10–29 and .30‡1999–2008 4 DCIS, 6 IDC§
Note.–Patients in references 20–22 had undergone treatment for Hodgkin lymphoma, and patients in reference 23 had undergone treatment for Hodgkin or non–Hodgkin lymphoma.
* Numbers in parentheses are ranges.
† IDC 5 invasive ductal carcinoma.
‡ Doses in 42 patients were unknown.
§ Two cases were DCIS with microscopic foci of intraductal carcinoma.
Table 1
Recommendations for Breast Imaging Screening from National or International Organizations
Organization and Year Cumulative Radiation Dose (Gy) Annual Screening Protocol
Children’s Oncology Group, 2004 (3) 20 Mammography at 25 years or 8 years after RT
Children’s Oncology Group, 2008 (4) 20 Mammography and MR imaging at 25 years or 8 years after RT
American Cancer Society, 2007 (5) 10–30 (RT) Mammography 30 years, MR imaging 30 years
UK National Breast Cancer Screening Program, 2009 (6) ,17 (RT) MR imaging at 25–29 years, mammography and/or MR imaging at
30–50 years, three yearly mammographic examinations at
.50 years in the NHSBSP
EUSOMA Group, 2010 (7) NA MR imaging 8 years after RT
Children’s Oncology Group, 2010 (8) 20 Mammography and MR imaging at 25 years or 8 years after RT
Note.—EUSOMA 5 European Society of Breast Cancer Specialists, NA = not available, NHSBSP 5 National Health Service Breast Screening Program, RT 5 radiation therapy.
Recently, one study described the ra-
diobiologic effects that occurred with
mammographic radiation–induced DNA
damage (17). A low and repeated dose
effect and a lack of repair of DNA dam-
age were highlighted in agreement with
findings from another recent work (18).
The knowledge about radiobiologic ef-
fects could change screening protocols
(eg, in those with a high family risk of
breast cancer) while we wait for studies
about potential low-dose carcinogenic
effects and additional studies about ra-
diologic features of breast cancer (19).
Even if data are still limited by a small
sample size in women previously treated
with chest radiation for Hodgkin disease
(Table 2), histologic and radiologic data
of breast cancer seem to be different
from those in patients with a high family
risk of breast cancer, notably from
BRCA1 mutations, with probably more
ductal carcinoma in situ (DCIS) than in
high family risk groups.
Histologic and Radiologic Data about
Breast Cancers
In survivors of pediatric and young
adult cancer who have previously un-
dergone treatment for Hodgkin disease,
about 77%–85% of breast cancers are
invasive ductal carcinoma at histologic
examination (8,24–28) and about 15%–
20% are DCIS, which is similar to that
found in the general population. Before
assessments of MR imaging, retrospec-
tive data suggest that breast cancer that
occurs after chest radiation therapy is
detectable with mammography in 80%–
100% of cases (28,29–31). In two pro-
spective studies without systematic MR
imaging, investigators reported that
mammography could depict small and
node-negative cancers but might be
limited by the high breast density linked
to young age (Table 2) (20,22). In one
of those studies, four of five mam-
mographically detected cancers were
DCIS (22). Three prospective recall
studies reported that most cancers
were evident on mammograms (20–
22). Mammographic sensitivity was be-
lieved to be due to a high prevalence of
DCIS-associated calcifications. Interna-
tional societies have recommended the

OPINION: Mammographic Screening Modalities in Women Previously Treated for Hodgkin Disease Colin et al
Radiology: Volume 265: Number 3—December 2012 n radiology.rsna.org 671
use of MR imaging in the absence of
data that demonstrate superior efficacy
over mammography in this specific pop-
ulation, taking into account a substan-
tial improvement in MR imaging sensi-
tivity in women with a high familial risk
of breast cancer (32–35). Two studies
included MR imaging investigations
(22,23). In a recent retrospective study
assessing the utility of screening MR
imaging, four of 10 breast cancers were
detected with MR imaging alone (23).
A combination of MR imaging and
mammography should be more efficient
in screening for breast cancer than the
use of either modality alone, but fur-
ther radiologic and histologic studies
are necessary. In addition, further stud-
ies are necessary to confirm the in-
creased ability to detect DCIS with MR
imaging on the basis of the experience
of both radiologists and MR imaging
centers with regard to the detection of
subtle signs such as nonmass enhance-
ments (36).
Epidemiologic Data about Radiation-
induced Breast Cancer Risks
In 2004, the Children’s Oncology
Group recommended annual screening
for women exposed to chest radiation
of at least 20 Gy, with screening start-
ing at 25 years of age or 8 years after
treatment (3). In women treated before
age 20 years with median doses of
40 Gy, the estimated cumulative breast
cancer risk is as high as one in eight by
age 40 years (2,37). The risk is higher
in young women treated before 20 years
of age, especially for those treated be-
fore the age of 15 years. Factors that
favor the development of secondary
breast cancer were very young age at
treatment and the use of chemotherapy
(but specific agents were not identified).
The median age at which breast can-
cer is diagnosed after chest irradiation
reported from cohort studies is not in-
formative because it is dependent on the
length of follow-up. The pertinent infor-
mation is the cumulative excess of cases
of breast cancer at a given age. At what
age does this excess become clinically
important? Up to what age does this ex-
cess remain? And, because of the known
latency in radiation-induced cancer,
does a minimal delay between radiation
exposure and breast cancer occurrence
exist? Up to now, no cohort of a popula-
tion exposed to radiation during child-
hood has been followed up until the ex-
tinction of the cohort. Therefore, we do
not know the effect of childhood expo-
sure in elderly people.
One could expect that because the
incidence of breast cancer in the general
population is extremely low before the
age of 30 years, radiation-induced breast
cancer is very low before this attained
age (38). As a general matter, radiation
increases the risk of many abnormalities
by multiplying the spontaneous rate de-
pending on the radiation dose. Few pub-
lished studies on breast cancer after ra-
diation therapy estimate the excess of
cases of breast cancer according to at-
tained age. They are mostly in agreement
with a quasi-absence of risk of radiation-
induced breast cancer up to an age of 30
years. This result is in agreement with
data from atomic bomb survivors in Hi-
roshima and Nagasaki (39).
The magnitude of the minimal delay
between irradiation and breast cancer
is still debated because of the correla-
tion between attained age and delayed
development of cancer. In addition, to
our knowledge, no study has investi-
gated the possible role of chemotherapy
on this delay. No breast cancer excess
was observed before 5 years of follow-up,
and the excess observed 5–10 years
after irradiation was not significant;
however, the excess observed at least
10–15 years after irradiation was sig-
nificant (2,40,41). Therefore, a minimal
delay of 8–10 years could be an accept-
able time period to begin screening.
Radiobiology: A Compromised DNA
Damage Repair and a Low and
Repeated Dose Effect
The past 25 years have seen important
advances in the field of radiobiology,
notably by considering factors such as
radiation type, energy radiation, cellu-
lar model, and individual radiosensitiv-
ity. In particular, immunofluorescence
technique permits detection of indi-
vidual DNA damage inside each cell
nucleus. Several studies demonstrated
radiologic radiation–induced DNA dou-
ble-strand breaks with the g-H2AX bio-
marker (42–45).
Important advances with doses as
low as 1 mGy have concerned tumoral
and nontumoral human cells (17,18,
46,47). The lack of repair at 24 hours
of DNA damage induced at low doses in
mammary epithelial cells (17) was in
agree ment with findings in other stud-
ies that showed any substantial g-H2AX
foci loss for up to 72 hours after irradi-
ation (2.5 mGy) in human and nontu-
moral cells (18) and persistent radia-
tion-induced DNA double-strand breaks
up to 14 days after irradiation (1.2
mGy) (47). However, DNA damage due
to mam mographic exposures must be
confirmed with studies that include
more patients with analysis of DNA
damage repair at more than 24 hours
after mammography exposure. Some
radiobiologic studies also suggest the
existence of nonlinear low-doses phe-
nomena. Notably, a phenomenon called
“hypersensitivity to low-radiation dos-
es” causes a drastic decrease of clono-
genic cell survival in the range of 1–50
mGy and was first demonstrated in hu-
man tumoral cells (48,49). The hyper-
sensitivity to low radiation doses phe-
nomenon was confirmed in nontumoral
human cells by using different end
points (46,50,51). However, all of these
studies involved high-energy gamma or
x-rays, and the experimental protocols
did not reflect the exact conditions of
mammographic exposures (ie, low and
repeated doses within a few minutes in
the milligray range by using relatively
low-energy x-rays [,30 kV]).
In addition, genetic factors such as
mutations of the ATM (ataxia telangiec-
tasia mutated) protein activity, a kinase
initiating the response to the presence of
double-stand breaks, were likely to be
involved in the genesis of both lym-
phoma and breast cancer (52,53). ATM
kinase is at the crossroads of numerous
signaling and repair pathways of double-
strand breaks and may contribute to the
balance between repair and misrepair
(54). ATM mutations augment cell pro-
liferation and increase genomic instabil-
ity and tumor progression (55,56). ATM

OPINION: Mammographic Screening Modalities in Women Previously Treated for Hodgkin Disease Colin et al
672 radiology.rsna.org n Radiology: Volume 265: Number 3—December 2012
mutations and impaired ATM protein
expression were described in various
lymphoproliferative malignancies. A to-
tal absence of ATM kinase activity was
associated with ataxia telangiectasia
syndrome, which is one of the most hy-
perradiosensitive human syn dromes and
is almost exclusively associated with the
development of lymphoid tumors (57).
However, the frequency of homozygous
mutations of ATM is low. Heterozygous
ATM gene mutations have also been sug-
gested in breast cancer predisposition
(58,59). Other mutations of the ATM
gene exist as well. Reiman et al (57) es-
timated a 30-fold increased risk of
breast cancers in heterozygous carriers.
Evidence of cancer susceptibility, partic-
ularly in breast cancer, was shown, with
an overall estimated relative risk of 2.23;
the risk was 4.94 in carriers younger
than 50 years (60).
Full-Field Digital Mammography:
Accuracy in Detecting Calcifications
and a Decrease in Mean Glandular
Dose
DCIS is typically detected on the basis of
calcifications on mammograms, but re-
cent improvements in MR imaging sensi-
tivity in the detection of DCIS as well as
infiltrative carcinoma were demonstrated
(36) and must be confirmed with further
studies. Furthermore, calcifications oc-
curring in ducts are less likely to be
masked by high mammographic breast
density. Digital mammography is replac-
ing conventional screen-film sys tems in
breast cancer screening in many Western
countries. Some studies showed that the
detection of cancer on the basis of calcifi-
cations and/or DCIS was improved with
full-field digital mammography compared
with screen-film mammography (Table
3). The most important limitation of
these studies was the range of ages,
which does not correspond to the young
population characterized by its high pro-
portion of mammographically dense
breasts. From this point of view, a large
prospective study in North America, the
Digital Mammographic Imaging Screen-
ing Trial (DMIST), was particularly infor-
mative by performing prospectively both
digital and screen-film mammography in
the same screened population, taking
into account commonly used breast den-
sity categories (63,64,70).
Accuracy of Calcification and/or DCIS
Detection in Dense Breasts
In 2002 and 2003, the first studies per-
formed with paired-examination stud-
ies and screening with both digital
and screen-film mammography did not
report a significant difference between
mammography technologies (61,62). In
the first study, a prototype workstation
was used for soft-copy reading of mam-
mograms (61). In the second study (62),
the authors gave many reasons why some
obvious cancers might have been missed
with full-field digital mammography,
including insufficient experience of ra-
diologists in soft-copy reading and sub-
optimal reading environment. Then, in
2005, data from the DMIST (63)
showed that digital mammography
performed significantly better than
screen-film mam mography in pre- and
perimenopausal women younger than
50 years with dense breasts. This sig-
nificantly better accuracy was most
likely attributable to differences in im-
age contrast. The investigators
grouped the four density categories
from the fourth edition of the Breast
Imaging Reporting and Data Systems
(BI-RADS) into two main categories:
nondense breast (involving BI-RADS
density categories 1 and 2) and dense
breast (involving BI-RADS density cat-
egories 3 and 4), which represent 53%
and 47% of the population, respec-
tively. In dense breasts, analyses re-
vealed that readers were twice as
likely to rate a cancer as more visible
on the digital images than to rate a can-
cer as equally visible on the digital and
screen-film mammograms (odds ratio,
2.28; 95% confidence interval: 1.61,
3.23; P 5 .0001). In particular, calcifi-
cations revealing cancer tended not to
be missed on the screen-film mammo-
grams for fatty breasts (four cancers
were revealed by calcifications with full-
field digital mammography and screen-
film mammography); conversely, in
dense breasts, the detection of cancer
with calcifications was significantly bet-
ter with digital mammography than with
screen-film mammography (17 cancers
were revealed with full-field digital mam-
mography and seven with screen-film
mammography) (64).
Other studies compared the accu-
racies of full-field digital mammography
and screen-film mammography in two
different populations, with a control pop-
ulation undergoing screen-film mammog-
raphy (65–69). Most investigators report-
ed that the accuracy of full-field digital
mammography in the detection of calcifi-
cations and/or DCIS was significantly
higher than that of screen-film mammog-
raphy (65,67,68). In two studies, the ac-
curacy of full-field digital mammography
was similar to that of screen-film mam-
mography (66,69). In a retrospective
study covering the years 2004 and 2005,
digital and screen-film mammography
were compared in two concurrent screen-
ing cohorts of women (65). Each cohort
had 14 385 age-matched participants.
The detection rate with full-field digital
mam mography was higher than that with
screen-film mammography for cancers
depicted as clustered microcalcifications
(0.26% vs 0.12%, respectively; P 5
.007), in younger women (age range,
50–59 years; 0.63% vs 0.42%, P 5 .09),
and in denser breasts (1.09% vs 0.53%,
P 5 .24).
Others studies showed improved
cancer detection with soft-copy digital
versus screen-film mammography read-
ing (71,72). The issue remains difficult
because authors concluded that the in-
terpretation accuracy might be influ-
enced by the postprocessing algorithm
during soft-copy reading (73). How-
ever, the trend toward the use of digital
mammography is inevitable and more
attractive because of image acquisi-
tion, display, and storage and because
of the possibilities for soft-copy image
analysis—especially in the detection of
calcifications.
Decrease of Delivered Doses
In 2008, the National Coordinating
Centre for the Physics of Mammogra-
phy Equipment of the National Health
Service of the Breast Screening Pro-
gram reported doses from different

OPINION: Mammographic Screening Modalities in Women Previously Treated for Hodgkin Disease Colin et al
Radiology: Volume 265: Number 3—December 2012 n radiology.rsna.org 673
Table 3
Accuracy of Digital Mammography versus Screen-Film Mammography for Detecting Breast Cancer Calcifications and/or DCIS in
Screening Program Conditions
Study and Year
Digital Mammography No. of Examinations
with Screen-Film
Mammography* Patient Age (y) Detection of Calcifications Detection of DCISTechnique No. of Examinations
Lewin et al, 2002 (61) FFDM (soft-copy reading,
prototype workstation)
6736 6736 40 NS NA
Skaane et al, 2003 (62) FFDM (soft-copy reading) 3683 3683 50–69 NS NS
Pisano et al, 2005 (63);
Pisano et al, 2009 (64)†
DM (hard-copy reading) 42 760 42 760 47–62 DM was significantly better
than SFM in dense breasts;
DM was comparable to SFM
in fatty breasts
NA
Del Turco et al, 2007 (65) FFDM (soft-copy reading) 14 385 14 385 50–69 Detection rate for cancers
depicted as calcifications
was higher with FFDM than
with SFM (0.26% vs 0.12%,
respectively; P 5 .007)
NA
Skaane et al, 2007 (66) FFDM (soft-copy reading) 6944 16 985 45–69 Difference between FFDM
and SFM was not
significant (detection
rate, 70.6% vs 70.9%,
respectively; P 5 NA)
Difference between
FFDM and SFM
was not significant
(detection rate,
0.16% vs 0.12%,
respectively; P 5 .55)
Vigeland et al, 2008 (67) FFDM (soft-copy reading) 18 239 324 763 50–69 NA Detection rate was
higher with FFDM
than with SFM
(0.21% vs 0.11%,
respectively;
P , .001)
Hambly et al, 2009 (68) FFDM (soft-copy reading) 35 204 153 619 50–64 Detection rate was significantly
higher with FFDM than with
SFM (0.19% vs 0.13%,
respectively; P 5 .01)
Detection rate was
higher with FFDM
than with SFM (0.12
vs 0.7, respectively;
P 5 .009)‡
Vinnicombe et al, 2009 (69) FFDM (hard-copy reading) 8478 31 720 50–70 FFDM was equal to SFM NA
Note.—Studies using computer-aided diagnosis were excluded. DM 5 digital mammography, FFDM 5 full-field digital mammography, NA 5 not available (data were not reported), NS 5 not significant,
SFM 5 screen-film mammography.
* Patients who underwent screen-film mammography were used as a control group.
† A total of 42 760 patients underwent both digital and screen-film mammography.
‡ Calcifications revealed DCIS.
breast imaging technologies (ie, com-
puted radiography, full-field digital mam-
mography, or digital radiography and
screen-film mammography) to reach a
minimum acceptable and achievable
image quality standard for 0.1-mm and
0.25-mm detail (74). The doses re-
quired were lower with all full-field dig-
ital mammography systems than with
screen-film mammography and com-
puted radiography systems. An experi-
mental study (75) suggested that dose
reduction in digital mammography has
a measurable but modest effect on the
diagnostic accuracy in the detection of
microcalcifications and masses.
In clinical conditions, comparison of
acquisition parameters and breast dose
were recorded and analyzed from sub-
jects enrolled in the DMIST (76). Ana-
lyzed technical parameters included
breast compression force, compressed
breast thickness, mean glandular dose,
and the number of additional views
needed for complete breast coverage.
Investigators showed that the mean
glandular dose per acquired view with
full-field digital mammography was 22%
lower than that with screen-film mam-
mography, with sizeable variations in
average doses depending on the manu-
facturer of the full-field digital mam-
mography system. The mean glandular
dose per view averaged 2.37 mGy for
screen-film mammography and 1.86
mGy for full-field digital mammography.

OPINION: Mammographic Screening Modalities in Women Previously Treated for Hodgkin Disease Colin et al
674 radiology.rsna.org n Radiology: Volume 265: Number 3—December 2012
When extra views were included, the
mean glandular dose per subject with
full-field digital mammography was 17%
lower than that for with screen-film
mammography (4.15 mGy vs 4.98 mGy,
respectively).
Others compared the mean glandu-
lar dose in full-field digital mammog-
raphy and screen-film mammography
systems used in a national mammogra-
phy screening program (77); the mean
glandular dose with full-field digital mam-
mography was significantly lower than
that with screen-film mammography.
Conclusion
The increased risk of breast cancer
with additional low doses of radiation
at screening mammography raises an
important question in the patients with
a radiation-induced posttherapeutic risk
of breast cancer who are investigated at
young age and have dense breasts. The
balance between benefit and risk is nev-
ertheless not known. The specific linear
relationship between the radiation-in-
duced risk of breast cancer and dose
indicates a need for reduction of non-
justified radiation exposures. In addi-
tion, radiobiologic data indicating a
lack of repair of DNA damage induced
at low doses must be taken into ac-
count. Because of the potential for
DNA damage in a two-view screening
protocol, we recommend that screen-
ing mammographic views be limited to
one single view (oblique) per breast in
addition to breast examination and MR
imaging investigation. This single view
may enable detection of calcifications
that may reflect DCIS, although further
radiologic and histologic studies are
necessary to confirm a sufficient inci-
dence of DCIS and breast cancer calci-
fications to maintain mammography as
part of the protocol in this at-risk popu-
lation. Annual screening mammography
can be recommended from age 30 years,
and not earlier, as indicated by several
international organizations. Evidence
suggests that an increase in genetic sus-
ceptibility enhances the risk from low-
dose radiation exposures. Among these
new recommendations, it must be em-
phasized that full-field digital mammog-
raphy (or digital radiography) systems
should be used because of accuracy for
detecting calcifications and/or DCIS in
dense breasts, delivering lower doses
than that with computed radiography
systems or screen-film mammography.
It must be kept in mind that some coun-
tries cannot afford MR examinations
and must rely on mammographic screen-
ing alone. If we consider current multi-
disciplinary data, these new recommen-
dations could be stressed in term of
mammographic screening in associa-
tion with MR imaging in these young
patients at high risk of breast cancer
because of radiation treatments. They
could increase patient and clinician
adherence to screening mammography,
although the optimal schedule of this
follow-up is not clearly defined. Because
patients with Hodgkin disease are also
candidates for repeat scanning with
body computed tomography (CT) and/
or positron emission tomography/CT,
the importance of optimizing acquisi-
tion parameters by using all breast irra-
diation imaging technologies must be
highly considered.
Disclosures of Conflicts of Interest: C.C. No rel-
evant conflicts of interest to disclose. F.d.V. Fi-
nancial activities related to the present article:
none to disclose. Financial activities not related
to the present article: institution has a grant or
grant pending with Electricity of France; owns
stock or stock options in EDF and pharmaceuti-
cal companies. Other relationships: none to dis-
close. A.N. Financial activities related to the pre-
sent article: none to disclose. Financial activities
not related to the present article: is a paid consul-
tant for private practice in medical physics. Other
relationships: none to disclose. M.C. No relevant
conflicts of interest to disclose. C.D. No relevant
conflicts of interest to disclose. N.F. No relevant
conflicts of interest to disclose. P.J.V. Financial
activities related to the present article: none to
disclose. Financial activities not related to the
present article: received payment for develop-
ment of educational presentations from Abbott
and Philips. Other relationships: none to disclose.
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