Breast cancer is the most frequently diagnosed cancer among women in Europe. Dense breast tissue, present in around 40–50% of women undergoing mammographic screening, both reduces the sensitivity of full-field digital mammography and independently increases the risk of developing breast cancer. While supplemental imaging can improve cancer detection in women with dense breasts, clinical practice, guideline implementation, and professional awareness vary greatly across European countries. This doctoral study sought to address these disparities and inform best practice through a multi-phase, mixed-methods approach conducted in four sequential phases.
Phase 1 comprised a systematic review and meta-analysis of the diagnostic performance of supplemental imaging modalities, including magnetic resonance imaging (MRI), digital breast tomosynthesis (DBT), automated breast ultrasound (ABUS), hand-held ultrasound (HHUS), molecular breast imaging (MBI), and contrast-enhanced mammography (CEM).
Phase 2 involved qualitative semi-structured interviews with radiologists and radiographers from various European countries to explore their knowledge, experiences, and challenges in implementing supplemental imaging in breast cancer screening.
Phase 3 used an online survey to quantify current screening practices, awareness of existing guidelines, and professionals’ readiness to adopt supplemental imaging.
Phase 4 integrated findings from all previous phases to develop evidence-based recommendations for harmonising screening practices for women with dense breasts across Europe.
The results revealed significant inconsistencies in the use of supplemental screening. Many professionals recognised the limitations of mammography in dense breasts, yet their access to, and utilisation of, supplemental imaging varied widely. Knowledge and training gaps were apparent, along with barriers such as limited resources, lack of standardised protocols, and unclear or absent national guidance.
This research emphasises the urgent need for consistent, equitable breast cancer screening policies and practices. The evidence-based recommendations developed provide a practical framework for improving clinical practice, supporting guideline implementation, and ultimately enhancing breast cancer detection in women with dense breasts throughout Europe.
By addressing current gaps in awareness, training, and resource allocation, and promoting harmonised approaches, this study contributes to improving early detection and health outcomes for a substantial proportion of women at risk.
This PhD study was led by Ms Deborah Mizzi (Department of Radiography, University of Malta), with contributions from Prof. Francis Zarb (Department of Radiography, University of Malta), Professor Clare Allely (School of Health and Society, University of Salford, Manchester) and Dr Claire Mercer (School of Health and Society, University of Salford, Manchester). For further information, please contact Ms Deborah Mizzi by email.
