# Cancers not detected in one-view breast tomosynthesis screening—characteristics and reasons for non-detection

## TL;DR

This study investigates why some breast cancers are missed in digital breast tomosynthesis screening, finding that normal-appearing density is a common reason for missed cancers.

## Contribution

The study classifies non-detected cancers in tomosynthesis screening and identifies key reasons for false negatives.

## Key findings

- False negatives in DBT screening were most commonly due to normal-appearing density.
- False negatives had lower rates of high breast density and spiculated densities compared to true positives.
- Spiculated features were present in false negatives but less frequently than in true positives.

## Abstract

Limited understanding exists regarding non-detected cancers in digital breast tomosynthesis (DBT) screening. This study aims to classify non-detected cancers into true or false negatives, compare them with true positives, and analyze reasons for non-detection.

Conducted between 2010 and 2015, the prospective single-center Malmö Breast Tomosynthesis Screening Trial (MBTST) compared one-view DBT and two-view digital mammography (DM). Cancers not detected by DBT, i.e., interval cancers, those detected in the next screening round, and those only identified by DM, underwent a retrospective informed review by in total four breast radiologists. Reviewers classified cancers into true negative, false negative, or non-visible based on both DBT and DM findings and assessed radiographic appearances at screening and diagnosis, breast density, and reasons for non-detection. Statistics included the Pearson X2 test.

In total, 89 cancers were not detected with DBT in the MBTST; eight cancers were solely in the DM reading mode, 59 during subsequent DM screening rounds, and 22 interval cancers. The proportion of cancers classified as false negative was 25% (22/89) based on DBT, compared with 18% (14/81) based on DM screening. The primary reason for false negatives was normal-appearing density, 50% (11/22). False negatives exhibited lower rates of high breast density, 36% (8/22), compared with true positives, 61% (78/129), p = 0.04, and spiculated densities were less frequent in false negatives, 41% (9/22) compared with true positives, 68% (88/129), p = 0.01.

False negatives in one-view DBT screening commonly presented with spiculated features, but less frequently than true positives, and were missed or misinterpreted due to benign appearances.

Question
Cancers not detected in digital breast tomosynthesis screening, including false negatives, remain partly unexplored.

Findings
The most common reason behind false-negative cancers in a large screening trial was a normal-appearing density.

Clinical relevance
Recognizing the factors contributing to false negative findings in digital breast tomosynthesis screening is essential to further improve cancer detection.