Breast Cancer Screening Across Borders
Practices and perspectives in Europe, the U.S. and South Korea
Breast cancer screening practices vary across the globe, driven by differences in health care policy, population risk and available technology. Still, radiologists everywhere share a common goal: early detection to save lives.
The importance of risk stratification, supplemental imaging for women with dense breasts, and AI were additional similarities discussed during a lively RSNA 2025 session featuring presenters from Europe, the U.S. and South Korea.
Europe's Playbook for Smarter Screening
Across Europe, organized screening programs form the backbone of breast cancer detection, with national data guiding population-based decisions on when and how women are screened.
The Netherlands offers an example of this approach, according to Thiemo van Nijnatten, MD, PhD, consultant radiologist in the Department of Radiology and Nuclear Medicine at Maastricht University Medical Center+, and at the Dutch Expert Centre for Screening, LRCB, Nijmegen, in the Netherlands.
In the European Union, about 1 in 11 women will develop breast cancer before age 74, according to the European Cancer Information System. In the Netherlands, the figure is closer to 1 in 8, based on data from the Dutch National Institute for Public Health and the Environment.
“In a Dutch setting, full-field digital mammography (2D) is the foundation of population-based screening for women ages 50 to 75, with intervals ranging from one to three years depending on the country,” Dr. van Nijnatten said.
Supplemental screening for women with dense breasts also plays a central role.
Backed by evidence from large-scale scientific trials, these approaches are increasingly integrated into organized programs with efforts underway to expand access, Dr. van Nijnatten noted.
The European Society of Breast Imaging recommends that women be informed of breast density and, for those with extremely dense breasts (BI-RADS category D), receive an MRI every two to four years.
"Dense breasts reduce mammography sensitivity from 95% to 60%, increase breast cancer risk by four times, and are associated with higher interval cancer rates,” Dr. van Nijnatten said. “Automated breast density scoring is used in the Dutch breast cancer screening program to invite women with extremely dense breasts for supplemental imaging—contrast-enhanced mammography or abbreviated MRI—as part of the ongoing DENSE-2 trial.”
These strategies aim to maintain high diagnostic performance while improving accessibility and reducing the need for full MRI-guided biopsies.
Dr. van Nijnatten also emphasized the value of well-trained staff, citing a recall rate of 2.3% in the Netherlands. “Organized screening programs, including those in the Netherlands, have demonstrated cost efficiency and resulted in a significant reduction of breast cancer related mortality,” he said.
Risk factors and initial mammography findings, not simply the availability of additional technologies, should drive decisions about whether to recall a woman for supplemental imaging.
“Organized screening programs, including those in the Netherlands, have demonstrated cost efficiency and resulted in a significant reduction of breast cancer related mortality.”
— THIEMO VAN NIJNATTEN, MD, PHD
Equity and Access Shape U.S. Screening
In the United States, breast cancer screening is shaped by a combination of technological innovation and decentralized policy, with no single national screening program.
“Guidelines issued by multiple organizations call for screening to begin no later than age 40,” said Georgia G. Spear, MD, chief of breast imaging and vice chair of women’s imaging at Northwestern Medicine in Chicago.
Against that backdrop, approximately 1 in 8 women in the U.S. will be diagnosed with breast cancer in their lifetime, according to the American Cancer Society. “Incidence is rising, particularly among women under age 50,” Dr. Spear said. “Black women have higher incidence rates before age 40 and significantly higher mortality rates across all ages, while Hispanic women also show increased incidence trends.”
Breast density further complicates screening decisions. More than half of women in their 40s, 40% in their 50s, and 25% over age 60 have dense breast tissue, she added.
Advocacy efforts have prompted policy changes aimed at improving awareness and access, Dr. Spear said. These include a federal rule requiring breast density notification for all patients. Medicare covers screening mammography for people ages 65 and older but does not yet mandate coverage for supplemental screening based on breast density alone.
“The future of screening in the United States lies in risk-adapted models, with AI playing a larger role alongside technological advances, all with an emphasis on equity and access.”
— GEORGIA G. SPEAR, MD
Digital breast tomosynthesis, which all U.S. guidelines agree improves cancer detection, is widely used for screening women ages 40 to 75 and now serves as the foundation of screening in many practices.
“Using a multimodality approach to supplemental screening is important to reach all women in our practice,” Dr. Spear said, noting that her institution performs about 90,000 screening mammograms each year. “We're using automated breast ultrasound as well as abbreviated plus ultra-fast MRI based on each patient's level of risk and breast density. Women at high risk for developing breast cancer benefit from additional imaging including MRI or contrast-enhanced mammography.”
“Screening decisions should be individualized,” Dr. Spear added. “Risk assessment can help us triage patients for supplemental screening. The future of screening in the United States lies in risk-adapted models, with AI playing a larger role alongside technological advances, all with an emphasis on equity and access.”
South Korea's Model for Risk-Based Screening
In South Korea, breast cancer screening is anchored by a national program designed to reflect local epidemiology, according to Hee Jung Shin, MD, a radiologist in the Department of Radiology and Research Institute of Radiology at the University of Ulsan College of Medicine, Asan Medical Center in Seoul, South Korea.
Breast cancer is among the most commonly diagnosed cancers in Korean women, with incidence rising sharply over the past two decades. “Despite the increase, five-year relative survival stands at 94.3%, among the highest in Asia and comparable to global leaders,” Dr. Shin said.
Two population characteristics shape Korea’s screening approach: earlier age at diagnosis and high breast density. Breast cancer is most commonly diagnosed in women in their 40s—about a decade earlier than in many Western countries—and dense breast tissue is highly prevalent across screening populations.
“Risk-based personalized screening, with broader integration of AI and MRI techniques aimed at balancing diagnostic performance, cost and accessibility, is expected to drive a paradigm shift in breast cancer screening in Korea.”
— HEE JUNG SHIN, MD
Under Korea’s National Cancer Screening Program, women ages 40 to 69 are invited to undergo biennial mammography, supported by universal National Health Insurance. Dr. Shin noted that participation reached 72.7% in 2023, among the highest globally.
Mammography remains the foundation of detection, but supplemental US is widely used for women with dense breasts, supported by studies demonstrating increased cancer detection. AI is also playing an increasing role.
“In a large prospective multicenter study, the use of mammography AI-based computer-aided detection within a screening setting increased cancer detection by 13.8% without a significant increase in recall,” Dr. Shin said.
In ongoing trials, Korean investigators are also exploring how MRI techniques, including diffusion-weighted MRI, can be optimized to balance diagnostic performance, cost and accessibility.
“Looking ahead, risk-based personalized screening, with broader integration of AI and MRI techniques aimed at balancing diagnostic performance, cost and accessibility, is expected to drive a paradigm shift in breast cancer screening in Korea,” Dr. Shin added.
For More Information
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