
==== Front
Lancet Reg Health Eur
Lancet Reg Health Eur
The Lancet Regional Health - Europe
2666-7762
Elsevier

S2666-7762(24)00235-7
10.1016/j.lanepe.2024.101068
101068
Correspondence
Refining the role of contrast-enhanced mammography in breast cancer screening: insights from the RACER trial
Pesapane Filippo filippo.pesapane@ieo.it
∗
Cassano Enrico enrico.cassano@ieo.it
∗∗
Breast Imaging Division, Radiology Department, IEO European Institute of Oncology IRCCS, Via Giuseppe Ripamonti 437, Milan 2014, Italy
∗ Corresponding author. filippo.pesapane@ieo.it
∗∗ Corresponding author. enrico.cassano@ieo.it
06 9 2024
10 2024
06 9 2024
45 10106822 8 2024
29 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
==== Body
pmcThe RACER trial by Neeter and colleagues1 is a significant contribution to breast cancer care, marking the first multicentre, open-label, randomized controlled clinical trial on contrast-enhanced mammography (CEM) in a breast cancer screening context. It demonstrates that CEM offers diagnostic accuracy comparable to conventional imaging. However, these findings also raise important questions about the most appropriate clinical application of CEM.

The RACER trial demonstrated CEM's heightened sensitivity, detecting 13 additional malignant lesions compared to 3 with conventional imaging. While this seems advantageous, it is crucial to consider whether these findings improve patient outcomes or contribute to overdiagnosis of indolent cancers.

In the rapidly evolving field of radiology, assessing the correlation between a specific imaging modality and long-term outcomes is challenging, as the technology may become outdated before studies are completed.2 However, the true clinical value of imaging lies in its ability to enhance patient survival and reduce mortality rates, not just in its diagnostic accuracy.3 While imaging alone does not directly improve patient health, its benefit is realized when it effectively guides patients toward evidence-based and effective treatments.

The study’s focus on diagnostic performance may not fully consider potential biases such as lead-time, length-time, and selection biases, which could impact the perceived effectiveness of CEM. Lead-time bias, for example, might create the impression of earlier detection without necessarily reflecting an improvement in overall patient management. Length-time bias could skew results by detecting slower-growing tumors that are inherently more favorable. Selection bias could arise if healthier, more health-conscious individuals are more likely to participate in trials and screenings, potentially affecting the generalizability of the findings.2

Moreover, the trial does not address the economic impact of widespread CEM use, especially in resource-limited settings, where the costs may outweigh the benefits over conventional methods. Given the role of socioeconomic factors in breast cancer screening, there is a risk that access to advanced technologies like CEM could exacerbate existing health inequities, while it is essential to ensure that the benefits of screening are accessible to all individuals, regardless of their background.4

The RACER trial provides valuable insights into refining the role of CEM in breast cancer screening, helping to identify where it can be most beneficial. While conventional imaging is effective, CEM might be best reserved for now for staging or addressing complex cases requiring detailed assessment. This approach could optimize CEM’s strengths while managing the risks of overdiagnosis and higher healthcare costs. While the RACER trial supports CEM’s use in breast cancer screening, its routine adoption as a first-line tool requires careful consideration indeed. Further studies on long-term outcomes and cost-effectiveness are essential before CEM is fully integrated into screening protocols.

Contributors

Filippo Pesapane conceptualized the letter, drafted the initial text, and provided critical revisions.

Enrico Cassano contributed to the analysis of the RACER trial's findings, assisted in the drafting process, and provided additional insights into the potential implications of the study.

Both authors have directly accessed and verified the underlying data referenced in this letter and confirm that they had full access to all the data discussed, taking full responsibility for the content of the letter.

Declaration of interests

The authors declare no conflicts of interest.
==== Refs
References

1 Neeter L. Nelemans P.J. Raat H.P.J. Contrast-enhanced mammography versus conventional imaging in women recalled from breast cancer screening (RACER trial): a multicentre, open-label, randomised controlled clinical trial Lancet Reg Health Eur 44 2024 100987
2 Pesapane F. Rotili A. Raimondi S. Evolving paradigms in breast cancer screening: balancing efficacy, personalization, and equity Eur J Radiol 172 2024 111321
3 Bretthauer M. Kalager M. Principles, effectiveness and caveats in screening for cancer Br J Surg 100 1 2013 55 65 23212620
4 Oluwasanu M. Olopade O.I. Global disparities in breast cancer outcomes: new perspectives, widening inequities, unanswered questions Lancet Glob Health 8 8 2020 e978 e979 32710868
