Recommendations from the European Breast Cancer Guidelines

Should screening using tomosynthesis (including synthesised 2D images) vs. digital mammography be used for early detection of breast cancer in asymptomatic women?

Recommendation

The ECIBC's Guidelines Development Group suggests that women who are not at high risk of breast cancer and do not have symptoms have either a mammogram or have tomosynthesis when being screened for breast cancer.

Recommendation strength

  •   Strong recommendation against the intervention
  •   Conditional recommendation against the intervention
  • Conditional recommendation for either the intervention or the comparison
  •   Conditional recommendation for the intervention
  •   Strong recommendation for the intervention

A recommendation can be strong or conditional.

When a recommendation is strong, most women will want to follow it. When a recommendation is conditional, the majority of women want to follow it but may need more discussion with their healthcare professional first.

What would following this recommendation mean for you?

It might be important to speak with your healthcare professional to determine if you are at high, average or low risk of breast cancer and whether you have or do not have any symptoms of breast cancer.

In countries where the tests are used, you may have a choice to have digital mammography or digital breast tomosynthesis.

To decide which test is better for you, you may wish to speak with your healthcare professional about these tests and how you feel about·

  • · the radiation exposure of the tests
  • · the chances of finding breast cancer with either test which may depend on your age
  • · the chance of being called back for further tests which find that you do not have cancer,
  • · what could happen in the long term, and
  • · your comfort during the tests.

Who is this recommendation for?

  • You are between 45 and 74
  • You do not have a high risk of breast cancer
  • You do not have symptoms of breast cancer

Justification

This recommendation suggests having either a digital mammogram or digital breast tomosynthesis (3D x-rays) when being screened because the overall benefits and harms of each may be similar. Digital breast tomosynthesis may find more breast cancers (about 2 to 4 more per 1000 women). However, it is uncertain whether finding more breast cancers leads to finding more advanced breast cancers or fewer deaths. On the other hand, more women may have more unnecessary tests with digital breast tomosynthesis than with digital mammography (about 4 to 110 more per 1000 women). It is uncertain whether women who have digital breast tomosynthesis may have to come back for more tests, compared to those having digital mammography, but digital breast tomosynthesis may increase a woman’s exposure to radiation.

The ECIBC's Guidelines Development Group thought that women may feel differently about the benefits and harms and might need to discuss them with their healthcare professional before deciding.

More research is being done now that will provide more information in the future about whether screening with digital breast tomosynthesis is better than with digital mammography.

The ECIBC's Guidelines Development Group also noted that the costs are higher with digital breast tomosynthesis.

 

 

Considerations

Subgroup

Women with high mammographic breast density are likely to benefit most from the increased detection capability of DBT. However, this group was not specifically considered in this question.

Implementation

- Evidence will be emerging from ongoing and newly starting screening trials on tomosynthesis that may influence the current recommendations.
 
- In general, the GDG believed it is important to educate women and health professionals on the risk of radiation, and the very small increase in dose with DBT, in the context of possible benefits of screening.
 
- The GDG identified variability in the quality of DBT machines currently available and their methods of capturing images. The MBTST study used a machine that has a wide-angle form of DBT image capture and may result in different breast cancer detection rates. The Malmo study used a single view DBT format.
 
- The GDG notes that new quality assurance standards of technologies and screening programmes must be considered in choosing DBT over DM. The GDG emphasised that specific standards for synthesised 2D imaging, and their use in comparison to previously captured DM screening images will be necessary in order to implement this recommendation.
 
- There will be significantly increased data storage needs for screening programmes using DBT as compared to DM.
 
- The GDG noted that health equity in access to screening should be considered for countries choosing DBT-based screening programmes, due to different resource settings and the capacity for different countries to be able to pay for DBT over DM which may lead to increased health inequities.

Monitoring and Evaluation

- Quality control/standardisation of the technology for better image storage should be undertaken.

- Quality standards should be developed, in particular for the image quality of synthesised 2D images from the tomosynthesis technology.

Research Priorities

- Evidence will be emerging from ongoing and newly starting screening trials on tomosynthesis that may influence the current recommendations.

- Collecting evidence relevant to implementation challenges of DBT-based screening programmes.

- Further research information on harms of DBT, including rates of overdiagnosis of breast cancer are warranted.

- Further research is needed to build the evidence on benefits and harms of DBT vs DM through comparison of direct outcomes, including impacts of interval cancer incidence, stage of breast cancer at detection and mortality reduction.

- Research investigating the cost-effectiveness of a breast cancer screening programme using DBT is needed to inform decision-making on breast cancer screening.

- Research is needed to define the quality parameters that need to be fulfilled for DBT-based breast cancer screening programmes to be implemented.

Evidence

Download the evidence profile

Assessment

Background

Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women, with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers) (Ferlay 2012). Breast cancer ranks as the fifth cause of death from cancer overall (522 000 deaths), the most frequent cause of cancer death in women in less developed regions (324 000 deaths, 14.3% of total), and it is now the second cause of cancer death in more developed regions (198 000 deaths, 15.4%) after lung cancer (Ferlay 2012).

Screening programmes play a crucial role in early breast cancer detection; it can increase the chance of survival as well as have an impact on the rate of death from breast cancer. Mammography remains the best method to detect breast cancer in an early stage. Mammography is a technique of imaging which produces a 2D image of the 3D organ. Inevitably, this implies that lesions can be obscured by superposition of dense tissue. Indeed, the superposition of tissue can lead to false positives as well as false negatives.

Digital breast tomosynthesis is a pseudo-3D imaging technique based on a series of low dose images of the breast from different angles and therefore has the potential to overcome the tissue superposition issue thus improving detection of breast lesions (Rafferty 2013; Gur 2009). The series of projections is then processed by a reconstruction algorithm to estimate the 3D radiographic appearance of the breast which can be viewed in successive slices. Additional software can also allow the construction of synthesised 2D images.

Management of Conflicts of Interest (CoI): CoIs for all Guidelines Development Group (GDG) members were assessed and managed by the Joint Research Centre (JRC) following an established procedure in line with European Commission rules. GDG member participation in the development of the recommendations was restricted, according to CoI disclosure. Consequently, for this particular question, the following GDG members were recused from voting: Edoardo Colzani, Roberto d'Amico, Jan Danes, Solveig Hofvind, Miranda Langendam, Elsa Pérez, and Kenneth Young.

For more information please visit http://ecibc.jrc.ec.europa.eu/gdg-documents

Is the problem a priority?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
Breast cancer ranks as the fifth cause of death from cancer overall (522 000 deaths), the most frequent cause of cancer death in women in less developed regions (324 000 deaths, 14.3% of total), and it is now the second cause of cancer death in more developed regions (198 000 deaths, 15.4%) after lung cancer (Ferlay 2012). Breast cancer is the fourth cancer with the highest disease burden (Tsilidis 2016).

Digital mammography (DM) is widely used in screening and diagnosis of breast cancer. However, some aspects such as superposition of breast tissue reduce the sensitivity of mammography and increase false-positives and false negatives. Digital Breast Tomosynthesis (DBT) might provide better imaging and discriminative capacity in these cases.
How substantial are the desirable anticipated effects?
Don't know *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Quality of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with digital mammography Risk difference with*
Breast cancer detection rate34344
(2 observational studies)
a

LOW
b
OR 1.45
(1.30 to 1.63)
c
Study population
629 per 100.000a280 more per 100.000
(187 more to 392 more)
Recall rate7500
(1 observational study)

LOW
b
RR 1.43
(1.20 to 1.71)
Low
2.200 per 100.000d946 more per 100.000
(440 more to 1.562 more)
High
15.600 per 100.000d6.708 more per 100.000
(3.120 more to 11.076 more)
False positive recall34174
(2 observational studies)
e

VERY LOW
b f g
OR 1.75
(0.98 to 3.10)
Low
10.700 per 100.000e6.634 more per 100.000
(192 fewer to 16.384 more)
High
41.500 per 100.000e13.886 more per 100.000
(490 fewer to 27.242 more)
Radiation doses0
(3 observational studies)

LOW
h i
-Radiation doses for DBT vary by manufacturer and protocol but were approximately twice 20-30% higher than those reported for DM in these studies.j
  1. Median or mean of the control group of the included studies as appropriate unless otherwise specified.
  2. Although only women with suggestive findings of malignancy were followed–up, it was agreed that there was not an important risk of information bias, as the same strategy was implemented in both arms of the included studies, and the effects were consistent across them.
  3. Incremental cancer detection was 193 cancers per 100,000 women (from 107 more to 278 more).
  4. Baseline risk calculated from Roman 2014 (PMID 24972452) and Hofvind 2012 (PMID 22972811).
  5. Baseline risk calculated from Roman 2014 (PMID 24972452).
  6. Although the STORM study (2013/2014) and MALMO study (2015) evaluated women recalled differently (radiologist vs. radiologist plus meeting arbitration) the results were consistent.
  7. 95% CI probably crosses the clinical decision threshold (as the CI is wide, a different clinical decision regarding the intervention may be taken depending on whether the lower or the higher limit is considered).
  8. Radiation exposure is a surrogate outcome of "other cancer related to radiation".
  9. Results were consistent independently of the technology used (Hologic Selenia Dimensions or Siemens Mammomat Inspiration).
  10. Doses levels are known to vary (diagnostic reference levels are typically country/region and system specific).

* Risk difference with screening using tomosynthesis (including synthesised 2D images).
Additional Considerations

The currently included studies only present data from first round DBT plus DM screening.

The included studies did not assess the outcomes of breast cancer mortality, quality of life, and other causes of mortality.

The GDG agreed that DBT has a large effect on cancer detection rate.

The anticipated effects on mortality, cancer stage, quality of life, and interval cancer detection rate are not known as the studies included did not examine these outcomes.
Therefore, the GDG agreed that overall desirable anticipated effects were not known.

How substantial are the undesirable anticipated effects?
Varies *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Quality of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with digital mammography Risk difference with*
Breast cancer detection rate34344
(2 observational studies)
a

LOW
b
OR 1.45
(1.30 to 1.63)
c
Study population
629 per 100.000a280 more per 100.000
(187 more to 392 more)
Recall rate7500
(1 observational study)

LOW
b
RR 1.43
(1.20 to 1.71)
Low
2.200 per 100.000d946 more per 100.000
(440 more to 1.562 more)
High
15.600 per 100.000d6.708 more per 100.000
(3.120 more to 11.076 more)
False positive recall34174
(2 observational studies)
e

VERY LOW
b f g
OR 1.75
(0.98 to 3.10)
Low
10.700 per 100.000e6.634 more per 100.000
(192 fewer to 16.384 more)
High
41.500 per 100.000e13.886 more per 100.000
(490 fewer to 27.242 more)
Radiation doses0
(3 observational studies)

LOW
h i
-Radiation doses for DBT vary by manufacturer and protocol but were approximately twice 20-30% higher than those reported for DM in these studies.j
  1. Median or mean of the control group of the included studies as appropriate unless otherwise specified.
  2. Although only women with suggestive findings of malignancy were followed–up, it was agreed that there was not an important risk of information bias, as the same strategy was implemented in both arms of the included studies, and the effects were consistent across them.
  3. Incremental cancer detection was 193 cancers per 100,000 women (from 107 more to 278 more).
  4. Baseline risk calculated from Roman 2014 (PMID 24972452) and Hofvind 2012 (PMID 22972811).
  5. Baseline risk calculated from Roman 2014 (PMID 24972452).
  6. Although the STORM study (2013/2014) and MALMO study (2015) evaluated women recalled differently (radiologist vs. radiologist plus meeting arbitration) the results were consistent.
  7. 95% CI probably crosses the clinical decision threshold (as the CI is wide, a different clinical decision regarding the intervention may be taken depending on whether the lower or the higher limit is considered).
  8. Radiation exposure is a surrogate outcome of "other cancer related to radiation".
  9. Results were consistent independently of the technology used (Hologic Selenia Dimensions or Siemens Mammomat Inspiration).
  10. Doses levels are known to vary (diagnostic reference levels are typically country/region and system specific).

* Risk difference with screening using tomosynthesis (including synthesised 2D images).
Additional Considerations

The results for overall recall rate and false positive recall rate came from different studies, and were not mutually consistent.

In addition, the GDG agreed that based on the available evidence the effect on recall rate is likely to vary based on baseline recall rate in the population screened, conferring a reduction in recall in programmes with pre-existing high recall rates, and possibly an increase when existing rates are low (Gilbert, 2016).

False positive rates vary considerably between programmes, and in some programmes, rates are high (Roman, 2014).

The GDG considered that while there may be technique-and manufacturer specific differences in radiation doses, the dose from DBT alone is within the range currently accepted for DM alone.

What is the overall certainty of the evidence of effects?
Very low *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG had no concerns on the evidence of greater test accuracy of DBT due to the higher breast cancer detection rate. However, due to the varied undesirable effects and the uncertainty of the overall effects because of lack of data on how the accuracy of DBT (the detection rate) relates to stage at diagnosis, aggressiveness of treatment and mortality, important patient-centred outcomes, the GDG agreed there was very low certainty of the evidence of effects.


Is there important uncertainty about or variability in how much people value the main outcomes?
Important uncertainty or variability *
* Possible answers: ( Important uncertainty or variability , Possibly important uncertainty or variability , Probably no important uncertainty or variability , No important uncertainty or variability , No known undesirable outcomes )
Research Evidence
No specific studies focusing in tomosynthesis were identified. The findings, all from mammography studies (JRC Technical Report PICO 10-11, contract FWC443094012015; available upon request), however, are likely to be generalisable tomosynthesis, as both screening tests are associated with similar desirable and undesirable effects.

A systematic review shows that participants in mammography screening programmes place a low value on the psychosocial and physical effects of false positive results and overdiagnosis (JRC Technical Report PICO 10-11, contract FWC443094012015). Women generally consider these undesirable effects acceptable (low confidence). However, these findings are of limited value, mainly given the significant concerns regarding the adequacy of the information provided to women, in order to make an informed decision about participation. Also, acceptability of false positive results is based on studies of participants who have already received a false positive result. Their preferences may differ from the general population. Another finding is that breast cancer screening represents a significant burden for some women due to the associated psychological distress and inconvenience.

Regarding breast cancer diagnosis, there is very limited data available on people's views. One of the main themes identified in the literature is that people disvalue highly the anxiety caused by delays in the receipt of results of diagnostic procedures, or by a lack of understanding of the tests due to suboptimal communication with physicians (moderate confidence). Also, people have a higher overall preference towards more comfortable, brief diagnostic procedures (moderate confidence).
Additional Considerations

From the studies reviewed there was not much confidence in the findings and there is, therefore, uncertainty in how much people value the main outcomes. The GDG agreed that the increase in breast cancer detection rate (although there is uncertainty about how this affects breast cancer mortality), as well as the variation in recall rate, and the increase in radiation exposure are likely to be valued very differently by women.

The preference for shorter examination times is of limited relevance, given that acquisition time for tomosynthesis is very similar to that for 2D mammography.

Does the balance between desirable and undesirable effects favor the intervention or the comparison?
Probably favors the intervention *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , Don't know )
Additional Considerations

Given the lack of research and the uncertainty of the effects of DBT screening on mortality, the GDG could not reach consensus on whether the balance favours the intervention or comparison so voting was conducted: 10 members voted that the balance probably favours the intervention; six members voted don't know; two members abstained.

How large are the resource requirements (costs)?
Moderate costs *
* Possible answers: ( Large costs , Moderate costs , Negligible costs and savings , Moderate savings , Large savings , Varies , Don't know )
Research Evidence
No relevant economic evaluations were identified.
Additional Considerations

The GDG agreed that the resources required for moving from digital mammography to tomosynthesis may be moderate. These resources may include, amongst other factors: costs of the technology, capital costs of the machines and the lifetime of the machine, capacity for data storage, and additional time for radiologists to read tomosynthesis images.

One observational study (Wallis 2012) included in the systematic review of Gilbert et al. (Gilbert 2016) reported that radiologists’ reading time would have an increase of approximately 100% (two times higher than DM alone) for tomosynthesis compared with digital mammography.

Staff cost may vary depending on the country context and these costs are not transferable from one country to another. Although the studies reviewed above suggested an increase in recall rate with DBT, a number of excluded studies found the opposite (Gilbert 2016).

Despite the savings that may occur with DBT due to a potential reduced recall rate, the extra costs mentioned above (equipment, additional radiologists time, etc) would probably not be outweighed.

What is the certainty of the evidence of resource requirements (costs)?
No included studies *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Research Evidence
No relevant economic evaluations were identified.
Does the cost-effectiveness of the intervention favor the intervention or the comparison?
No included studies *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , No included studies )
Research Evidence
No relevant economic evaluations were identified.
What would be the impact on health equity?
Varies *
* Possible answers: ( Reduced , Probably reduced , Probably no impact , Probably increased , Increased , Varies , Don't know )
Additional Considerations

The GDG felt that within programmes there may be policy decisions to restrict the programme, if there are increased costs and the programme is unable to fund universal participation. This could have influences on equity in either direction.

Is the intervention acceptable to key stakeholders?
Varies *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No specific studies focusing on tomosynthesis (including synthesised 2D images) were identified. The findings, all from mammography studies, however, are likely to be generalisable to tomosynthesis (including synthesised 2D images) in addition to digital mammography, as both screening tests are associated with similar desirable and undesirable effects.

However, a systematic review (JRC Technical Report PICO 16-17, contract FWC443094032016; available upon request) found the following barriers associated with breast cancer screening with mammography: (
a) lack of knowledge and misperceptions regarding preventive medicine and breast health (high confidence in evidence), (b) poor communication skills of healthcare providers (high confidence in evidence), (c) poor accessibility to breast screening, especially among women with disabilities (high confidence in evidence), (d) fear and stress related to the procedure and the possibility of cancer diagnosis (high confidence in evidence), (e) pain and discomfort during the procedure (moderate confidence in evidence), (f) embarrassment and shyness during the procedure (moderate confidence in evidence), (g) lack of support and encouragement from family members, caregivers and social network (moderate confidence in evidence), (h) lack of information regarding the available resources (low confidence in evidence) and (i) low prioritisation of breast cancer screening (low confidence in evidence). Women and relevant stakeholders expressed similar opinions.
Additional Considerations

Participants:
There is likely variability in acceptability for women. If there is a higher radiation dose women may be more concerned. On the other hand, women who come for screening may be concerned that they are not getting the screening technology with the highest detection rate. Women may appreciate the increased confidence in the screening result if there is higher detection of cancers with DBT compared to DM. Participation rates in the trials reviewed are high, which may indicate their general acceptability of DBT.

Radiologists:
DBT may be preferred by radiologists reading screening tests because their certainty in the diagnosis may be higher when using DBT than when using DM.

Policymakers:
In settings with universal healthcare coverage, for directors of hospitals and screening programmes, it may not be an acceptable intervention, despite the increased detection capability, because there will likely be increased costs.

Is the intervention feasible to implement?
Varies *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Additional Considerations

The GDG felt that in contexts where there are the resources to support this and where there is access to new technologies that are capable of DBT, it is feasible. For other countries without the technology and resources to support this it may not be feasible. In addition, although DBT requires some extra training for radiologists, this was not seen by GDG as a major barrier to implementation. The need to establish standards for synthesised 2D imaging for implementation was mentioned by the GDG.

Bibliography

Evidence of effects and background
  • Bernardi D, Macaskill P, Pellegrini M, Valentini M, Fantò C, Ostillio L, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-  2): a population-based prospective study. Lancet Oncol. 2016 Aug;17(8):1105-13.
  • Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on day/month/year.
  • Gilbert FJ, Tucker L, Young KC.Digital breast tomosynthesis (DBT): a review of the evidence for use as a screening tool.Clin Radiol. 2016 Feb;71(2):141-50.
  •  
  • Gur D, Abrams GS, Chough DM, Ganott MA, Hakim CM, Perrin RL, et al. Digital breast tomosynthesis: observer performance study. AJR American Journal of Roentgenology. 2009;193(2):586-91.
  • Hofvind S, Ponti A, Patnick J, Ascunce N, Njor S, Broeders M, et al. False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes. J Med Screen. 2012;19 Suppl 1:57-66.
  • Lang K, Andersson I, Rosso A, Tingberg A, Timberg P, Zackrisson S. Performance of one-view breast tomosynthesis as a stand-alone breast cancer screening modality: results from the Malmo Breast Tomosynthesis Screening Trial, a population-based study. Eur Radiol. 2015.
  • Lång K, Nergården M, Andersson I, Rosso A, Zackrisson S. False positives in breast cancer screening with one-view breast tomosynthesis: An analysis of findings leading to recall, work-up and biopsy rates in the Malmö Breast Tomosynthesis Screening Trial.Eur Radiol. 2016 Mar 4.
  • Paulis LE, Lobbes MB, Lalji UC, Gelissen N, Bouwman RW, Wildberger JE, Jeukens CR.Radiation exposure of digital breast tomosynthesis using an antiscatter grid compared with full-field digital mammography. Invest Radiol. 2015 Oct;50(10):679-85.
  • Rafferty EA, Park JM, Philpotts LE, Poplack SP, Sumkin JH, Halpern EF, et al. Assessing radiologist performance using combined digital mammography and breast tomosynthesis compared with digital mammography alone: Results of a multicenter, multireader trial. Radiology. 2013;266(1):104-13.
  • Roman M, Skaane P, Hofvind S. The cumulative risk of false-positive screening results across screening centres in the Norwegian Breast Cancer Screening Program.Eur J Radiol. 2014 Sep;83(9):1639-44.
  • Skaane (a) P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47-56.
  • Skaane (b) P, Bandos AI, Gullien R, et al. Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration. Eur Radiol 2013;23:2061e71.
  • Skaane P, Bandos AI, Eben EB, et al. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images Radiology 2014;271:655e63.
  • Tsilidis KK, Papadimitriou N, Capothanassi D et al. Burden of Cancer in a Large Consortium of Prospective Cohorts in Europe. J Natl Cancer Inst. 2016 May 6;108(10).
  • Wallis MG, Moa E, Zanca F, Leifland K, Danielsson M. Two-view and single-view tomosynthesis versus full-field digital mammography: high-resolution X-ray imaging observer study. Radiology 2012; 262: 788–96.
Economic evidence
  • Gilbert FJ, Tucker L, Young KC. Digital breast tomosynthesis (DBT): a review of the evidence for use as a screening tool. Clin Radiol. 2016 Feb; 71(2): 141-50.
  • Wallis MG, Moa E, Zanca F, Leifland K, Danielsson M. Two-view and single-view tomosynthesis versus full-field digital mammography: high-resolution X-ray imaging observer study. Radiology 2012; 262: 788–96.