Comparative Evaluation of Digital Breast Tomosynthesis and Contrast-Enhanced Mammography in Breast Cancer Screening

Abstract

Background: Breast cancer remains a leading cause of cancer-related mortality and is the most frequent cancer diagnosed in women globally. Early detection by imaging screening is crucial to reducing disease-specific mortality and improve treatment outcomes. The traditional screening modality for many years has been conventional digital mammography (DM); however, its diagnostic accuracy is known to be influenced by lesion morphology, breast density, and technical limitations, which can increase recall rates and reduce sensitivity. To overcome the limitations of conventional imaging modalities, advanced imaging modalities, such as digital breast tomosynthesis (DBT), contrast-enhanced mammography (CEM), and magnetic resonance imaging (MRI), have been developed. Although these advanced imaging modalities have been developed, it is still challenging to select the optimal imaging modality because of the differences in their accuracy, cost, accessibility, radiation exposure, and rates of false positives. As such, a comprehensive review of the current breast imaging modalities is needed. Methods: A systematic literature search was performed on PubMed, Scopus, Google Scholar, and Web of Science to identify literature published between 2010 and 2025. The keywords used included breast cancer screening, digital mammography, DBT, contrast-enhanced mammography, breast MRI, and BI-RADS. Studies evaluating clinical outcomes, sensitivity, specificity, and diagnostic accuracy were included. Result: Digital breast tomosynthesis is found to have improved lesion conspicuity and reduced recall rates when compared to digital mammography. Contrast-enhanced mammography and MRI are more sensitive in high-risk women and those with dense breasts. Various modalities have varying costs, radiation exposure, availability, and false-positive rates. Conclusion: Breast imaging has moved towards a risk-adapted and multimodal approach. Although digital mammography is still the cornerstone, a combination of structural and functional imaging modalities is the best approach for optimal detection, especially in dense breasts and high-risk patients. Tailored imaging strategies, facilitated by the use of BI-RADS and artificial intelligence, are the key to achieving optimal diagnostic outcomes with a minimum of unnecessary procedures.