Jacky Luiten

General discussion and future perspectives | 129 9 avoided by screening and the estimated number of cases of overdiagnosis and subsequent overtreatment. The ratio of lives saved versus overtreated cases varies from 1 to 0.4–3. 8,9 A disadvantage of mammography screening, besides potential overdiagnosis and overtreatment, are the false positive recalls. These are women recalled for a suspicious abnormality at screening mammography, but whose workup does not reveal (pre ‐ ) malignant disease. Keeping in mind the false positive recalls and recalled abnormalities without malignant potential, further diagnostic interventions should be as minimal invasive as possible. Therefore, the recent increase in invasive surgical excision biopsies, following SCNB, is an unfavorable development [ this thesis, chapter 3 ]. This increase is probably related to improved imaging techniques, leading to the detection of smaller breast lesions of unknown clinical significance, the so ‐ called ‘high ‐ risk lesions’. 10,11 The optimal management of high ‐ risk lesions remains a matter of ongoing debate. Considerable variation in the upgrading of different type of high ‐ risk lesions to malignancy has been reported, resulting in mixed recommendations of either radiologic surveillance or diagnostic surgical excision of every high ‐ risk lesion. 12 ‐ 18 Falomo et al . reported serious inconsistencies in the management of these lesions at academic institutions across the United States, with surgical excision rates ranging from 39% to 95% between centers. 19 Since surgical excision is still regarded as the gold standard to obtain a definitive histopathologic diagnosis, routine surgical excision of these high ‐ risk lesions may be considered in order to minimize the risk of missing malignant disease. 15 However, as the proportion of high ‐ risk lesions being upgraded to malignancy remained stable in our study over the years, the increased excision rate of these lesions resulted in an increasing number of women with a benign outcome following diagnostic surgical excision [ this thesis, chapter 4 ]. The use of this type of excision for diagnostic purposes should be kept to a minimum as it both lowers the sensitivity of future screening mammography for cancer detection as well as it is an invasive procedure, usually performed under general anesthesia. 20,21 Most DCIS lesions are detected at mammography screening by the presence of microcalcifications. However, not all microcalcifications found at screening are related to underlying DCIS. Digital mammography has a higher sensitivity for the detection of microcalcifications than screen ‐ film mammography, which resulted in a five ‐ fold increased recall rate for suspicious microcalcifications, thereby decreasing the positive predictive value (PPV) of screen ‐ detected microcalcifications by 40% [ this thesis, chapter 5 ]. Given this observed decrease in PPV, one may raise the question whether all recalled microcalcifications require