Jacky Luiten

136 | Chapter 9 play a key role in informing women the PRISMA trial investigates the acceptability of ‘personalized screening’ in women as well as medical specialists. Although implementation of ‘personalized screening’ will be challenging it might be a promising strategy to optimize the harm ‐ benefit ratio of mammographic screening in the future. Women who may benefit from ‘personalized screening’ are those with extremely dense breast tissue. Those women have an increased risk of breast cancer and their cancers are also less likely to be detected on mammography. 77,78 In 2019 the DENSE trial concluded that the use of supplemental MRI screening in women with extremely dense breast tissue and normal results on screening mammography resulted in the diagnosis of significantly fewer interval cancers. 79 However, the downside is an increased false positive rate, which leads to overdiagnosis, therefore MRI is not routinely used in mammography screening yet. 79 Even if the integration of various clinical, radiological, histological, and molecular markers will improve our ability to distinguish between progressive and non ‐ progressive premalignant lesions, women’s acceptability of watchful waiting remains an issue. For many patients it is very difficult to distinguish between premalignant and invasive disease, which may drive patients to invasive treatment from a ‘better be safe than sorry’ point of view. 80 Therefore, breast cancer specialists need a thorough understanding of this delicate issue to explain this in an understandable manner to their patients. A possible improvement might be excluding the word ‘cancer’ or ‘premalignant lesion’, since the terminology used to describe DCIS has significant impact on patients’ perception. 81 In conclusion, tailoring recalls, biopsies and invasive treatments to the likelihood that the lesion will progress and become invasive is a desirable step in preventing overtreatment.