Background and Objectives: The aim of our study was to assess the diagnostic accuracy of four imaging modalities—digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US), and breast magnetic resonance imaging (MRI)—applied individually and in combination in early cancer detection in women with dense breasts. Methods: This single-center retrospective study was conducted from January 2021 to September 2024 at the Oncology Institute of Vojvodina in Serbia and included 168 asymptomatic and symptomatic women with dense breasts. Based on the exclusion criteria, the final number of women who were screened with all four imaging methods was 156. The reference standard for checking the diagnostic accuracy of these methods is the result of a histopathological examination, if a biopsy is performed, or a stable radiological finding in the next 12–24 months. Results: The findings underscore the superior diagnostic performance of breast MRI with the highest sensitivity (95.1%), specificity (78.7%), and overall accuracy (87.2%). In contrast, DM showed the lowest sensitivity (87.7%) and low specificity (49.3%). While the combination of DM + DBT + US demonstrated improved sensitivity to 96.3%, its specificity drastically decreased to 32%, illustrating as ensitivity–specificity trade-off. Notably, the integration of all four modalities increased sensitivity to 97.5% but decreased specificity to 29.3%, suggesting an overdiagnosis risk. DBT significantly improved performance over DM alone, likely due to enhanced tissue differentiation. US proved valuable in dense breast tissue but was associated with a high false-positive rate. Breast MRI, even when used alone, confirmed its status as the gold standard for dense breast imaging. However, its widespread use is constrained by economic and logistical barriers. ROC curve analysis further emphasized MRI’s diagnostic superiority (AUC = 0.958) compared with US (0.863), DBT (0.828), and DM (0.820). Conclusions: This study provides a unique, comprehensive comparison of all four imaging modalities within the same patient cohort, offering a rare model for optimizing diagnostic pathways in women with dense breasts. The findings support the strategic integration of complementary imaging approaches to improve early cancer detection while highlighting the risk of increased false-positive rates. In settings where MRI is not readily accessible, a combined DM + DBT + US protocol may serve as a pragmatic alternative, though its limitations in specificity must be carefully considered.

Background : The aim of this study was to assess the diagnostic accuracy for digital mammography, digital breast tomosynthesis, ultrasonography and breast MRI, as a screening methods in dense breasts, applied individually and in combination in detection of an early cancer. Methods: The retrospective study was conducted from January 2021 to september 2024 at the Oncology Institute of Vojvodina in Serbia, which included 168 women with dense breasts who were referred for an examination because of regular control or objective findings in breasts, and who underwent all 4 diagnostics imaging: digital mammography (DM), digital breast tomosynthesis (DBT), ultrasonography (US) and breast MRI. According to the 5th edition of ACR BIRADS atlas, suspicious malignancy was categorized as BIRADS 4 and 5, and benign findings as BIRADS 1, 2 and 3. The reference standard for checking the diagnostic accuracy of these methods was the result of histopathology, if the biopsy is done, or stable radiological finding in the next 12-24 months. Results: The examined women were aged from 28 to 77 years. Histopathology analysis revealed malignancy in 89 women, while 67 had a benign finding (19 was biopsy verified). DM has the lowest sensitivity (87.7%) and specificity (49.3%) in an early cancer detection. Adding of DBT to DM, sensitivity increased to 88.9%, and specificity to 56%. US has a high sensitivity of 90.1%, but a very low specificity of 48%. Breast MRI has the highest sensitivity 95.1%, and specificity 78.7%. Combination of DM+DBT and US yield increased the sensitivity, but decrease the specificity because of high rate of false positive findings. The highest PPV and NPV had breast MRI, 82.8% and 93.7% respectively, and the lowest digital mammography, 65.1% and 78.7% respectively. Adding of breast MRI to DM+DBT+US didnot significant change results in a sensitivity of 97.5%, but it has decreased specificity to 29.3%. Conclusions: US in combination with DM and DBT, can significantly improve the diagnostic accuracy in screening of dense breasts, similar as breast MRI, in regions where there are no magnetic resonance units. Limiting factors are low specificity and high PPV.