Clinical Significance of Combined Density and Deep-Learning-Based Texture Analysis for Stratifying the Risk of Short-Term and Long-Term Breast Cancer in Screening

Assessing a woman's risk of breast cancer is important for personalized screening. Mammographic density is a strong risk factor for breast cancer, but parenchymal texture patterns offer additional information which cannot be captured by density. We aimed to combine BI-RADS density score 4th Edition and a deep-learning-based texture score to stratify women in screening and compare rates among the combinations. This retrospective study cohort study included 216,564 women from a Danish populations-based screening program. Baseline mammograms were evaluated using BI-RADS density scores (1-4) and a deep-learning texture risk model, with scores categorized into four quartiles (1-4). The incidence rate ratio (IRR) for screen-detected, interval, and long-term cancer were adjusted for age, year of screening and screening clinic. Compared with subgroup B1-T1, the highest IRR for screen-detected cancer were within the T4 category (3.44 (95% CI: 2.43-4.82)-4.57 (95% CI: 3.66-5.76)). IRR for interval cancer was highest in the BI-RADS 4 category (95% CI: 5.36 (1.77-13.45)-16.94 (95% CI: 9.93-30.15)). IRR for long-term cancer increased both with increasing BI-RADS and increasing texture reaching 5.15 (4.31-6.16) for the combination of B4-T4 compared with B1-T1. Deep-learning-based texture analysis combined with BI-RADS density categories can reveal subgroups with increased rates beyond what density alone can ascertain, suggesting the potential of combining texture and density to improve risk stratification in breast cancer screening.