STREAM Trial Design: Evaluating DBT Breast Cancer Screening in the Netherlands

Overview

The STREAM trial is a prospective, population-based study assessing the effectiveness and cost-effectiveness of digital breast tomosynthesis (DBT) screening compared to digital mammography (DM) in Dutch women aged 50 to 75. It aims to evaluate short-, medium-, and long-term outcomes including detection rates, recall rates, interval cancer rates, and stakeholder acceptability.

Background

The Dutch breast cancer screening programme currently offers biennial digital mammography (DM) with double reading by radiologists, achieving high detection and low recall rates. Digital breast tomosynthesis (DBT) is a newer imaging technique that may improve cancer detection but its impact on interval cancer rates and recall rates in the Dutch setting remains unclear. Given workforce constraints and economic considerations, optimizing DBT reading strategies is essential for feasibility. The STREAM trial was designed to address these knowledge gaps by comparing DBT with DM screening in a real-world population.

Data Highlights

Key Findings

• The Dutch screening programme achieves high detection (6.9–7.9/1000) and low recall (2.4%) rates with biennial DM.
• DBT has shown improved cancer detection rates in European trials but unclear effects on interval cancer rates.
• STREAM is a large, prospective, non-randomised trial comparing two rounds of DBT screening to DM in a representative Dutch population.
• DBT images are double-read with arbitration for discrepancies, mirroring current DM reading protocols.
• Strategies to reduce DBT reading time include using fewer views, thicker image slices, and AI assistance.
• STREAM will assess short-term (participation, recall, detection, PPV), medium-term (advanced cancers, interval cancers, incident recall), and long-term (mortality, overdiagnosis, cost-effectiveness) outcomes.

Clinical Implications

The STREAM trial will provide critical evidence on whether DBT screening can improve cancer detection without increasing recall rates in a population with already high DM performance. Optimized DBT reading strategies may address workforce and cost challenges, potentially enabling broader implementation. Clinicians should anticipate updated screening protocols and guidelines based on STREAM outcomes.

Conclusion

The STREAM trial is a pivotal study designed to evaluate the clinical effectiveness, acceptability, and cost-effectiveness of DBT breast cancer screening in the Netherlands. Its results will inform future screening policy and practice.

References

1. Dutch Cancer Screening Programme Reports 2019-2022
2. Houssami et al. 2021 -- DBT Screening Outcomes and Interval Cancer Rates
3. European DBT Screening Trials Meta-Analysis 2020
4. STREAM Trial Protocol 2023 -- Design and Justification