Cancer Treatment Today

Lay Summary:
MRI is becoming widely accepted for breast cancer screening. For evaluation of suspected cancer, there must be a mammographic or ultrasound quandary that MRI can elucidate.

Diagnostic:For evaluation of suspected cancer, according to 2008 European guidelines, there must be mammographic of ultrasound findings that MRI can clarify. Most guidelines do not recommend MRI for dense breasts alone but one lukewarmly endorses this idea. BC Guideline says: “MRI can be useful in a small number of patients when there is an equivocal mammographic finding, i.e. a possible architectural distortion, or mass seen only in one view, in whom there is no ultrasound or clinical correlate. Many of these patients have heterogeneously dense breasts.” It is worth it to point out that the young women have dense breasts.

Screening: MRI is becoming widely accepted for breast cancer screening. The responsible use of MRI for the evaluation of the breast is focused primarily on patients with a high probability of breast cancer, and it includes screening in women who are known or likely carriers of a BRCA1 or BRCA2 mutation. Most of the available data are based on annual MRI screening; there is a lack of evidence regarding shorter or longer screening intervals. Further, while good data are available for the first screening exam (ie, the “prevalent screen”), considerably less data are available from subsequent screening exams (ie, “incidence screens”), and the available data include relatively short follow-up times. Most studies of annual MRI have shown few interval cancers, certainly fewer than with mammography. Given the probably shorter duration of the detectable preclinical phase, or sojourn time, in women with BRCA mutations, MRI has demonstrated superiority to mammography in this group. Therefore, to the best of our knowledge, MRI should be performed annually in appropriate patients.

The American Cancer Society published new recommendations for breast-cancer screening in women at high risk for breast cancer. In the 2003 update to its guideline for breast-cancer screening, the American Cancer Society stated that women at increased risk for breast cancer might benefit from the earlier initiation of screening, shorter screening intervals, or the addition of screening methods such as breast ultrasound or MRI. On the basis of newer evidence, as well as requests from clinicians for greater guidance in the use of breast MRI, the guideline now recommends annual breast-cancer screening by means of MRI for women with approximately 20% or greater lifetime risk of breast cancer, according to risk models that are largely dependent on a strong family history of breast or ovarian cancer. Women who have received radiation treatment to the chest, such as for Hodgkin disease, compose a well-defined group that is at high risk. Although evidence of the efficacy of MRI screening in this group is lacking, it is expected that MRI screening might offer similar benefit as for women with a strong family history, particularly at younger ages and within 30 years of treatment. Because of the high risk of secondary breast cancer in this group, MRI screening is recommended based on expert consensus opinion.
The updated guideline also states that there is insufficient evidence to make a recommendation for or against MRI screening in women with a personal history of breast cancer, carcinoma in situ, or atypical hyperplasia or in women with extremely dense breasts.

MRI is also indicated for evaluation of suspected rupture of silicone, and some experts say, saline implants.

MRI is being used more and more often and for a an increasingly wider variety of reasons. However, there have been concerns about the increasing use of breast MRI and and about maintaining their quality of the examinations.

The reports of 4,271 breast MRIs from eight large scale clinical trials were reviewed recently by CD Lehman. Overall the sensitivity ranged from 71% to 100% in these reports, however the call-back rates were low at 10% and the risk of having a benign biopsy was reported at 5%, a significant improvement over mammography.

It is unclear whether the results reported by Lehman and colleagues could be reproduced in all centers offering MRI today. Of particular concern are facilities that perform breast MRI but lack the ability to perform biopsies. Patients at such facilities who require follow-up evaluation at a center with the capacity to perform a biopsy in effect have to undergo a repeat of the entire imaging procedure. The new American Cancer Society guidelines strongly recommend that breast MRI not be performed in the absence of the capacity to perform biopsies.

Guidelines: ASCO recently issued a new set of screening guidelines published in the CA journal.

The new guideline is published the ACS journal CA: A Cancer Journal for Clinicians. It recommends MRI screening in addition to mammograms for women who meet at least one of the following conditions:

they have a BRCA1 or BRCA2 mutation
they have a first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors
they had radiation to the chest between the ages of 10 and 30
they have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative
The recommendations are based on studies that were published after the ACS last revised its breast cancer early detection guidelines in 2002-2003. At that time, the panel concluded there was not enough evidence to recommend for or against MRI in high-risk women, so the guideline advised these women to make the decision after talking with their doctor. Now there is more solid evidence that MRI is useful for certain women.

Another way to go about determining necessity is to calculate risk using models other than Gail. NCCN 2012 in its breast cancer screening guideline specifically says that it should not be Gail, because it is not sufficiently genetic risk based. It recommends BRCA-Pro or modified Gail, see BSCR-B.

The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%.

There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15% to 20% according to risk assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as:

Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
Having dense breasts (“extremely” or “heterogeneously” dense) as seen on a mammogram.

Guidelines do not recommend the use of MRI to survey patients with benign breast changes.
The American College of Radiology practice guidelines include 12 indications for the performance of breast MRI. ACR and SBI suggest that annual screening
MRI be performed in addition to annual mammography
for women with 20% lifetime risk for the development
of breast cancer.
In addition to having the BRCA1 or BRCA2 mutation, a family history that may suggest a genetic predisposition to breast cancer includes having
2 first-degree relatives with breast cancer, a first-degree relative with premenopausal breast cancer, a family history of breast and ovarian cancer, a first-degree relative with more than one independent cancer, and having a male relative with breast cancer.

http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs

American College of Radiology Practice Guidelines for the Performance of Magnetic Resonance Imaging of the Breast. Available at: http://www.acr.org. Accessed onSeptember 13, 2010.

Lehman CD (2006). “”Role of MRI in screening women at high risk for breast cancer”". Journal of Magnetic Resonance Imaging 24 (5): 964

Robert A. Smith et al, American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 CA Cancer J Clin 2003; 53:141-169

Bae MS, et al.Breast Cancer Detected with Screening US: Reasons for Nondetection at Mammography. Radiology. 2014 Feb;270(2):369-77. doi: 10.1148/radiol.13130724. Epub 2013 Nov 6.

Schacht DV, et al. Importance of a personal history of breast cancer as a risk factor for the development of subsequent breast cancer: results from screening breast MRI. AJR Am J Roentgenol. 2014 Feb;202(2):289-92

R. A. Smith The Evolving Role of MRI in the Detection and Evaluation of Breast Cancer
N. Engl. J. Med., March 29, 2007; 356(13): 1362 – 1364.

R. M. Mann et al, Breast MRI: guidelines from the European Society of Breast Imaging Eur Radiol. 2008 July; 18(7): 1307–1318

http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Breast/Diagnosis/MRI.htm

Eduard A. van Bodegravenet al,  European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 218, November 2017, Pages 5-11

Revised: 11/19/08