From the Guidelines
Individuals with a history of breast cancer are considered high risk and typically require more intensive surveillance, with the American College of Radiology recommending annual breast MRI surveillance for women with a personal history of breast cancer and dense breasts, as well as those diagnosed before 50 years of age 1. The standard recommendation for breast cancer survivors is annual mammography, often starting 6-12 months after the completion of initial treatment. For many breast cancer survivors, especially those with dense breast tissue or who were diagnosed at a young age, alternating mammograms with breast MRIs every year is recommended, rather than every six months, as the evidence does not support the need for more frequent imaging in this population 1. This enhanced surveillance protocol helps detect potential recurrences or new primary breast cancers at earlier, more treatable stages. The risk of developing a second breast cancer is significantly higher in survivors compared to the general population, with estimates suggesting a 3-5% risk over the first five years after diagnosis. This elevated risk persists long-term, which is why lifelong surveillance is important. Some key factors that influence the surveillance plan include:
- Genetic mutations (like BRCA1/2)
- Age at diagnosis
- Breast density
- Characteristics of the original tumor Patients should discuss their personal surveillance plan with their oncologist or breast specialist to ensure it's tailored to their specific risk profile. A large observational study from BCSC data of 812,164 women compared mammographic and MRI performance in women with and without a personal history of breast cancer, and found that MRI was more likely to be performed in patients with a family history of breast cancer and personal history of breast cancer and in women with dense breast tissue 1. Another study found that the use of MRI yielded lower new cancer detection rates in the first 3 years following breast cancer surgery, with greater MRI cancer detection rates beyond 3 years following breast cancer therapy 1. The American College of Radiology recommends annual breast MRI surveillance for any woman with a lifetime risk of breast cancer of 20% or greater 1. In a recent study of BRCA mutation carriers and women of 20% or higher lifetime risk for breast cancer, sensitivity for breast cancer detection was 90.0% using MRI versus 37.5% for mammography and 37.5% for ultrasound 1. MRI has consistently been shown to outperform mammography and ultrasound, even when these latter modalities are used together and in mixed high-risk populations 1. The specific details of the surveillance plan may vary depending on individual factors, but the key takeaway is that annual mammography and breast MRI surveillance are essential for breast cancer survivors, especially those with dense breast tissue or a history of breast cancer at a young age 1.
From the Research
Breast Cancer Screening for High-Risk Individuals
- A history of breast cancer does not automatically qualify someone as high risk after treatment, as the risk assessment depends on various factors, including genetic mutations, family history, and personal medical history 2.
- Current US guidelines recommend more intensive breast cancer screening and preventive strategies for patients at more than 20% lifetime risk for breast and ovarian cancer (high risk for breast and ovarian cancer [HRBOC]) 3.
- For women with a history of breast cancer, especially those diagnosed before age 50 or with dense breasts, annual supplemental breast MRI is recommended 2.
Screening Modalities for High-Risk Individuals
- Yearly mammograms alternating with yearly MRIs are recommended for women at high risk, including those with BRCA1 or BRCA2 mutations, or a calculated lifetime risk of 20% or more 3, 2.
- MRI is more sensitive for detecting breast cancers than mammography, ultrasound, or clinical breast examination alone, especially in BRCA1 and BRCA2 mutation carriers 4, 5.
- The combination of MRI and mammography has a higher sensitivity (94%) compared to mammography alone (39%) for detecting breast cancer in high-risk women 5.
Benefits of MRI Surveillance
- MRI surveillance is effective in downstaging breast cancers and has been associated with a significant reduction in breast cancer mortality in women with BRCA1 sequence variations 6.
- However, further studies are needed to determine the benefits of MRI surveillance for women with BRCA2 sequence variations 6.