What is the recommended protocol for breast MRI screening in high-risk patients?

Recommended Protocol for Breast MRI Screening in High-Risk Patients

Annual breast MRI with IV contrast is recommended for high-risk women beginning as early as age 25, with annual mammography added at an appropriate age based on specific risk factors. 1

High-Risk Categories Requiring Breast MRI Screening

• Women with genetics-based increased risk (such as BRCA1/2 mutations) should undergo annual breast MRI starting at age 25-30, with annual mammography added at an appropriate age (typically between 25-40 depending on risk type) 1, 2
• Women with a calculated lifetime risk of 20% or more should receive annual breast MRI beginning at age 30, along with annual mammography 1
• Women with a history of chest or mantle radiation therapy at a young age should begin annual MRI at age 25 or 8 years after radiation therapy, whichever is later 1, 2
• Women with personal histories of breast cancer and dense breast tissue should undergo annual supplemental breast MRI 1, 2
• Women diagnosed with breast cancer before age 50 should receive annual MRI surveillance in addition to mammography 1, 2

Technical Protocol Specifications

• Full protocol breast MRI should be performed without and with IV contrast 1
• Abbreviated breast MRI protocols with IV contrast may be considered as an alternative, as studies show similar diagnostic accuracy to conventional full protocol MRI 1
• MRI without IV contrast is not supported by evidence for screening high-risk women 1

Performance Characteristics of Breast MRI in High-Risk Screening

• MRI combined with mammography yields 91-98% sensitivity for breast cancer detection in high-risk women 1
• The incremental cancer detection rate of MRI in high-risk women ranges from 8-29 per 1,000, with higher rates (26 per 1,000) in BRCA mutation carriers 1
• Breast MRI detects small, node-negative invasive cancers at earlier tumor stages compared to mammography 1
• Screening MRI reduces interval cancers in high-risk populations 1, 3

Important Considerations and Limitations

• Breast MRI has higher recall rates than mammography (15.1% versus 6.4%) 1
• Higher frequency of BI-RADS category 3 assessments with MRI compared to mammography (14.8% versus 11.8%) 1
• Greater frequency of image-guided biopsies with MRI than mammography (11.8 versus 2.4%) 1
• The very high negative predictive value of breast MRI (approaching 100%) makes it uniquely capable of ruling out cancer in appropriate circumstances 4

Alternative Screening Options

• For high-risk women who cannot undergo MRI, ultrasound should be considered as an alternative supplemental screening method 1
• Women should be counseled that ultrasound has inferior cancer detection rates compared to MRI 1, 5
• Contrast-enhanced mammography may be considered as an alternative to MRI in high-risk women 2, 5
• Adding ultrasound to the combination of mammography and MRI does not identify additional cancers and is therefore not routinely recommended 1, 6

Risk Assessment Recommendations

• All women should undergo breast cancer risk assessment by age 25-30, especially Black women and those of Ashkenazi Jewish heritage 1, 6
• Early risk assessment allows identification of high-risk women who can benefit from enhanced screening protocols 2, 6