What are the Magnetic Resonance Imaging (MRI) guidelines for breast cancer screening?

From the Guidelines

MRI is recommended as a supplemental screening tool for women at high risk for breast cancer, not as a replacement for mammography, and should be performed annually in addition to mammography for women with a lifetime risk of breast cancer greater than 20-25%. This includes women with BRCA1 or BRCA2 gene mutations, first-degree relatives with these mutations, history of chest radiation between ages 10-30, or certain genetic syndromes like Li-Fraumeni 1. Women with a personal history of breast cancer, dense breast tissue, or those with atypia on previous biopsies may also benefit from MRI screening, although the evidence is less strong for these groups 1. The screening should be performed with contrast (gadolinium) and interpreted by radiologists experienced in breast MRI.

Key considerations for MRI screening include:

• Women with a known BRCA mutation, women who are untested but have a first-degree relative with a BRCA mutation, or women with an approximately 20% to 25% or greater lifetime risk of breast cancer based on specialized breast cancer risk-estimation models 1
• Women with a personal history of breast cancer (including ductal carcinoma in situ) 1
• Women with a history of biopsy-confirmed, high-risk benign conditions (atypical ductal hyperplasia, lobular breast neoplasia, atypical columnar cell hyperplasia, papillary lesions of the breast, or radial scar) 1
• Women with significant mammographic breast density 1
• The timing of MRI should ideally be scheduled during days 7-14 of the menstrual cycle in premenopausal women to minimize background enhancement that can interfere with interpretation 1

It is essential to note that MRI offers higher sensitivity than mammography, particularly in dense breast tissue, and can detect cancers not visible on mammography. However, it has lower specificity, leading to more false positives and unnecessary biopsies 1. Therefore, careful patient selection and consideration of the potential benefits and harms of MRI screening are crucial.

From the Research

MRI Guidelines for Breast Cancer Screening

• The American College of Radiology recommends supplemental annual screening with contrast-enhanced MRI or contrast-enhanced mammography for women with a family history of breast cancer who are high risk (≥20% lifetime risk) or have dense breasts 2.
• For women with BRCA mutations, a highly sensitive breast screening regimen that includes MRI and mammography is recommended, starting by age 25 or 30 3.
• Meta-analysis of multiple observational studies has demonstrated a combined sensitivity of 94% for MRI plus mammography compared to 39% for mammography alone in BRCA mutation carriers 3.
• The addition of MRI to mammography has been shown to improve the detection of breast cancers in high-risk women, including those with BRCA mutations 4, 5.
• The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend biennial screening mammography for average-risk women 50 to 74 years of age, but individualized decision-making is recommended for average-risk women 40 to 49 years of age 6.
• Supplemental screening with MRI may be beneficial for women at high risk of breast cancer, including those with a family history or genetic mutations 4, 5, 3.

Key Findings

• MRI is more sensitive for detecting breast cancers than mammography, ultrasound, or clinical breast examination alone in high-risk women 4, 5.
• The combination of MRI and mammography has been shown to have a higher sensitivity than mammography alone in detecting breast cancers in BRCA mutation carriers 3.
• The specificity of MRI plus mammography is lower than mammography alone, but improves significantly after the first round of screening 3.

Screening Recommendations

• Women with a family history of breast cancer and a lifetime risk of ≥20% should consider supplemental annual screening with contrast-enhanced MRI or contrast-enhanced mammography 2.
• Women with BRCA mutations should start a highly sensitive breast screening regimen that includes MRI and mammography by age 25 or 30 3.
• Average-risk women 50 to 74 years of age should undergo biennial screening mammography, while individualized decision-making is recommended for average-risk women 40 to 49 years of age 6.