Is magnetic resonance imaging (MRI) indicated for a 35-year-old female with a family history of breast cancer, specifically a mother diagnosed at 53 years old?

From the Guidelines

MRI screening is not routinely indicated for a 35-year-old female with only a mother diagnosed with breast cancer at age 53. The current recommendation would be to start annual mammography at age 40, or potentially 5-10 years before the age of the earliest breast cancer diagnosis in a first-degree relative (in this case, starting between ages 43-48) 1. MRI screening is generally reserved for women with a higher lifetime risk of breast cancer (>20-25%), which typically includes those with genetic mutations like BRCA1/2, a strong family history involving multiple relatives, previous chest radiation therapy before age 30, or certain genetic syndromes. This patient's family history alone (single first-degree relative diagnosed after age 50) does not meet the threshold for MRI screening. However, formal risk assessment using models like Tyrer-Cuzick or BRCAPRO would be appropriate to calculate her lifetime risk more precisely 1. If genetic testing reveals a high-risk mutation or if risk calculation shows >20% lifetime risk, then annual MRI screening would be recommended as a supplement to mammography.

Some key points to consider:

• The American Cancer Society recommends annual breast MRI for breast cancer screening in high-risk women, starting as early as 25 years of age 1.
• The National Comprehensive Cancer Network (NCCN) also recommends annual MRI as an adjunct to screening mammogram and clinical breast examination for women aged 25 years or older with a genetic predisposition to breast cancer 1.
• A study published in the Journal of the American College of Radiology found that MRI has a higher sensitivity for detecting breast cancer than mammography, although the specificity of MRI is lower, resulting in a higher rate of false-positive findings 1.
• The use of MRI, however, may potentially be associated with higher false-positive results and higher costs relative to mammography 1.

In terms of morbidity, mortality, and quality of life, the most important consideration is to identify women at high risk of breast cancer and provide them with appropriate screening and preventive measures. In this case, since the patient's family history alone does not meet the threshold for MRI screening, annual mammography starting at age 40 or 5-10 years before the age of the earliest breast cancer diagnosis in a first-degree relative is recommended. However, if genetic testing reveals a high-risk mutation or if risk calculation shows >20% lifetime risk, then annual MRI screening would be recommended as a supplement to mammography.

From the Research

Breast Cancer Screening for High-Risk Women

• Women with a family history of breast cancer, such as a first-degree relative (mother, sister, or daughter) diagnosed with breast cancer, are considered high-risk and may benefit from earlier and more frequent screening 2.
• The age at which to start screening is often recommended to be 10 years younger than the age at which the relative was diagnosed, but evidence suggests that initiating screening 5-8 years earlier than the relative's diagnosis age may be beneficial for women with a relative diagnosed at or before age 45 2.

Role of MRI in Breast Cancer Screening

• Magnetic Resonance Imaging (MRI) has been shown to be more sensitive than mammography, ultrasound, and clinical breast examination (CBE) in detecting breast cancers in high-risk women, including those with BRCA1 and BRCA2 mutations 3, 4, 5, 6.
• Studies have demonstrated that MRI can detect breast cancers at an earlier stage, with higher sensitivity and specificity compared to other screening modalities 3, 6.
• The combination of MRI and mammography has been shown to have a higher sensitivity than mammography alone, with a combined sensitivity of 94% compared to 39% for mammography alone 5.

Screening Strategies for High-Risk Women

• Annual screening strategies, including MRI and mammography, have been compared in several studies, with alternating digital mammography (DM) and MRI starting at age 25 years showing the highest life expectancy for BRCA1 and BRCA2 mutation carriers 4.
• The addition of MRI to mammography and CBE has been shown to improve the detection of breast cancers in high-risk women, with a significant reduction in interval cancers 3, 6.
• However, the optimal screening strategy for individual women should consider their personal risk factors, screening benefits, and associated risks, as well as their acceptance of false-positive results 4.