Breast MRI (Magnetic Resonance Imaging): the most sensitive breast-cancer screening tool available

Breast MRI (Magnetic Resonance Imaging): the most sensitive breast-cancer screening tool available.

MRI is the most sensitive breast-cancer screening tool available. Breast MR imaging is known to detect more cancers than conventional tests, such as mammography and ultrasound. An MRI uses a magnetic field and radio frequencies to produce a detailed picture of the internal structure of the breast. This procedure may be indicated for patients meeting the following criteria:

  • Women who have a family history of breast cancer in close relatives
  • Further evaluation of an abnormality on a mammogram
  • Women at elevated risk (≥ 20% lifetime using the Claus model) for breast cancer should be offered annual screening breast magnetic resonance imaging in addition to mammography
  • Further evaluation following a breast cancer diagnosis to determine the extent of the cancer
  • Follow-up evaluation after a lumpectomy
  • Evaluation of breast cancer in patients undergoing chemotherapy
  • Evaluation of the status of breast implants

Did you know that 1 in 8 women will be diagnosed with breast cancer in her lifetime? While you can’t prevent cancer, it is important to be proactive about your health.

An estimated 268,600 new cases of breast cancer were diagnosed in 2019 in the US.

41,000 Americans die from breast cancer every year.

The good news is that most women can survive breast cancer if it’s found and treated early.

Identifying  Women Who Meet Criteria for High-Risk Screening MRI

Current American Cancer Society guidelines recommend annual screening MRI beginning by age 25 to 30 in women who have a lifetime risk (LTR) of breast cancer of 20 to 25% or more. Any of the models used to predict the risk of a pathogenic mutation, or the Claus model,  can be used to estimate lifetime risk for purposes of screening MRI guidelines. Annual screening MRI is also recommended in women who are known to carry pathogenic mutations in BRCA1 or BRCA2 (unless the woman has had a bilateral mastectomy), and in women who are first-degree relatives of known mutation carriers but who are themselves untested.

At Advanced Women’s Imaging, we use the Claus Assessment Tools, designed to predict an individual’s lifetime risk of developing breast cancer. Not all tools can be appropriately applied to all patients. Each tool is most effective when the patient’s characteristics and family history are similar to those of the study population on which the tool was based.

With the Claus model, lifetime breast cancer risk estimates are based on family history. The Claus model considers the number and ages of onset of breast cancer in first- and second-degree relatives. It also distinguishes between maternal and paternal relatives.

What it tells you: The patient’s 5 years and lifetime risk to develop breast cancer. Remaining risk based on age is also calculated and displayed at 5-year increments using interpolation.

What it takes into account: Family history of breast cancer and ages of cancer diagnoses. The original model developed in 1991 only took into account family history of breast cancer; later versions took into account ovarian cancer data. An expanded Claus model developed in 2004 also take into account bilateral breast cancer and risks for three or more affected relatives.

Why is it Important to have a Breast MRI?


About half of women over 40 have dense breasts; about 10% have very dense ones. That raises their risk of cancer and makes it harder to spot on mammograms. Researchers studied different scanning methods on 40,000 Dutch women aged 50 to 75 with very dense breasts. MRI scans spotted more cancers than any other type of screening.

Dense breasts are associated with 2 important risks: the risk that cancer will be masked on the mammogram and the increased risk of getting breast cancer. Mammograms miss over 50% of cancers in women with the densest breasts, so offering them the only mammography for breast cancer screening is discriminatory. Women with dense breasts deserve the same opportunity for early detection of breast cancer, as women with non-dense breasts. Women at elevated risk (≥ 20% lifetime) for breast cancer should be offered annual screening breast magnetic resonance imaging in addition to mammography.

Large scale supplemental screening with ultrasound in Connecticut (the first state to mandate density notification) shows 3-4 cancers per thousand women screened, and these ultrasound-detected cancers are almost all small, invasive and node-negative. NOT DCIS, which arguably may be “overdiagnosed.”

If those cancers go undetected, they grow until they are detected by palpation, as “interval cancers,” which are larger at diagnosis and more often node-positive than screen-detected cancers. They tend to be higher nuclear grade, and more aggressive with a greater predominance of HER2 and triple-negative molecular subtypes. They have a poorer prognosis compared to screen-detected cancers.

Research from Italy showed that the highest Breast Density category, compared with the other three together, had double the invasive BC risk, 5X the risk of interval cancer, and almost fourfold risk of advanced cancer.

Some studies also report that Bi-annual MRI is better than annual mammography in high-risk women. Undergoing magnetic resonance imaging (MRI) scans twice a year is more effective for early detection of breast cancer in young women with high genetic risk of the disease as compared to getting one annual mammogram, report the researchers. Results of the study were presented at the annual San Antonio Breast Cancer Symposium. For the study, the research team performed dynamic contrast-enhanced magnetic resonance imaging (MRI) every 6 months in conjunction with annual mammography (MG). Eligible participants had a cumulative lifetime breast cancer risk ≥ 20% and/or tested positive for a pathogenic mutation in a known breast cancer susceptibility gene. 295 women, including 157 mutation carriers (75 BRCA1, 61 BRCA2) were prospectively enrolled between 2004-2016. The mean age of the participants at entry was 43.3 years.

  • The sensitivity of bi-annual MRI alone was 88.2% and annual MG plus bi-annual MRI was 94.1%.
  • The cancer detection rate of bi-annual MRI alone was 0.7% per 100 screening episodes, which is similar to the cancer detection rate of 0.7% per 100 screening episodes for annual MG plus bi-annual MRI.

The results suggest that for women with high-risk genetic mutations, intensive efforts to find small early cancers can be crucial to improving outcomes.

“This study demonstrates for the first time that aggressive breast cancers can be caught early, without excessive recalls or biopsies,” said Olufunmilayo Olopade, MD, the Walter L. Palmer Distinguished Service Professor and Associate Dean for Global Health at the University of Chicago Medical Center.

In this study, DCE-MRI every 6 months “performed well for early detection of invasive breast cancer in genomically stratified high-risk women,” said Gregory Karczmar, professor of radiology at the University of Chicago. “This is the ultimate goal of breast cancer screening,” he added, “detecting node-negative, invasive tumors less than 1 centimeter.”

“For these patients, annual mammography did not provide any additional benefit to bi-annual dynamic contrast-enhanced MRI scans,” the authors write. Mammograms are routinely used to screen for breast cancer, but they are “not the best option for about 40 percent of women,” Karczmar said. “This includes those with dense breasts as well as those with significant genetic risks.”

“MRI is much more sensitive than mammography,” he added. “It can find invasive breast cancers sooner than mammograms and it can rule out abnormalities that appear suspicious on a mammogram.

The American Cancer Society (ACS) currently recommends an annual DCE-MRI( dynamic contrast-enhanced MRI scans,
as well as an annual mammogram for women who are at high risk, typically starting at age 30. “Bi-annual MRI performed well for early detection of invasive breast cancer in genomically stratified high-risk women. No benefit was associated with annual MG screening plus bi-annual MRI screening,” concluded the authors.

Multiparametric breast MR imaging protocol is a fast diagnostic test, allowing the examination results in high sensitivity and negative predictive values. Thus, breast MR imaging as a problem-solving tool improves patient care by avoiding the anxiety related to follow-up examinations and possibly missed cancer diagnoses. Breast MR imaging yields excellent diagnostic results if used as a problem-solving tool independent of referral reasons. The number of suspicious incidental lesions detected by MR imaging is low but has a substantial malignancy rate. In one study population which included the largest number to date, patients undergoing 3 Tesla breast MR imaging for problem-solving. Breast MR imaging had a high negative predictive value of 99.2% and a high PPV of 72.6%. In other words, only three of 10 biopsies recommended based on positive breast MR imaging (BI-RADS 4 and 5) findings were false-positive, and thus, unnecessary, while in eight of 10 patients with a negative MRI result (BI-RADS 1–3), biopsies or further follow-up examinations could be avoided. This came at the cost of two false-negative findings—both of which, however, were detected by short-term follow-up examinations that were initiated due to breast MR imaging BI-RADS 3 lesions, and one of which was detected exclusively by MR imaging. Therefore, all cancers were visualized as enhancing lesions by breast MR imaging. These findings validate that MR imaging is a safe diagnostic instrument if applied as a problem-solving tool in inconclusive cases, as malignancy can be reliably excluded. Furthermore, the number of incidental MR imaging findings that required follow-up or invasive diagnostic procedures were as low as 5.3% but yielded a substantial malignancy rate of 37.5%.

In conclusion, breast MR imaging yields excellent diagnostic results if used as a problem-solving tool independent of referral reasons. The number of suspicious incidental lesions detected by MR imaging is low but has a substantial malignancy rate.

There are several breast cancer risk assessment tools that doctors use to calculate a woman’s risk of breast cancer. One of the most well-known is the Claus Model.

The Claus model includes the number of first- and second-degree relatives with breast cancer and the age of cancer onset. The Claus model was developed from the cancer and steroid hormone (CASH) population-based, case-control study involving 4,730 patients with histologically documented breast cancer and 4,688 matched controls. This model is based on the premise that breast cancer risk is transmitted as an autosomal-dominant trait and bases the statistical calculation on the genetic relationships between the affected relatives and the woman in question.

In terms of outcomes, the lifetime risk of breast cancer estimated by the Tyrer-Cuzick and Claus models includes the risk of both invasive breast cancer and ductal carcinoma in situ (DCIS).

Know Your Risk

Did you know that 1 in 8 women will be diagnosed with breast cancer in her lifetime? While you can’t prevent cancer, it is important to be proactive about your health.

The BREAST CANCER RISK ASSESSMENT helps you protect your overall health and assess your breast cancer risk and Lifetime Risk (LTR) of developing breast cancer

There are several breast cancer risk assessment tools that doctors use to calculate a woman’s risk of breast cancer. One of the most well-known is the Claus Model, which assesses breast cancer risk-based

At Advanced Women’s Imaging, we use the Claus Assessment Tools, designed to predict an individual’s lifetime risk of developing breast cancer. Not all tools can be appropriately applied to all patients. Each tool is most effective when the patient’s characteristics and family history are similar to those of the study population on which the tool was based.

With the Claus model, lifetime breast cancer risk estimates are based on family history. The Claus model considers the number and ages of onset of breast cancer in first- and second-degree relatives. It also distinguishes between maternal and paternal relatives.

What it tells you: The patient’s 5 years and lifetime risk to develop breast cancer. Remaining risk based on age is also calculated and displayed at 5-year increments using interpolation.

What it takes into account: Family history of breast cancer and ages of cancer diagnoses. The original model developed in 1991 only took into account family history of breast cancer; later versions took into account ovarian cancer data. An expanded Claus model developed in 2004 also take into account bilateral breast cancer and risks for three or more affected relatives.

If the lifetime risk is greater than 20 percent using the Claus model, the patient qualifies for high-risk surveillance, according to the American Cancer Society. Women at elevated risk (≥ 20% lifetime) for breast cancer should be offered annual screening breast magnetic resonance imaging in addition to mammography.

The Breast Cancer Risk Assessment Tool

The Breast Cancer Risk Assessment Tool allows patients to estimate the risk of developing invasive breast cancer over the next 5 years and up to age 90 (lifetime risk).

The tool uses a woman’s personal medical and reproductive history and the history of breast cancer among her first-degree relatives (mother, sisters, daughters) to estimate absolute breast cancer risk—her chance or probability of developing invasive breast cancer in a defined age interval.

Several breast cancer risk assessment tools have been developed that combine known major risk factors. Risk models either predict the risk of a pathogenic mutation in BRCA1 or BRCA2, risk of developing invasive breast cancer, or both. Risk models can be useful in stratifying patients into risk categories to facilitate personalized screening and surveillance plans for clinical management of the patient.

Lifetime Risk (LTR) of developing breast cancer

Occurrence(s) of breast cancer in first-degree and second-degree female relative(s) by decade age of diagnosis

MRI screening (for 20% lifetime risk threshold)

“Mammograms miss over 50% of cancers in women with the densest breasts, so offering them the only mammography for breast cancer screening is discriminatory. Women with dense breasts deserve the same opportunity for early detection of breast cancer, as women with non-dense breasts.” Paula B Gordon, Radiologist, Clinical Professor, University of British Columbia

Having an MRI 

Magnetic resonance imaging involves using a strong magnetic field and does not involve any X-ray radiation. It is often carried out together with the injection of a contrast medium called gadolinium into the vein. MRI scanning will not usually be done if you are pregnant or if you have certain types of metal within your body. You will be asked to fill in a questionnaire first to ensure it is safe for you to have an MRI. The ideal time for MRI of the breast is approximately between day five and 15 of the menstrual cycle in premenopausal women.

For most MRI exams of the breast, You’ll be positioned face-down on a platform that has openings to accommodate your breasts. Unlike a mammogram, no compression is used. You’ll be positioned in the MRI unit and asked to remain still while the images are taken. The imaging session usually lasts between 30 minutes and an hour, with the entire procedure being completed within an hour and a half. Unless your doctor instructs you otherwise, you can follow your normal routine on the day of the MRI. Any metal objects will interfere with the MRI unit, so you’ll be asked to remove all jewelry, watches, removable metal dental work, eyeglasses, and any other metal items.

The good news is that most women can survive breast cancer if it’s found and treated early.

* If you are a woman age 40 to 49, talk with your doctor about when to start getting mammograms and how often to get them.

* If you are a woman age 50 to 74, be sure to get a mammogram every 2 years. You may also choose to get them more often.

Talk to a doctor about your risk for breast cancer, especially if a close family member of yours had breast or ovarian cancer. Your doctor can help you decide when and how often to get mammograms or breast MRI

Estimating your personal risk of breast cancer

If you don’t know your personal risk of breast cancer, it makes sense to talk to your doctor about scheduling time to talk about risk factors and use a tool to estimate your risk.

If you know that you have a higher-than-average risk of breast cancer, you and your doctor will develop a screening plan tailored to your unique situation. General recommended screening guidelines include:

  • a monthly breast self-exam
  • a yearly breast exam by your doctor
  • a digital mammogram every year starting at age 40

Your personal screening plan also may include:

  • breast MRI
  • breast ultrasound

Talk to your doctor about developing a specialized program for early detection that meets your individual needs and gives you peace of mind.

It also makes good sense to do all that you can to keep your risk of breast cancer as low as it can be. Some lifestyle choices you may want to consider are:

  • maintaining a healthy weight
  • exercising every day
  • limiting or avoiding alcohol
  • eating a healthy diet that’s low in processed foods, sugar, and trans fats
  • not smoking

To learn more about breast cancer risk and other options to keep your risk as low as it can be.

Take your BREAST CANCER RISK ASSESSMENT at:

https://advancedimagingnj.com/women/breast-cancer-risk-assessment/

The information in this document does not replace a medical consultation. It is for personal guidance use only. We recommend that patients ask their doctors about what tests or types of treatments are needed for their condition.

References:

Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer 1994; 73:643-651

http://www.ncbi.nlm.nih.gov/pubmed/19569248 and http://www.ncbi.nlm.nih.gov/pubmed/16288118

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