Breast Cancer Treatment Center
March 30, 2007
Update on the American Cancer Society's MRI breast cancer screening recommendations
The American Cancer Society (ACS) has issued new recommendations related to breast cancer screening with Magnetic Resonance Imaging (MRI) in high risk women.
New evidence on breast MRI screening has become available since the ACS last issued guidelines for the early detection of breast cancer in 2003. A guideline panel has reviewed this evidence and developed new recommendations for women at different defined levels of risk.
Who should be screened using MRI?
Women with an approximately 20 to 25 percent or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated with radiation for Hodgkin's disease should be screened using MRI. There are several risk subgroups, including those with a personal history of treated breast cancer for which the available data are insufficient to recommend for or against MRI screening. Please check with your doctor.
Why not screen everyone using MRI?
MRI can be helpful in very high-risk women. It should be stressed that conventional mammography is very effective in the broad spectrum of women at average risk for breast cancer. Please speak with your doctor about your specific case.
At what age should MRI screening begin for women at high risk?
For most women at high risk, screening with mammography and MRI should begin at age 30 and continue for as long as a woman is in good health. The decision regarding when to initiate screening should be based on shared decision making between patients and their health care providers, taking into consideration individual circumstances and preferences.
How can a woman know what is the estimate of her lifetime risk of breast cancer?
Healthcare providers can use a number of programs to calculate a woman's breast cancer risk. The ACS guideline provides information about three risk models. The three risk models utilize different combinations of risk factors, are derived from different data sets, and vary in the age to which they calculate cumulative breast cancer risk. As a result, they may generate different risk estimates for a given patient, so please check with your doctor.
Should all women undergo genetic testing?
Genetic testing is beyond the scope of these guidelines, but is reviewed by the American Society of Clinical Oncology (ASCO) on its People Living with Cancer Web site.
ASCO also has included a policy statement update on genetic testing for cancer susceptibility on its Web site.
It is not necessary to undergo genetic testing in order to be considered at increased risk for breast cancer and a candidate for MRI screening. You are encouraged to talk to your doctor about your specific case.
How many women are estimated to fall into the high risk group recommended to receive MRI in addition to mammography?
Among the 65-70 million women in the U.S. who are in the age groups for which regular mammography is recommended, perhaps 1-2 percent will fall into risk categories where consideration of MRI screening will be appropriate. However, it is important to note that it is unlikely that the entirety of the population at high family risk would be judged to be candidates for annual MRI. For example, MRI screening may not be very useful as women reach the ages of 60 and older. Again, please check with your doctor.
The guidelines recommend MRI in addition to, not instead of, mammography. Why do women who get MRI screening still need to have annual mammograms?
For the majority of women at high-risk, it is critical that MRI screening be provided in addition to, not instead of, mammography. Many cancers will be detected by both MRI and mammography, however, some cancers are detectable only by MRI and some are detectable only by mammography.
Are there concerns regarding cost, availability, and/or access among those for whom MRI screening is recommended?
There are substantial concerns about costs of and limited access to high-quality MRI breast screening services for women with increased breast cancer risk. In addition, it is critical that women who get MRI screening have access to MRI-guided biopsies in case the MRI finds something suspicious, yet MRI-guided biopsies are not widely available. With many communities not providing MRI screening and with MRI-guided biopsies not widely available, it is recognized that these recommendations may generate concerns in high-risk women who may have limited access to this technology. Please talk with your doctor.
What are the potential harms or risks of MRI screening?
As with mammography and other screening tests, false negative and false positive results do occur. False negatives can lead to missed cancers, with potentially worse prognosis; false positives may lead to increased anxiety and potential harms associated with unnecessary interventions for benign lesions.
The specificity of MRI is significantly lower than that of mammography in all studies to date, resulting in more recalls and biopsies. Most call-backs, however, can be resolved without biopsy. The call-back and biopsy rates of MRI are higher than for mammography in high-risk populations; while the increased sensitivity of MRI leads to a higher call-back rate it also leads to a higher number of cancers detected.
Will insurance cover the cost of MRI screening?
There is no simple answer to this question, but it is likely that most of the major plans will cover MRI screening if a woman's physician can demonstrate that it is appropriate based on her risk profile. It is likely that these updated guidelines will contribute to greater access to MRI for women at a very high risk of breast cancer.
Will the National Breast and Cervical Cancer Early Detection Project (NBCCEDP) cover these exams for high risk women?
While the program has not decided on that issue, it is unlikely MRI will be covered by the program in the near future. Since the program is designed to focus primarily on uninsured women with an average risk of breast cancer, particularly those ages 50 to 64, it's unlikely that there will be an increased demand for these services right away. At current funding levels, and if the program were to focus on the needs of high risk women, considerably fewer women of average risk could be screened and receive the benefits of early detection.
Sources:
American Cancer Society
Robyn Birdwell, MD, Section Head, Division of Breast Imaging, Brigham and Women's Hospital
Eric Winer, MD, Director, Breast Oncology Center, Dana-Farber Cancer Institute
