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Breast Cancer Screening in High-Risk Women: Does MRI Add Value?

Yes, according to findings from this study of almost 2000 high-risk women.

These Dutch investigators compared the efficacy of magnetic resonance imaging with that of mammography for screening in 1909 women (mean age, 40) at high risk for breast cancer (lifetime risk, 15%); 358 of these women had BRCA or other mutations (lifetime risk, 50%-85%). From November 1999 to October 2003, participants underwent annual mammography and dynamic breast MRI with gadolinium-contrast; clinical breast exams were performed every 6 months. Most mammograms and MRIs were performed on the same day, between menstrual cycle days 5 and 15; radiologists interpreting one imaging study were blinded to the results of the other.

During a median follow-up of 2.9 years, 51 malignant breast tumors (including 44 invasive cancers) were identified. Of 45 evaluable cancers, MRI detected 32 (22 not visible on mammography) and missed 13 (8 visible on mammography). Mammography detected 18 cancers and missed 27. The following test characteristics refer to cases with BI-RADS scores of 0 (additional testing needed), 3 (probably benign), 4 (suspicious abnormality), or 5 (highly suggestive of malignancy): Sensitivities of clinical breast examination, mammography, and MRI were 17.8%, 40.0%, and 71.1%, respectively; specificities were 98.1%, 95.0%, and 89.8%; and positive predictive values were 9.6%, 8.0%, and 7.1%.

Comment: MRI is a useful breast-imaging modality in younger women with dense breast tissue; however, drawbacks include high costs and concerns about specificity. In this study of high-risk women, MRI was indeed more sensitive than mammography, but it was also less specific and had a lower positive predictive value -- leading to twice as many unnecessary additional examinations and three times as many unnecessary biopsies.

An editorialist notes that no data support MRI screening of normal-risk women and that, ideally, breast MRI should be performed at facilities that can perform biopsies of lesions detected by MRI alone. Nonetheless, this study indicates that adding MRI to clinical breast examination and mammography leads to earlier detection of breast cancer in high-risk women.

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health September 9, 2004

Citation(s):

Kriege M et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med 2004 Jul 29; 351:427-37.

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• Medline abstract (Free)

Liberman L. Breast cancer screening with MRI -- What are the data for patients at high risk? N Engl J Med 2004 Jul 29; 351:497-500.

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• Medline abstract (Free)