Elsevier

Academic Radiology

Volume 15, Issue 12, December 2008, Pages 1590-1595
Academic Radiology

Review article
MRI and Mammography Surveillance of Women at Increased Risk for Breast Cancer: Recommendations Using an Evidence-based Approach

https://doi.org/10.1016/j.acra.2008.06.006Get rights and content

Rationale and Objectives

To evaluate breast cancer screening with mammography and magnetic resonance imaging (MRI) in high-risk populations, including women with the BRCA mutation, using an evidence-based approach.

Methods

The MEDLINE, PubMed, EBM Reviews, ACP Journal Club, Cochrane Database MEDSEARCH, and SCOPUS databases were accessed and searched for articles up to August 2007. Articles were collected using the following terms and medical subject headings (MeSH) that applied to the focused clinical question: “BRCA1” and “BRCA2” with “mammography,” “MRI,” “prevention,” “screening,” and “surveillance.” References from retrieved articles were also used to identify relevant papers. Abstracts were screened and relevant papers retrieved. Retrieved papers were graded for quality. Summary performance measures were obtained by random effects modeling of study-specific performance estimates and standard errors derived from the multiple 2 × 2 tables. Additionally, studies meeting the Centre for Evidence-Based Medicine level 2b quality were reviewed.

Results

In women with an increased risk without the BRCA gene, cancer detection rates by MRI were 0.011 (95% confidence interval [CI] 0.003–0.019), by mammography 0.005 (95% CI 0.002–0.008), and by a combination of both, 0.012 (95% CI 0.004–0.020). False-positive rates by MRI, mammography, or a combination of both were 0.10 (95% CI 0.03–0.18), 0.05 (95% CI 0.03–0.06), and 0.14 (95% CI 0.04–0.24). In BRCA positive women, cancer detection rates by MRI were 0.027 (95% CI 0.015–0.040), by mammography 0.010 (95% CI 0.005–0.016), and by a combination of both 0.031 (95% CI 0.018–0.045). False-positive rates by MRI, mammography, or a combination of both were 0.10 (95% CI 0.01–0.19), 0.05 (95% CI 0.03–0.07), and 0.14 (95% CI 0.04–0.24), respectively.

Conclusions

The data support an essential role for screening MRI in women with an increased risk for breast cancer.

Section snippets

Materials and methods

The MEDLINE, PubMed, EBM Reviews, ACP Journal Club, Cochrane Database MEDSEARCH, and SCOPUS databases were accessed and searched for articles up to August 2007. Articles were collected using the following terms and medical subject headings (MeSH) that applied to the focused clinical question: “BRCA1” and “BRCA2” with “mammography,” “MRI,” “prevention,” “screening,” and “surveillance.” References from retrieved articles were also used to identify relevant papers.

The abstracts of articles

Results

Study level data of reported performance characteristics of screening by MRI alone (Table 1), mammography alone (Table 2), and a combination of MRI and mammography (Table 3) are summarized. To derive summary performance characteristics, initially, all studies were aggregated. Four of the eight studies identified did not segregate women by BRCA 1/2 mutation status, therefore, summary performance is reported for all patients (Table 4). Aggregating across studies, screening by MRI alone had the

Discussion

Combining the data for the current best evidence from three prospective level 2 diagnostic studies using a standard meta-analysis technique demonstrates that both MRI alone and the combination of MRI and mammography have much greater sensitivities than mammography alone. This is true in women with strong family histories for breast cancer and for women who are BRCA 1/2 positive. When looking at the summary performances for false-positive rates, although mammography alone had the lowest false

Conclusion

Currently, no mortality benefit has been demonstrated from screening women with BRCA mutations, and without long-term follow up it is impossible to assess disease status years later in these higher risk women. However, our analysis of the current best evidence demonstrates that MRI, when available, should play a primary role in the imaging surveillance of women at high risk for breast cancer.

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