The supplemental value of mammographic screening over breast MRI alone in BRCA2 mutation carriers

Breast Cancer Screening for Women at Higher-Than-Average Risk: Updated Recommendations From the ACR

Early detection decreases breast cancer death. The ACR recommends annual screening beginning at age 40 for women of average risk and earlier and/or more intensive screening for women at higher-than-average risk. For most women at higher-than-average risk, the supplemental screening method of choice is breast MRI. Women with genetics-based increased risk, those with a calculated lifetime risk of 20% or more, and those exposed to chest radiation at young ages are recommended to undergo MRI surveillance starting at ages 25 to 30 and annual mammography (with a variable starting age between 25 and 40, depending on the type of risk). Mutation carriers can delay mammographic screening until age 40 if annual screening breast MRI is performed as recommended. Women diagnosed with breast cancer before age 50 or with personal histories of breast cancer and dense breasts should undergo annual supplemental breast MRI. Others with personal histories, and those with atypia at biopsy, should strongly consider MRI screening, especially if other risk factors are present. For women with dense breasts who desire supplemental screening, breast MRI is recommended. For those who qualify for but cannot undergo breast MRI, contrast-enhanced mammography or ultrasound could be considered. All women should undergo risk assessment by age 25, especially Black women and women of Ashkenazi Jewish heritage, so that those at higher-than-average risk can be identified and appropriate screening initiated.

Challenges and Changes of the Breast Cancer Screening Paradigm

Since four decades mammography is used for early breast cancer detection in asymptomatic women and still remains the gold standard imaging modality. However, population screening programs can be personalized and women can be divided into different groups based on risk factors and personal preferences. The availability of new and evolving imaging modalities, for example, digital breast tomosynthesis, dynamic-contrast-enhanced magnetic resonance imaging (MRI), abbreviated MRI protocols, diffusion-weighted MRI, and contrast-enhanced mammography leads to new challenges and perspectives regarding the feasibility and potential harms of breast cancer screening. The aim of this review is to discuss the current guidelines for different risk groups, to analyze the recent published studies about the diagnostic performance of the imaging modalities and to discuss new developments and future perspectives. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 6.

The yield and effectiveness of breast cancer surveillance in women with PTEN Hamartoma Tumor Syndrome

BACKGROUND

Women with PTEN Hamartoma Tumor Syndrome (PHTS) are offered breast cancer (BC) surveillance because of an increased BC lifetime risk. Surveillance guidelines are, however, expert opinion-based because of a lack of data. We aimed to assess the yield and effectiveness of BC surveillance and the prevalence and type of breast disease in women with PHTS.

METHODS

Sixty-five women with PHTS who visited our center between 2001 and 2021 were included. Surveillance consisted of annual magnetic resonance imaging (MRI) and mammography from ages 25 and 30 years, respectively.

RESULTS

Thirty-nine women enrolled in the BC surveillance program (median age at first examination, 38 years [range, 24-70]) and underwent 156 surveillance rounds. Surveillance led to detection of BC in 7/39 women (cancer detection rate [CDR], 45/1000 rounds) and benign breast lesions (BBLs) in 11/39 women. Overall sensitivity₂ (which excludes prophylactic-mastectomy detected BCs) was 100%, whereas sensitivity₂ of mammography and MRI alone was 50% and 100%, respectively. Overall specificity was higher in follow-up rounds (86%) versus first rounds (71%). Regardless of surveillance, 21/65 women developed 35 distinct BCs (median age at first diagnosis, 40 years [range, 24-59]) and 23/65 developed 89 BBLs (median age at first diagnosis, 38 years [range, 15-61]). Surveillance-detected BCs were all T1 and N0, whereas outside surveillance-detected BCs were more often ≥T2 (60%) and N+ (45%) (p < .005).

CONCLUSIONS

The findings show that annual BC surveillance with MRI starting at age 25 years enables detection of early-stage BCs. Performance measures of surveillance and CDR were both high. BBLs were commonly present, underlining the importance of evaluation of all lesions independently.

LAY SUMMARY

Breast cancer surveillance leads to decreased tumor stage and improved survival. Breast cancer surveillance with breast magnetic resonance imaging from age 25 years onward is recommended.

Breast Cancer Screening Strategies for Women With ATM, CHEK2, and PALB2 Pathogenic Variants: A Comparative Modeling Analysis

IMPORTANCE

Screening mammography and magnetic resonance imaging (MRI) are recommended for women with ATM, CHEK2, and PALB2 pathogenic variants. However, there are few data to guide screening regimens for these women.

OBJECTIVE

To estimate the benefits and harms of breast cancer screening strategies using mammography and MRI at various start ages for women with ATM, CHEK2, and PALB2 pathogenic variants.

DESIGN, SETTING, AND PARTICIPANTS

This comparative modeling analysis used 2 established breast cancer microsimulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) to evaluate different screening strategies. Age-specific breast cancer risks were estimated using aggregated data from the Cancer Risk Estimates Related to Susceptibility (CARRIERS) Consortium for 32 247 cases and 32 544 controls in 12 population-based studies. Data on screening performance for mammography and MRI were estimated from published literature. The models simulated US women with ATM, CHEK2, or PALB2 pathogenic variants born in 1985.

INTERVENTIONS

Screening strategies with combinations of annual mammography alone and with MRI starting at age 25, 30, 35, or 40 years until age 74 years.

MAIN OUTCOMES AND MEASURES

Estimated lifetime breast cancer mortality reduction, life-years gained, breast cancer deaths averted, total screening examinations, false-positive screenings, and benign biopsies per 1000 women screened. Results are reported as model mean values and ranges.

RESULTS

The mean model-estimated lifetime breast cancer risk was 20.9% (18.1%-23.7%) for women with ATM pathogenic variants, 27.6% (23.4%-31.7%) for women with CHEK2 pathogenic variants, and 39.5% (35.6%-43.3%) for women with PALB2 pathogenic variants. Across pathogenic variants, annual mammography alone from 40 to 74 years was estimated to reduce breast cancer mortality by 36.4% (34.6%-38.2%) to 38.5% (37.8%-39.2%) compared with no screening. Screening with annual MRI starting at 35 years followed by annual mammography and MRI at 40 years was estimated to reduce breast cancer mortality by 54.4% (54.2%-54.7%) to 57.6% (57.2%-58.0%), with 4661 (4635-4688) to 5001 (4979-5023) false-positive screenings and 1280 (1272-1287) to 1368 (1362-1374) benign biopsies per 1000 women. Annual MRI starting at 30 years followed by mammography and MRI at 40 years was estimated to reduce mortality by 55.4% (55.3%-55.4%) to 59.5% (58.5%-60.4%), with 5075 (5057-5093) to 5415 (5393-5437) false-positive screenings and 1439 (1429-1449) to 1528 (1517-1538) benign biopsies per 1000 women. When starting MRI at 30 years, initiating annual mammography starting at 30 vs 40 years did not meaningfully reduce mean mortality rates (0.1% [0.1%-0.2%] to 0.3% [0.2%-0.3%]) but was estimated to add 649 (602-695) to 650 (603-696) false-positive screenings and 58 (41-76) to 59 (41-76) benign biopsies per 1000 women.

CONCLUSIONS AND RELEVANCE

This analysis suggests that annual MRI screening starting at 30 to 35 years followed by annual MRI and mammography at 40 years may reduce breast cancer mortality by more than 50% for women with ATM, CHEK2, and PALB2 pathogenic variants. In the setting of MRI screening, mammography prior to 40 years may offer little additional benefit.

12-year review of MRI-detected breast cancers. How often was a diagnosis of malignancy established using targeted ultrasound and standard 14-gauge core biopsy?

INTRODUCTION

This retrospective study aimed to determine the percentage of MRI-detected breast cancers diagnosed using targeted ultrasound and standard 14-gauge (14g) biopsy in the setting of an Australian breast MRI service. This is of clinical relevance because malignancies not identifiable on mammography or by ultrasound may then require more invasive, technically demanding and costly MRI-guided interventional procedures, usually by large-core vacuum-assisted biopsy (VAB) or hook-wire localisation with open surgical biopsy.

METHODS

On review of the 12-year period 2006-2018, we identified 67 new breast cancer events in 64 women where the diagnosis was made on the basis of the MRI scan findings either alone (n = 60) or in combination with a concurrent mammogram (n = 7), with no recorded clinical abnormality. The percentage in which malignancy was confirmed on histopathology using targeted ultrasound in combination with 14g biopsy was determined versus other biopsy methods, for both invasive cancer and in situ disease.

RESULTS

Ultrasound-guided 14g biopsy was successful in establishing the presence of malignancy in 42/46 (91%) of events with a final diagnosis of invasive cancer, with 2 more proven by MRI-guided interventional procedures (1 VAB and 1 hook-wire) and 1 by open surgical biopsy. In the final case, a 5 mm focus on MRI with no sonographic correlate at the initial presentation was only identified and biopsied by ultrasound at 12-month follow-up. For events with a final diagnosis of DCIS/pLCIS (pleomorphic LCIS, n = 2), US-guided 14g biopsy was successful in 10/21 (48%), while 4/7 events with corresponding mammographic microcalcifications were proven by x-ray stereotactic interventions. A further 5 events had MRI-guided interventions (3 VAB and 2 hook-wires) and 1 an open surgical biopsy to confirm malignancy. In the final case (a woman with a 30 × 20 mm focal area of non-mass enhancement with corresponding microcalcifications consistent with DCIS), a pathologic diagnosis was not made until the patient presented 5 years later with invasive disease. There were also 3 instances of upgrades to invasion on final surgical pathology, one from pLCIS to microinvasion and 2 others from DCIS to IDC. Among the DCIS/pLCIS events, semi-random 14g core biopsy (sampling at the expected location of the MRI abnormality without a specific sonographic correlate) proved to be successful in 3 women.

CONCLUSION

Ultrasound-guided 14g core biopsy established a malignant diagnosis in 91% of invasive cancers and in 48% of DCIS/pLCIS cases. This relatively non-invasive, technically easy to perform and low-cost biopsy procedure can be used immediately when targeted ultrasound shows a correlate for a suspicious MRI scan finding. Careful imaging-pathologic correlation is required after 14g biopsy, and a discordant result will usually prompt recourse to an MRI-guided VAB or hook-wire localisation.

The Usefulness of Spectral Mammography in Surgical Planning of Breast Cancer Treatment-Analysis of 999 Patients with Primary Operable Breast Cancer

Contrast-enhanced spectral mammography (CESM) is a promising, digital breast imaging method for planning surgeries. The study aimed at comparing digital mammography (MG) with CESM as predictive factors in visualizing multifocal-multicentric cancers (MFMCC) before determining the surgery extent. We analyzed 999 patients after breast cancer surgery to compare MG and CESM in terms of detecting MFMCC. Moreover, these procedures were assessed for their conformity with postoperative histopathology (HP), calculating their sensitivity and specificity. The question was which histopathological types of breast cancer were more frequently characterized by multifocality–multicentrality in comparable techniques as regards the general number of HP-identified cancers. The analysis involved the frequency of post-CESM changes in the extent of planned surgeries. In the present study, MG revealed 48 (4.80%) while CESM 170 (17.02%) MFMCC lesions, subsequently confirmed in HP. MG had MFMCC detecting sensitivity of 38.51%, specificity 99.01%, PPV (positive predictive value) 85.71%, and NPV (negative predictive value) 84.52%. The respective values for CESM were 87.63%, 94.90%, 80.57% and 96.95%. Moreover, no statistically significant differences were found between lobular and NST cancers (27.78% vs. 21.24%) regarding MFMCC. A treatment change was required by 20.00% of the patients from breast-conserving to mastectomy, upon visualizing MFMCC in CESM. In conclusion, mammography offers insufficient diagnostic sensitivity for detecting additional cancer foci. The high diagnostic sensitivity of CESM effectively assesses breast cancer multifocality/multicentrality and significantly changes the extent of planned surgeries. The multifocality/multicentrality concerned carcinoma, lobular and invasive carcinoma of no special type (NST) cancers with similar incidence rates, which requires further confirmation.

[High-risk screening using magnetic resonance imaging]

BACKGROUND

Specialized breast cancer early detection programs with magnetic resonance imaging (MRI) in high-risk patients are by now well established in several countries. In Germany, such a program has been running as part of routine care since 2005.

OBJECTIVES

This review article will summarize current developments in high-risk screening with MRI.

MATERIALS AND METHODS

Experiences with the high-risk screening program in Germany over now more than 10 years as well as a review of the current literature will form the basis for this article.

RESULTS

The MRI of the breast is by far the most sensitive imaging modality for the detection of breast cancer and represents the back bone of high-risk screening. More than 90% of cancers detected at high-risk screening are visible on the MRI and more than 30% of cancers are detected primarily by MRI alone. However, a prerequisite for effective screening with MRI is a sufficiently high breast cancer incidence in the screened population. This is demonstrated by the fact that the positive predictive value of screening with MRI in women without a BRCA1/2 mutation in the age group between 30 and 39 years is unacceptably low with 2.9%.

CONCLUSIONS

In high-risk screening, MRI is the primary imaging tool with mammography and/or ultrasound added as adjunct if necessary. In women with a strong family history of breast cancer but no proven pathogenic mutation in one of the known risk genes in the index patient in the family, the high-risk screening should not routinely start at age 30, but should be postponed until the 10-year breast cancer risk passes a threshold of 5%.