In this issue of Academic Radiology , authors Giess et al. evaluate screening breast magnetic resonance imaging (MRI) in women previously treated for breast cancer. The authors retrospectively reviewed the MRI report findings and medical records of 1194 examinations in 691 women previously treated with either breast conservation surgery or mastectomy. Patients with genetic mutations, untested first-degree relatives of known mutation carriers, and history of chest irradiation were excluded from the study. Giess et al.’s primary findings were that screening breast MRI in these patients detected cancer in 1.0% of the examinations, had a 10.7% abnormal interpretation rate, and had a positive predictive value for malignancy of 17.9%. The study is important for many reasons.
Foremost, Giess et al.’s article addresses a very timely topic in breast imaging, especially as we move forward in the “era of personalized medicine.” The reported local recurrence rate in women treated with breast conservation surgery is 6.4% to 8.7% at 10 years and 14.3% at 20 years . In addition, published data in patients treated with breast conservation surgery demonstrate that there is decreased sensitivity with mammography . Women who were treated with mastectomy for breast cancer are also at risk for developing contralateral breast cancer. The reported rate of developing contralateral breast cancer at 20 years’ follow-up is 8.9% to 15.6% . Consequently, there continues to be a significant interest in supplemental screening with breast MRI in breast cancer survivors.
In 2007, the American Cancer Society issued recommendations for breast screening with MRI as an adjunct to mammography . Soon afterwards, the American College of Radiology and the Society of Breast Imaging endorsed these recommendations . The recommendation for breast MRI as a supplemental screening exam for women at the highest risk (>20% lifetime risk) for developing breast cancer, particularly those at risk for hereditary breast cancer and for which mammographic screening has a low sensitivity , has been well accepted and adopted into daily clinical practice. However, the American Cancer Society did not recommend for or against MRI as a supplemental screening exam in women who have a 15–20% lifetime risk for developing cancer, such as those with a history of breast cancer, because there were insufficient data . Thus, the decision has been left to each referring physician or practice group to screen or not to screen for occult cancer with supplemental MRI in patients previously treated for breast cancer.
Fast forward now to the end of 2015, academic and private practice clinicians subsequently continue to wait for a definitive recommendation on whether to use breast MRI screening as an adjunctive imaging exam in breast cancer survivors. Unlike the literature on breast MRI screening for women with a high risk for breast cancer, published data on breast MRI screening for patients previously treated for cancer have been limited . The article by Giess et al. is the largest published study to date on this subject. The results support recent published data by Elmore and Margenthaler and Gweon et al. that women previously treated for breast cancer remain an intermediate risk group, and the cancer detection rate in these studies ranged from 0.9% to 1.4%.
Radiologists are familiar with the mammography screening benchmarks of an abnormal interpretation rate (recall rate) of 10.6% and a positive predictive value 3 (PPV3) of 31.0% . However, there is no established benchmark for recall rate in breast MRI screening at this time. The abnormal interpretation rate reported in this study is 10.7%. Giess et al. report a study PPV3 value of 17.9%. Their result is slightly less than the currently accepted MRI screening benchmark PPV3 value of 20–50% . The results from this new study provide us a point of reference for breast MRI screening audit data in intermediate risk patients as the audit data continue to evolve.
Another important point addressed by Giess et al. is that MRI has a moderate specificity and is an expensive examination. With a moderate specificity, the exam could lead to a false-positive study and unnecessary biopsy with additional charges. The cost-effectiveness of breast MRI screening in different patient populations has been debated in the literature . Cost will continue to be a factor in modern medicine, especially in the United States, as health-care dollars continue to decrease and payment is dictated by multiple party payers. Consequently, it is important to identify women previously treated for breast cancer who are at the greatest risk of recurrence while utilizing health-care dollars wisely.
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References
1. Anderson S.J., Wapnir I., Dignam J.J., et. al.: Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast conserving therapy in the five national surgical adjuvant breast and bowel project protocols of node-negative breast cancer. J Clin Oncol 2009; 27: pp. 2466-2473.
2. Wapnir I.L., Anderson S.J., Mamounas E.P., et. al.: Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in five national surgical adjuvant breast and bowel project node-positive adjuvant breast cancer trials. J Clin Oncol 2006; 24: pp. 2028-2037.
3. Fisher B., Anderson S., Bryant J., et. al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347: pp. 1233-1241.
4. Houssami N., Abraham L.A., Miglioretti D.L., et. al.: Accuracy and outcomes of screening mammography in women with a personal history of early stage breast cancer. JAMA 2011; 305: pp. 790-799.
5. Gao X., Fischer S.G., Emami B.: Risk of second primary cancer in the contralateral breast in women treated for early stage breast cancer: a population-based study. Int J Radiat Oncol Biol Phys 2003; 56: pp. 1038-1045.
6. Reiner A.S., John E.M., Brooks J.D., et. al.: Risk of asynchronous contralateral breast cancer in noncarriers of BRCA 1 and BRCA 2 mutations with a family history of breast cancer: a report from the women’s environmental cancer and radiation epidemiology study. J Clin Oncol 2012; 31: pp. 433-439.
7. Saslow D., Boetes C., Burke W., et. al.: American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57: pp. 75-89.
8. Lee C.H., Dershaw D., Kopans D., et. al.: Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010; 7: pp. 18-27.
9. Brennen S., Liberman L., Dershaw D.D., et. al.: Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol 2010; 195: pp. 510-516.
10. Elmore L., Margenthaler J.A.: Breast MRI surveillance in women with prior curative-intent therapy for breast cancer. J Surg Res 2010; 163: pp. 58-62.
11. Schact D.V., Yamaguchi K., Lai J., et. al.: Importance of a personal history of breast cancer as a risk factor for the development of subsequent breast cancer results from screening breast MRI. AJR Am J Roentgenol 2014; 202: pp. 289-292.
12. Gweon H.M., Cho N., Han W., et. al.: Breast MR imaging screening in women with a history of breast conservation therapy. Radiology 2014; 272: pp. 366-373.
13. Breast Cancer Surveillance Consortium, National Cancer Institute : Performance Benchmarks for Screening Mammography. Available at: http://breastscreening.cancer.gov Accessed August 24, 2015
14. Sickles E.A., D’Orsi C.J.: ACR BI-RADS follow-up and outcome monitoring 2013.BI-RADS atlas: breast imaging and reporting data system 2013.2013.American College of RadiologyReston, VA:pp. 1-73.
15. Piccoli C.W.: Contrast enhanced breast MRI: factors affecting sensitivity and specificity. Eur Radiol 1997; 7: pp. S281-S288.
16. Moore S.G., Shenoy P.J., Fanucchi L., et. al.: Cost-effectiveness of MRI compared to mammography for breast cancer screening in a high risk population. BMC Health Serv Res 2009; 9: pp. 1-8.
17. Taneja C., Edelsberg J., Weycker D., et. al.: Cost-effectiveness of breast cancer screening with contrast-enhanced MRI in high-risk women. J Am Coll Radiol 2009; 6: pp. 171-179.
18. Freer P.E.: Mammographic breast density: impact on breast cancer risk and implications of screening. Radiographics 2015; 35: pp. 302-315.
19. Yi A., Cho N., Yang K.S., et. al.: Breast cancer recurrence in patients with newly diagnosed breast cancer without and with preoperative MR imaging. Radiology 2015; 276: pp. 695-705.
20. Van der Velden B.H., Dmitriev I., Loo C.E., et. al.: Association between parenchymal enhancement of the contralateral breast in dynamic contrast-enhanced MR imaging and outcome of patients with unilateral invasive breast cancer. Radiology 2015; 276: pp. 675-685.
21. Saltzman B.S., Malone K.E., McDougall J.A., et. al.: Estrogen receptor, progesterone receptor and HER2-neu expression in first primary breast cancers and risk of second primary contralateral breast cancer. Breast Cancer Res Treat 2012; 135: pp. 849-855.
22. Schnitt S.J.: Classification and prognosis of invasive breast cancer: from morphology to molecular taxonomy. Mod Pathol 2010; 23: pp. S60-S64.
23. Trop I., LeBlanc S.M., David J., et. al.: Molecular classification of infiltrating breast cancer: toward personalized therapy. Radiographics 2014; 34: pp. 1178-1195.