Breast MR Imaging Workshop 201413th September 2014

High-Risk Screening

Evidence-based Clinical Indications for Breast MRIDr. Muhamad Zabidi Ahmad, AMDI

Introduction • Worldwide in 2010, estimated 1,643,000 new cases of breast cancer1.

• 60% of breast cancer deaths are from less developed nations2.

• Increased screening program in 1990’s has led to early detection.

• Mainly by mammogram and/or ultrasound.

1. Jemal et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.2. World Health Organization. Breast cancer: Prevention and Control

Strategies for Screening

• Take into account the combined evidence for risk of breast cancer and effectiveness and harms of breast cancer screening.

• Mammogram is mainstay.• Role of MRI is emerging– In combination with

mammography, targeted to high-risk patients.

The Important Points

1Who are the high-risk group?

2What are the

experts say?

3In context of

our population

Who Are The High-risk Group?1

Risk Factors for Developing Breast Cancer

• Age – risks increases with age• Family history• Early menarche, late menopause• Oral contraceptive use• Age at first birth >30• Breast density on mammogram• BRCA mutation carrier• Alcohol

ACS• American Cancer Society

(2007)3 recommends annual MRI, in addition to mammogram, to women in these groups:– Known BRCA mutation

carriers– First degree relatives of

known BRCA carriers– Approximate lifetime risk of

breast cancer from 20 to 25 percent based on risk prediction model

3. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI asan adjunct to mammography. CA Cancer J Clin 2007; 57:75.

NCCN• National Comprehensive Cancer

Network (NCCN)4 recommended annual breast MRI in adjunct to mammography in these groups:– BRCA1 and BRCA2 mutation

carriers– First degree relative with BRCA1

or BRCA2 mutation– Family history of breast or

ovarian cancer– Received radiation treatment to

the chest between ages 10 and 30

– TP53 or PTEN genes mutation 4. Bevers TB, Anderson BO, Bonaccio E, et al. NCCN clinical practice guidelines in oncology: breast cancerscreening and diagnosis. J Natl Compr Canc Netw 2009; 7:1060.

Carriers of BRCA1, BRCA2, or TP53 mutation

First degree relative of someone who carries BRCA1, BRCA2, or TP53 mutation

Strong family history of breast or ovarian cancer; or both

Family history consistent with Li-Fraumeni syndrome*

*Li-Fraumeni syndrome – extremely rare AD hereditary disorder. Classical malignancy – sarcomas, cancers of the breast, brain and adrenal glands

Received radiation treatment to the chest between ages 10 and 30

2 What Are The Experts Say

A look into published literatures

No data from randomized control trials that show a benefit of screening by MRI in women with low to average risk of breast cancer.

Contributed partly by higher cost of MRI compared to mammography5.

Screening breast MRI is more sensitive but less specific than mammography for detection of invasive breast cancer in high-risk women in both retrospective and prospective studies.

5. http://www.uptodate.com/contents/screening-for-breast-cancer-evidence-for-effectiveness-and-harms?topicKey=PC%2F87311&elapsedTimeMs=0&source=machin%E2%80%A6

Morris et al.

• Retrospective study involving 367 women with high-risk developing breast cancer.

• Normal mammography findings.

• Screening MRI performed during 2 year period.

Morris et al.

• Among high-risk women, MRI led to biopsy in 17%.

• Cancer found in 24% of women undergoing biopsy.

• 4% from women who had MRI screening.

Warner et al.

• Retrospective study involving 236 high-risk women with BRCA1 and BRCA2 mutation.

• Underwent mammogram, MRI and ultrasound as well as clinical breast examination.

• From 1997 – 2003.

Warner et al.

• MRI is more sensitive in detecting breast cancer compared to mammography, ultrasound or clinical breast examination alone in BRCA1 and BRCA2 mutation women.

Stoutjesdijk et al.

• Retrospective study of all MRI and mammographic study between 1994 to 2001.

• 179 women.• MRI more accurate than

mammography in annual screening in women with hereditary risk of breast cancer.

Lehman et al.

• Prospective study involving 195 women over 6-month period.

• BRCA1/BRCA2 carrier in women 25 years old and older.

Lehman et al.

• Screening MR imaging had higher biopsy rate.

• Helped detect more cancers than either mammography or ultrasound alone.

Berg et al.

• Prospective study to determine cancer detection yield by ultrasound and MRI in women with elevated risk for breast cancer.

• 2809 women at 21 sites from 2004 to 2006.

• MRI resulted in higher detection rate.

• Reviewed 11 studies comparing test performance of screening MRI with mammography in high-risk women.

• Age ranging 40 to 47 years old.

• Sensitivity of MRI higher than mammography: 0.77 (95% CI 0.70 – 0.84) versus 0.39 (CI 0.37 – 0.41).

• Specificity of MRI lower than mammography: 0.86 (CI 0.81 – 0.92) versus 0.95 (CI 0.93 – 0.97).

• Sensitivity of MRI and mammography together was 0.94 (CI 0.90 – 0.97) and specificity was 0.77 (CI 0.75 – 0.80).

• However, the cost of running MRI for screening is higher

• Take longer time• Studies looking into more effective and faster

MRI acquisition

• Takes 3 minutes instead of 40 minutes

• T1 followed by contrast• Images substracted into individual

first postcontrast subtracted images (FAST) and fused into single MIP image

3 In Context of Our Population

• Incidence of breast cancer published in National Cancer Registry 2006 was 39.3 per 100,000 population.

• Most present at late stage.• Mammogram prevalence rate

of 7.6% (National Health Morbidity Survey 2006).

• MRI not used widely.

CPG 2nd Edition 2010 on management of breast cancer

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CPG on Management of Breast Cancer, 2nd Edition 2010

American Cancer Society recommendation for breast MRI screening.

Conclusion

• MRI as a screening tool for high-risk women• Valuable adjunct when used together with

mammogram• Limited resources for large scale screening

program

Thank you