In women with elevated breast cancer risk, screening strategies with breast MRI could increase cancer detection. They are also likely to be cost-effective.
Presenter: Ritse Mann, Radboud University Medical Center, Nijmegen, The Netherlands
Source: RSNA 2021
- MRI screening costs are dominated by the price of the MR unit. Bringing down the costs from currently 350 EUR per screening examination to 200 EUR seems possible.
- In women with extremely dense breast tissue, eradicating breast cancer mortality becomes a realistic option.
Performance of MRI Screening
Numerous studies on breast MRI for screening reflect its current use in a large number of participants. Especially recent studies show the potential of breast MRI for screening: It reaches sensitivities of 82-90% (Bick et al. 2019; Chiarelli et al. 2020). “So, we do miss some cancers with MRI,” said Ritse Mann, Radboud University Medical Center, Nijmegen, The Netherlands. Some of the missed lesions will become interval cancers, and some will still be found in mammography. “Should we therefore do both, breast MRI and mammography?” asked Mann.
Effect of Supplemental Mammography in an MRI-based Screening
Vreemann et al. (BCR 2018) investigated the added cancer detection of mammography when breast MRI is available, focusing on the value in women with and without BRCA mutation. In women under the age of 40, additional mammography screening of more than 1,800 women is needed to detect one additional cancer. This is different for women between 50 to 60 years: In this group, only 229 supplemental mammographies would be needed. But 80 percent of the cancers detected with mammography only are DCIS, as Vreemann et al. found. While the overall sensitivity of breast MRI is 89.6% (112/125), it is only 52.8% (66/125) for mammography.
Sensitivity Profile of MRI and Mammography
As Sung et al. (Radiology 2016) have shown, the more aggressive a breast cancer, the more likely it will be detected by MRI. “In mammography, it is basically the other way round,” explained Mann. “Our only concern is: we find a few more low-grade DCIS with MRI. You need to be aware of this.”
The sensitivity increase of supplemental mammography added to an MRI screening is about 5 percent on average, said Mann. The penalty, however, is a reduction in specificity of 0.5-2 percent. “This does not sound much, but it is actually a large number of false positive results,” said Mann.
“If you do MRI plus mammography, mammography is the supplemented screening technique – not the other way round,” Mann summarized.
Personalized Screening: Who Should Have Breast MRI?
Breast MRI screening should be offered to women with increased risk of breast cancer and women in which mammography only works poorly.
Genetic risk factors have shown to be useful for selecting women eligible for breast MRI screening (2.3 to 8-fold risk depending on the mutation).
Family history (1.5 to 3-fold) and personal history (2 to 3-fold) do increase the personal risk. The presence of lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), and atypical ductal hyperplasia (ADH) is associated with a 3 to 4-fold increased risk.
High breast density is also associated with an increased (2 to 3-fold) cancer risk.
MRI Plus Mammography: Effective for Women at Familial Risk
Mann presented the multicenter, randomized, controlled trial ‘FaMRIsc’ (Saadatmand S et al. 2019). In women with familial risk, mammography plus breast MRI showed a cancer detection rate of 14.2/1000, compared to 4.9/1000 for mammography alone. However, another feature is at least as important as the higher detection rate: the detected cancers are smaller on average (12 vs. 18 mm), detected at a lower stage, and are more often node negative (83 vs. 38%).
Cost-Effectiveness of Breast MRI For Screening Women at Familial Risk
Geuzinge et al. (JAMA Oncol 2020) calculated the cost-effectiveness of breast MRI screening for women at familial risk and found:
- An MRI every 1.5 years and no mammography was the most cost-efficient screening strategy at costs of approx. 21,000 EUR per QALY (quality-adjusted live year).
- The second most cost-effective strategy turned out to be an alternating strategy of one year MRI, the other year mammography.
Costs are dominated by the price of the MR unit – currently about 350 EUR per screening examination. “So, we should work to get the price down,” Mann demanded. He deemed costs of 200 EUR possible in the near future.
Risk Factor Dense Breast: Eradicate Mortality
DENSE, the large Dutch screening study (Bakker et al. 2019) revealed: Women with extremely dense breast tissue benefit significantly from additional MRI.
- 8,061 screening participants with negative mammography were offered supplemental screening MRI.
- 4,783/8,061 women actually underwent additional MRI.
- 79 breast cancers were detected, yielding an additional cancer detection of 16.5/1,000.
- Interval cancer rate was 0.8/1,000 with MRI compared to 5.0/1,000 without MRI.
In the second screening round (Veenhuizen et al. 2021) after two years,
- all detected cancers were node negative, and
- all detected cancers were at an early stage.
“This means: In this population, we are basically able to eradicate breast cancer mortality,” said Mann. “That is really massive. We have never been able to do something like this before.”
Geuzinge et al. (JNCI 2021) also calculated cost-effectiveness of different screening strategies for women with extremely dense breast tissue. They found:
- An MRI screening every 4 years is cost-effective at additional costs of 15,000 EUR per QALY
- This strategy would save 7.6/1,000 lives at costs of 75,000 EUR per live. “We think this is really cheap,” Mann concluded.
References
1. Bakker MF et al. DENSE Trial Study Group. Supplemental MRI Screening for Women with Extremely Dense Breast Tissue. N Engl J Med 2019;381(22):2091-2102.
https://doi.org/10.1056/NEJMoa1903986
2. Bick U et al. High-risk breast cancer surveillance with MRI: 10-year experience from the German consortium for hereditary breast and ovarian cancer. Breast Cancer Res Treat 2019;175(1):217-228.
https://doi.org/10.1007/s10549-019-05152-9
3. Chiarelli AM et al. Performance Measures of Magnetic Resonance Imaging Plus Mammography in the High Risk Ontario Breast Screening Program. J Natl Cancer Inst. 2020 Feb 1;112(2):136-144.
https://doi.org/10.1093/jnci/djz079
4. Geuzinge HA et al. Cost-effectiveness of Breast Cancer Screening With Magnetic Resonance Imaging for Women at Familial Risk. JAMA Oncol 2020;6(9):1381-1389.
https://doi.org/10.1001/jamaoncol.2020.2922
5. Geuzinge HA et al. Cost-Effectiveness of Magnetic Resonance Imaging Screening for Women With Extremely Dense Breast Tissue. JNCI 2021;113(11):1476–1483.
https://doi.org/10.1093/jnci/djab119
6. Saadatmand S et al. Lancet Oncology 2019;20(8):1136-1147 MRI versus mammography for breast cancer screening in women with familial risk (FaMRIsc): a multicentre, randomised, controlled trial.
https://doi.org/10.1016/s1470-2045(19)30275-x
7. Sung JS et al. Breast Cancers Detected at Screening MR Imaging and Mammography in Patients at High Risk: Method of Detection Reflects Tumor Histopathologic Results. Radiology 2016;280(3):716-22.
https://doi.org/10.1148/radiol.2016151419
8. Veenhuizen SGA et al. Supplemental Breast MRI for Women with Extremely Dense Breasts: Results of the Second Screening Round of the DENSE Trial. Radiology 2021;299(2):278-286.
https://doi.org/10.1148/radiol.2021203633
9. Vreemann S et al. The added value of mammography in different age-groups of women with and without BRCA mutation screened with breast MRI. Breast Cancer Res 2018;20(1):84.
https://doi.org/10.1186/s13058-018-1019-6
Presentation: Supplemental Breast MRI in Personalized Screening
Session code: W1-CBR07
Author: mh/ktg
Last update: 14 Feb, 2022
Presentation: Supplemental Breast MRI in Personalized Screening
Session code: W1-CBR07 Author: mh/ktg Last update: 14 Feb, 2022
