Should biannual MRIs replace annual mammograms in high-risk women?

Expert Guidelines

The National Comprehensive Cancer Network (NCCN) establishes guidelines for breast cancer screening and cancer care in the U.S. For women with increased risk (a lifetime risk for breast cancer of 20% or more), the guidelines recommend the following screening:

• Have clinical exams every 6–12 months, starting when you are identified as being at increased risk, but not before age 21
• Obtain a referral to genetic counselor or similarly trained health care provider, if you haven’t already done so.
• Start annual mammography screening 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not prior to age 30. Consider getting a 3-D mammogram.
• Begin annual breast MRI 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not prior to age 25.
• Consider recommended risk reduction strategies, such as preventive hormonal medications or risk-reducing surgeries that remove the breasts or ovaries.
• Develop breast awareness and report any changes to your health care providers

 

The National Comprehensive Cancer Network (NCCN) provides breast cancer risk management guidelines for people with BRCA1 and BRCA2 mutations. We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and can help you to determine the best risk management plan. 

Screening for women:

• Learn to be aware of changes in breasts beginning at age 18.
• Clinical breast exam every 6-12 months beginning at age 25.
• Annual breast MRI with contrast (or mammogram if MRI is unavailable) beginning at age 25 and continuing until age 75.
• Annual mammogram at age 30 until age 75 (consider 3D mammography if available).
• Screening after age 75 should be considered on an individual basis.

Risk reduction for women:

• Women should have a discussion with their doctors about of the advantages and disadvantages of risk-reducing mastectomy.
  • Research has shown that risk-reducing mastectomy can lower the risk for breast cancer in high risk women by about 90%. Despite this, mastectomy has not been shown to help high risk women live longer.
  • Even after mastectomies, some breast tissue-and therefore some breast cancer risk remains. 
• Women should have a conversation with their doctor about the possible benefits of tamoxifen or other estrogen-blocking drugs to reduce breast cancer risk in women with BRCA2 mutations. Research on the benefit of these drugs to reduce breast cancer risk in women with BRCA1 mutations has been mixed.

Risk management in men:

• Breast self-exam training and education beginning at age 35.
• Clinical breast exam every 12 months beginning at age 35.
• In men with enlarged breasts, (gynecomastia) consider annual mammogram in men with gynecomastia beginning at age 50 or 10 years younger then the earliest case of male breast cancer in the family (whichever comes first). 

The National Comprehensive Cancer Network (NCCN) provides guidelines for management of breast cancer risk in people with inherited mutations linked to breast cancer. We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and help you to determine the best risk management plan. 

ATM or CHEK2

• Begin yearly mammograms at age 40, or earlier based on the family history of breast cancer.
• Consider yearly MRI with contrast beginning at age 30-35.

BARD1, RAD51C or RAD51D 

• Beginning at age 40 (or earlier based on family history):
  • recommend yearly mammogram.
  • consider yearly breast MRI with contrast.

BRIP1

• No specific breast cancer screening guidelines. Risk management should be based on family history of cancer.

CDH1 

• Beginning at age 30 (or earlier based on family history):
  • recommend yearly mammogram.
  • consider yearly breast MRI with contrast.
  • discuss risk reducing mastectomy. 

PALB2

• Beginning at age 30 (or earlier based on family history):
  • recommend yearly mammogram.
  • recommend yearly breast MRI with contrast.
  • discuss risk reducing mastectomy. 

PTEN

• Beginning at age 18, learn to be aware of changes in breasts.
• Begining at age 25:
  • clinical breast exam every 6-12 months beginning at age 25 (or 10 years earlier than the youngest age of onset in the family).
• Beginning at age 30:
  • yearly mammography and breast MRI with contrast beginning at age 30-35 (or 5-10 years earlier than the youngest breast cancer in the family).  

RAD51C/RAD51D

 

• Yearly mammogram beginning at age 40 or 5-10 years younger than the earliest age of diagnosis in the family (but no later than age 40).
• Consider yearly breast MRI with contrast beginning at age 40 or 5-10 years younger than the earliest age of diagnosis in the family.

STK11

• Beginning at age 30:
  • clinical breast examination by a health care provider every 6 months starting at age 30.
  • recommend yearly mammogram.
  • recommend yearly MRI with contrast.

TP53

• Beginning at age 18, learn to be aware of changes in breasts.
• Beginning at age 20:
  • clinical breast examination by a health care provider every 6 months.
  • recommend yearly breast MRI with contrast beginning at age 20 or at the age of earliest breast cancer diagnosis if there is a history of breast cancer before age 20 in family.
• Beginning at age 30
  • recommend yearly mammogram. 
• Consider risk reducing mastectomy.

The National Comprehensive Cancer Network (NCCN) establishes guidelines for women with increased risk (a lifetime risk for breast cancer of 20 percent or more). The guidelines recommend the following screening:

• Have clinical exams every 6–12 months, starting when you are identified as being at increased risk, but not before age 21.
• Consider consulting with a genetic counselor or similarly trained health care provider, if you haven’t already done so.
• Consider consulting with a breast surgeon.
• Start annual mammography screening at age 40 or 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not before age 30. Consider getting a 3-D mammogram.
• Begin annual breast MRI at age 40 or 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not before age 25.
• Consider recommended risk reduction strategies, such as preventive hormonal medications.
• Develop breast awareness and report any changes to your health care providers.

NCCN has separate guidelines for breast screening in women with an inherited mutation. See our gene-by-gene listing to find specific risk-management guidelines for people with an inherited mutation linked to cancer.  

Questions To Ask Your Health Care Provider

• How often and with what method should I be screened for breast cancer?
• Will my MRI include contrast with a gadolinium-based agent?  If so, what health risks are associated with this contrast agent?
• Are there any other health risks associated with getting an MRI every 6 months instead of annually?
• Do I still need an annual mammogram if I have an MRI every 6 months?
• Will my insurance cover more frequent MRI screenings?

Open Clinical Trials

The following breast cancer screening clinical trials are currently enrolling participants:

•  NCT02620852: Women Informed to Screen Depending on Measures of Risk (WISDOM) study.  The goal of this study is to determine if breast cancer screening can be made better by personalizing each woman’s mammogram schedule, compared to the current one-size-fits-all, annual approach.
• NCT03979729: Breast Cancer Screening for Underserved Women: Comparing Outcomes and Lowering Recall Rates With 3D- vs. 2D-mammography is recruiting participants in New Mexico who are over age 40 to improve mammogram utility among underserved women.
• NCT03482557: Contrast Enhanced Spectral Mammography vs. MRI for Breast Cancer Screening is recruiting women 30 years or older who are already getting a breast biopsy. Participants will have a contrast-enhanced mammogram and a breast MRI before the biopsy. Radiologists will compare the images to see if the contrast enhanced mammograms and breast MRI are equally proficient at detecting breast cancer.
• NCT03729115: A Multi-Modality Surveillance Program for Women at High Risk for Breast Cancer is a clinical trial at the University of Chicago that is enrolling women age 21 and older who are BRCA1, BRCA2, PALB2 or TP53 carriers for an MRI and anxiety reduction trial.
• NCT03859492: Screening CEDM in Intermediate and High-Risk Patient Populations is a clinical trial at the Mayo Clinic in Arizona that is testing whether Contrast Enhanced Digital Mammography (CEDM) can improve breast cancer detection among women age 35 years and older who have an intermediate or high risk of breast cancer.
• NCT03233191: Digital Tomosynthesis Mammography and Digital Mammography in Screening Patients for Breast Cancer. The goal of this randomized phase III trial is to evaluate digital tomosynthesis mammography and digital mammography in screening patients for breast cancer.
• NCT03303846: Combined Breast MRI and Biomarker Strategies in Identifying High-risk Breast Cancer Patients trial. This clinical trial is recruiting participants age 18 and older. Study sites are in California, North Carolina, Ohio and Wisconsin.

The following are breast cancer screening or prevention studies enrolling people at high risk for breast cancer.   

• NCT04711109: Denosumab for Preventing Breast Cancer in Women with a BRCA1 Inherited Mutation (BRCA-P). This study will test the effectiveness of a drug (denosumab) on preventing the development of breast cancer in women with an inherited BRCA1 mutation.
• NCT04067726: Denosumab and Mammographic Density in Premenopausal Women With Dense Breasts (TRIDENT). This study is looking at the drug denosumab to learn if it can reduce breast density in high-risk premenopausal women who have dense breasts. 
• The Risk Factor Analysis of Hereditary Breast and Ovarian Cancer In Women  with BRCA1, BRCA2 or PALB2 Mutations.  This study seeks to improve researchers’ understanding of how hormonal, reproductive and lifestyle factors may be associated with cancer in high-risk people.
• NCT02620852: Women Informed to Screen Depending on Measures of Risk (WISDOM) study.  The goal of this study is to determine if breast cancer screening can be made better by personalizing each woman’s mammogram schedule, compared to the current one-size-fits-all, annual approach.

Additional risk-management clinical trials for people at high risk for breast cancer may be found here.