Breast Cancer: Screening MRI
A Practice Resource

These guidelines are systematically developed recommendations to support clinician and patient decisions about appropriate evaluation and treatment. They are not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by practitioners, considering each patient's needs on an individual basis. Guideline recommendations apply to populations of patients. Clinical judgment and shared decision-making are necessary to design treatment plans for individual patients.

Adopted 27 Oct 2005, Last reviewed 27 Oct 2005 Next review 27 Oct 2009

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In November of 2004, the KP Interregional New Technologies Committee approved the use of screening breast MRI in very specific patients who are at very high risk for breast cancer. These patients carry a known BRCA 1 or BRCA 2 gene mutation or are suspected of carrying a high risk genetic mutation based on genetic counseling. These patients usually have multiple close relatives with PREMENOPAUSAL breast cancer and/or ovarian cancer.

Breast MRI is a new modality in breast cancer evaluation. Much remains to be learned about the appropriate use and limitations of this form of imaging. Following are our current recommendations for the use of screening breast MRI:

Screening breast MRI may be used for appropriate high risk individuals ONLY AFTER GENETICS EVALUATION AND RECOMMENDATION that breast MRI be used. Screening Breast MRI should not be ordered for women without high genetic breast cancer risk or who have not had Genetics evaluations. Breast MRI is not a substitute for mammography. Some forms of early breast cancer (DCIS) are usually not seen on breast MRI. For high genetic risk individuals, yearly screening breast MRI alternating with yearly screening mammography is recommended so that either MRI or mammograms are performed every 6 months. Clinical breast exam should be performed on high genetic risk individuals every 6 months. If the clinical breast exam is normal, order either screening mammogram or screening breast MRI in appropriate sequence as indicated above. If the breast exam is abnormal, order diagnostic mammogram and refer to breast surgery. Do not order screening or diagnostic breast MRI. Patients should be aware of the risks and benefits of screening breast MRI .before scheduling this procedure. Although breast MRI appears to be more sensitive for finding breast cancer, it is also less specific. Thus there is an increased risk of biopsy or repeat studies because of false positive findings, with attendant increased psychological stress, risks of infection etc. There is also a lack of long term studies and no indication yet if this will improve mortality. Breast MRI also requires an IV contrast material and 2 specially timed appointments, lasting about an hour each. The risk/benefit information is included in patient instructions triggered by placing the order. Diagnostic Breast MRI should be ordered only by Radiology, Oncology, or Surgery.

PATIENT INFORMATION ABOUT SCREENING BREAST MRI

WHO SHOULD HAVE BREAST MRI?

Breast MRI has recently been approved by Kaiser Permanente as another way to find early breast cancer in women who are at very high genetic risk for developing breast cancer. Most of these women have the genetic mutation BRCA1 or BRCA2 in themselves or their families which increases their risk for the development of breast or ovarian cancer. Often in these families, breast cancer will occur in younger ages (premenopausal) and will be seen in several members of the family. Ovarian cancer is also more common. This genetic mutation is more common in people of Jewish descent.

Women with a strong family history of breast or ovarian cancer or men with breast cancer should first be evaluated by Genetics to determine risk and to discuss possible genetic testing to identify breast cancer gene mutations. If an abnormal breast cancer gene mutation is identified or thought likely, Genetics will discuss the options for either surgery, preventive measures or close surveillance (frequent screening tests), and they will order the appropriate tests, including breast MRI if recommended. Screening breast MRI can also be ordered by Primary Care or Gynecology but only AFTER Genetics has recommended screening breast MRI. It is not a substitute for mammography.

HOW IS BREAST MRI DONE?

If a woman chooses to have close surveillance rather than surgery, yearly screening breast MRI alternating with yearly screening mammography is recommended so that either MRI or mammograms are performed every 6 months. Usually these examinations start 10 years before the earliest breast cancer in the family, often between ages 25 and 35.

At this time, screening breast MRI is done only at Sunnyside Hospital, in Clackamas. Each breast takes about one hour to image and requires a injection of contrast solution into a vein. Both breasts must be done separately, at least 24 hours apart. In premenopausal women, breast MRI imaging must be scheduled on days 7 to 14 of the menstrual cycle. The woman must lie very still in the MRI machine, on her stomach, with her breasts hanging through openings underneath.

WHAT ARE THE BENEFITS AND RISKS OF BREAST MRI?

It is too early to know whether screening high risk women with breast MRI will improve survival. Although breast MRI can sometimes detect breast cancer not seen on mammograms or ultrasound (it is more sensitive), it is also less specific than standard breast imaging. This means that breast MRI can result in additional followup or biopsies of benign (noncancerous) findings. At this time, we are not able to use MRI imaging at Kaiser to guide or perform breast biopsies. If a suspicious imaging finding is visible only with MRI, it may be necessary to refer to another medical facility for the breast biopsy. In addition, not all breast cancers will be detectable on breast MRI. Breast MRI does not replace the need for screening mammograms.

Some women are unable to have breast MRI because they have metal implants. MRI is not painful, but some women will need medication to prevent claustrophobia when lying in the MRI tunnel.

WHERE CAN I GET MORE INFORMATION?

Further information about BRCA genes and breast MRI can be obtained at the Kaiser Permanente Home page at www.memberskaiserpermanente.org. Choose the Health Encyclopedia function and enter BRCA or Breast MRI.

Link to Breast & Ovarian Cancer: Screening for Inherited Risk

Link to Cancer: Breast Cancer Screening

BREAST MRI REFERENCES

Kriege, M et al; Efficacy of MRI and Mammography for Breast-Cancer Screening in Women with a Familial or Genetic Predisposition, NEJM 351;5, July 29, 2004 pp 427-437.

Warner, Ellen, MD et al; Surveillance of BRCA1 and BRCA2 Mutation Carriers with Magnetic Resonance Imaging, Ultrasound, Mammography and clinical Breast Exam JAMA Sept 15, 2004 vol 292, no. 11 pp 1317-1325

American Society of Breast Disease Policy Statement: The Use of Magnetic Resonance Imaging of the Breast (MRIB) for screening of Women at High Risk of Breast Cancer, June 28, 2004

Burke W, Daly M, Garber J, et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium. JAMA 197:277:997-1003

Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of early onset breast cancer: Implications for risk prediction. Cancer 1994; 73:646-651

Liberman L. Breast cancer screening with MRI: what are the data for patients at high risk? N Engl J Med 2004;351:497-500

Robson M, Offit K. Breast MRI for Women with Hereditary Cancer Risk JAMA 2004 vol 292; 1368-1370

American College of Radiology Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Breast 10/2004

Mincey B. Genetics and the Management of Women at High Risk for Breast Cancer; The Oncologist 2003;8:466-473

NCCN Clinical Practice Guidelines in Oncology Version 1.2005

Schottinger J. MRI for Screening Women at High Risk of Breast Cancer, Presentation for SCPMG 7/20/2003

Snyder, T and Kutner, S. Breast MRI Update: Northern California TPMG Breast MRI workgroup presentation draft 4/05

Work Group

Kate Crow, CGC Lois Eaton, NP Wayne Gilbert, MD Trudy Goodloe, MD Douglas Lackowski, MD Leesa Linck, MD Steven Thalberg, MD