Impact of MRI surveillance and breast cancer detection in young women with BRCA mutations

Based on several observational studies that have yielded consistent results, the combination of annual magnetic resonance imaging (MRI) plus mammography is now the standard of care for screening women with BRCA mutations who decline risk-reducing mastectomy. However, many of these women will develop breast cancer at a young age and, while most of these cancers will be very early stage, oncologists need to be aware of the unique issues faced by women in this age group due to the diagnosis and treatment. Fear of death, loss of fertility, premature menopause, relationship stress, career disruption and financial losses are only some of the problems that are either unique to young women or much more pronounced in this age group. Urgent referral to a fertility specialist of any woman who has not yet completed her family should be made as soon as the possible need for systemic treatment is recognized. The oncologist should also have a low threshold for referring young women to professionals experienced in navigating young women and their families through the psychosocial trauma of a breast cancer diagnosis.

Can breast MRI computer-aided detection (CAD) improve radiologist accuracy for lesions detected at MRI screening and recommended for biopsy in a high-risk population?

AIM

To evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) computer-aided detection (CAD) for breast MRI screen-detected lesions recommended for biopsy in a high-risk population.

MATERIAL AND METHODS

Fifty-six consecutive Breast Imaging Reporting and Data System (BI-RADS) 3-5 lesions with histopathological correlation [nine invasive cancers, 13 ductal carcinoma in situ (DCIS) and 34 benign] were retrospectively evaluated using a breast MRI CAD prototype (CAD-Gaea). CAD evaluation was performed separately and in consensus by two radiologists specializing in breast imaging, blinded to the histopathology. Thresholds of 50, 80, and 100% and delayed enhancement were independently assessed with CAD. Lesions were rated as malignant or benign according to threshold and delayed enhancement only and in combination. Sensitivities, specificities, and negative predictive values (NPV) were determined for CAD assessments versus pathology. Initial MRI BI-RADS interpretation without CAD versus CAD assessments were compared using paired binary diagnostic tests.

RESULTS

Threshold levels for lesion enhancement were: 50% to include all malignant (and all benign) lesions; and 100% for all invasive cancer and high-grade DCIS. Combined use of threshold and enhancement patterns for CAD assessment was best (73% sensitivity, 56% specificity and 76% NPV for all cancer). Sensitivities and NPV were better for invasive cancer (100%/100%) than for all malignancies (54%/76%). Radiologists' MRI interpretation was more sensitive than CAD (p=0.05), but less specific (p=0.001) for cancer detection.

CONCLUSION

The breast MRI CAD system used could not improve the radiologists' accuracy for distinguishing all malignant from benign lesions, due to the poor sensitivity for DCIS detection.

Willingness of breast cancer survivors to participate in a randomized controlled trial (RCT) of digital mammography with or without magnetic resonance imaging (MRI) as breast cancer (BC) surveillance: A feasiblity study

1534

Background: Although no RCT of MRI screening has ever been performed, and thus its impact on survival is unknown, MRI (plus mammography) has become the standard of care for screening women at very high risk for BC due to its superior sensitivity. The current ASCO guideline for surveillance of women with a past history of BC patients for ipsilateral recurrence or contralateral BC is annual mammography; however, MRI is often being ordered as well. A RCT for this population is still theoretically feasible assuming one could recruit a sufficient number of patients. We conducted a study to evaluate the willingness of BC survivors to participate in a RCT of digital mammography with or without MRI. Methods: In this multi-center, cross-sectional cohort survey, consecutive women ages 20 to 59 with invasive BC who had completed all primary therapy (except hormonal therapy), had at least one remaining breast and no evidence of metastatic disease, were consented in clinic to complete a self-administered questionnaire. Results: 348 women at four study sites across Toronto, Canada, were enrolled over 10 months. Median age 51 years, 76% Caucasian, 69% had BC within the last 5 years, 37% had previous mastectomy. At diagnosis, 71% BC had been visible on mammogram; 45% had undergone diagnostic MRI. 22% continued to have MRI as part of surveillance imaging, especially women younger than 40 years. 58% agreed to consider participating in the proposed RCT, and 16% remained neutral. Women who had undergone mastectomy were more likely to consider the trial (71% vs. 52%). The most common reason for not considering the trial was that they were already getting surveillance MRI. Other reasons were additional false positive tests and biopsies (34%), discomfort associated with MRI (28%), and fear that their anxiety about cancer recurrence would increase (16%). Conclusions: A RCT of MRI surveillance for BC survivors younger than age 60 is still feasible at centers where annual MRI is not yet routinely recommended for this population.

No significant financial relationships to disclose.

Rapid progression of prostate cancer in men with a BRCA2 mutation

Men with BRCA2 mutations have been found to be at increased risk of developing prostate cancer. There is a recent report that BRCA2 carriers with prostate cancer have poorer survival than noncarrier prostate cancer patients. In this study, we compared survival of men with a BRCA2 mutation and prostate cancer with that of men with a BRCA1 mutation and prostate cancer. We obtained the age at diagnosis, age at death or current age from 182 men with prostate cancer from families with a BRCA2 mutation and from 119 men with prostate cancer from families with a BRCA1 mutation. The median survival from diagnosis was 4.0 years for men with a BRCA2 mutation vs 8.0 years for men with a BRCA1 mutation, and the difference was highly significant (P<0.01). It may be important to develop targeted chemotherapies to treat prostate cancer in men with a BRCA2 mutation.

The BOADICEA model of genetic susceptibility to breast and ovarian cancers: updates and extensions

Multiple genetic loci confer susceptibility to breast and ovarian cancers. We have previously developed a model (BOADICEA) under which susceptibility to breast cancer is explained by mutations in BRCA1 and BRCA2, as well as by the joint multiplicative effects of many genes (polygenic component). We have now updated BOADICEA using additional family data from two UK population-based studies of breast cancer and family data from BRCA1 and BRCA2 carriers identified by 22 population-based studies of breast or ovarian cancer. The combined data set includes 2785 families (301 BRCA1 positive and 236 BRCA2 positive). Incidences were smoothed using locally weighted regression techniques to avoid large variations between adjacent intervals. A birth cohort effect on the cancer risks was implemented, whereby each individual was assumed to develop cancer according to calendar period-specific incidences. The fitted model predicts that the average breast cancer risks in carriers increase in more recent birth cohorts. For example, the average cumulative breast cancer risk to age 70 years among BRCA1 carriers is 50% for women born in 1920-1929 and 58% among women born after 1950. The model was further extended to take into account the risks of male breast, prostate and pancreatic cancer, and to allow for the risk of multiple cancers. BOADICEA can be used to predict carrier probabilities and cancer risks to individuals with any family history, and has been implemented in a user-friendly Web-based program (http://www.srl.cam.ac.uk/genepi/boadicea/boadicea_home.html).

Sensitivity of surveillance mammography for contralateral breast cancers and ipsilateral recurrences in survivors under 50

11009

Background: Annual mammography is currently the gold standard for surveillance of breast cancer survivors for both ipsilateral recurrence and contralateral new primaries. The risk of either of these events occurring has been found to be inversely proportional to age and is at least 1% per year if breast cancer was diagnosed before age 50. (Chen et al 1999) (Komoike et al 2006). However, the sensitivity of screening mammography is significantly lower in young women. We therefore sought to determine the effectiveness of surveillance mammography according to age of diagnosis using a prospective database. Methods: The Henrietta Banting Database prospectively follows all new cases of operable breast cancer diagnosed from 1987 - 2004 at Women’s College Hospital. From the 1992 women in the database, we selected all patients diagnosed before age 60 who subsequently developed non-metastatic contralateral cancers (n=71 ) or ipsilateral recurrences (n=11 ). Records were obtainable for 59 of these 82 patients. Results: Method of detection and stage of diagnosis are listed in table below for the 59 patients according to age of diagnosis of second cancers. Overall, mammography was less effective at detecting contralateral and recurrent breast cancers in younger women, detecting only 24% of these cancers in women under 50 compared to 74% in patients 50 and older (Chi-Square, p<0.001). In addition, 77% of patients under 50 whose second cancers were detected by methods other than mammography had negative surveillance mammograms in the 15 months prior to diagnosis. Conclusion: Since mammography detected only 24% of second primary breast cancers/ recurrences in survivors < age 50 and almost one third of all detected cancers were locally advanced, more sensitive imaging modalities such as breast MRI should be considered for surveillance of young survivors.

[Table: see text]

No significant financial relationships to disclose.

Preferences for breast cancer prevention among BRCA mutation carriers

17018

Purpose: Breast cancer screening with MRI is a new option available to patients with BRCA 1/2 mutations. We analyzed preferences for this modality and 10 other breast cancer- related health states and preventive measures among women without cancer or known high risk and women with BRCA mutations. Methods: Following IRB approval, we administered a time trade-off questionnaire to mutation carriers and to women without breast cancer or known high risk. We used Kruskal-Wallis test to compare the two groups with respect to continuous variables, chi-square tests to compare proportions, and the Wilcoxon signed rank test for pairwise comparisons. We then developed logistic regression models to analyze the association of mutation carrier status and demographic factors with willingness to trade time for each of the 11 health states. Results: Two-hundred-four women (44 mutation carriers and 160 without breast cancer or known high risk) responded to the questionnaire. Both groups assigned the highest preference rating to mammography and the next-highest to MRI, but the differences in ratings were not statistically significant. Both groups assigned the lowest preference ratings to having a child with a mutation and the next lowest to ovarian cancer. In pairwise comparisons, both groups ranked oophorectomy higher than ovarian cancer (p <0.01), but mutation carriers did not rank prophylactic mastectomy significantly differently from breast cancer (p=0.38). In the logistic regression models, mutation carrier status was not a statistically significant predictor of willingness to trade time for any health state, but younger age, lower income, and nonwhite race/ethnicity were associated with willingness to trade time for certain health states. Conclusion: Our data indicate that MRI is as acceptable as mammography to respondents, and that the preferences of BRCA 1/2 mutation carriers are similar to those of other women. Age and other demographic factors may be more important than mutation status in determining preferences. The preference ratings of individuals should not be inferred from demographic characteristics or mutation status. However, such ratings can help to clarify the quality of life implications of clinical decision-making and health care policy regarding breast cancer prevention.

No significant financial relationships to disclose.

Distress and breast cancer anxiety (BCA) among BRCA mutation carriers participating in MRI-based screening

20001

Background: MRI has consistently been shown to be a more sensitive screening tool than mammography (M) but its lower specificity could have negative psychological effects. In a pilot study (SABCS 2004) no adverse psychological effects of MRI screening were found. A larger study was then done to look particularly at the impact of imaging recalls and biopsies. Methods: BRCA mutation carriers having breast screening with annual M, MRI, and ultrasound (US) + 6monthly clinical breast examination (CBE) were asked to complete questionnaires: 1 - 2 wks pre, 4 - 6 weeks after, and 6 months after their imaging. Questionnaires included the hospital anxiety and depression scale (HADS), a modified Kash breast cancer anxiety scale (BCAS), the monitor/blunter scale, a rating of overall health on a linear analog scale, a 4 category rating of anxiety related to each screening modality, and a description of any recent life altering events. Results: 54 women (29 BRCA1, 25 BRCA2) completed at least 2 questionnaires (median 3, range 2–5). Mean age was 44 (range 28–64). 26% were surveyed during their 1st round of screening. There was a very strong correlation between the BCAS and HADS anxiety with 19 (35%) having baseline BCA of whom 15 (79%) were monitors compared to 60% monitors among the patients without BCA. At baseline 41 (76%) indicated moderate/high MRI related anxiety compared to 61%, 46%, and 43% for M, U/S and CBE. Of the 16 patients (30%) who had recalls ± biopsy (n = 5) while on this study, 10 (63%) had elevated BCA and 3(19%) increased depression at baseline. In all but 2 women whose anxiety increased due to life events, no scores changed significantly after recall or biopsy. Only 1 cancer was diagnosed during the study period. In the other 38 women scores changed significantly only as a result of life events. Conclusions: Despite a high false positive rate, MRI-based screening had no detectable adverse psychological effects on BRCA mutation carriers in this study.

No significant financial relationships to disclose.

Is mammography adequate for screening BRCA mutation carriers with low breast density?

10014

Background: Several large observational studies have demonstrated that magnetic resonance imaging (MRI) is much more sensitive than M (sensitivity 71–96% vs. 28–43%) for screening women > age 25 at high risk for hereditary breast cancer. However, MRI is much more costly and less specific than M. The extent to which the low sensitivity of M in these studies is due to the greater average breast density of younger women is unknown. Accordingly, we sought to determine the sensitivity of M and MRI according to breast density for the detection of breast cancer in a screening study of BRCA mutation carriers. Methods: Breast density was measured on the screening mammogram of the contralateral breast for all women who developed in-situ or invasive breast cancer on study. Density was measured in 2 ways: qualitatively according to the four categories characterized by the BIRADS system: 1) mostly fatty, 2) scattered fibroglandular tissue, 3) heterogeneously dense, 4) extremely dense; and semi-quantitatively using computer-aided techniques with subsequent classification as: A) ≤10%, B) 11–25%, C) 26%-50%, or D) >50% density. Results: Between 11/97 and 06/05 a total of 39 cases (12 in-situ and 27 invasive) were found in 36 mutation carriers (19 BRCA1 and 17 BRCA2). Mean age of the women with cancer was 48 (range 34 to 64). Average semi-quantitative breast density for BRCA1 mutation carriers was 28% and for BRCA2 was 27%. Sensitivity of M vs. MRI for in-situ cases was 25% vs. 83%, and for invasive cases was 30% vs. 93%. Sensitivities for BRCA1 and BRCA2 mutation carriers were similar. For BIRADS 1 to 4 respectively M detected 1/3 (33%), 5/11 (45%), 4/22 (18%), and 1/3 (33%) of cases; and for density groups A to D respectively detected 2/6 (33%), 7/15 (47%), 1/11 (9%) and, 1/7 (14%). Conclusion: Although there was a trend towards decreasing mammographic sensitivity with increasing density, even among BRCA mutation carriers with low breast density mammography is an inadequate screening tool.

No significant financial relationships to disclose.

Breast and ovarian cancer risks to carriers of the BRCA1 5382insC and 185delAG and BRCA2 6174delT mutations: a combined analysis of 22 population based studies

A recent report estimated the breast cancer risks in carriers of the three Ashkenazi founder mutations to be higher than previously published estimates derived from population based studies. In an attempt to confirm this, the breast and ovarian cancer risks associated with the three Ashkenazi founder mutations were estimated using families included in a previous meta-analysis of populatrion based studies. The estimated breast cancer risks for each of the founder BRCA1 and BRCA2 mutations were similar to the corresponding estimates based on all BRCA1 or BRCA2 mutations in the meta-analysis. These estimates appear to be consistent with the observed prevalence of the mutations in the Ashkenazi Jewish population.

Fulminant hepatic failure and the potential role of liver dialysis

Fulminant hepatic failure (FHF) carries a high mortality. We aimed to review the prognostic factors and explore the potential role of Liver Dialysis (LD). Fifty-two patients were reviewed. The etiologies were acetaminophen toxicity (33%), viral hepatitis (18%), autoimmune (10%), idiosyncratic drug reactions (8%), others (6%) and undetermined (25%). Patients with acetaminophen had a significantly higher survival compared to the non-acetaminophen group (p=0.04). Patients with grade 3 encephalopathy had a mortality of 68%, among 5 patients with grade IV encephalopathy, 2 survived and both had had treatment with LD. Chi-square with Fisher's exact test was used for statistical analysis. Our study confirmed that the diagnosis of non-acetaminophen induced FHF and reduced initial serum factor V level are associated with fatal outcome. Timely OLT significantly improved the survival. The role of LD in hepatic regeneration or as a bridge to OLT needs to be further studied with prospective control trials.

Intensive radiologic surveillance: a focus on the psychological issues

Although women who carry BRCA1 or BRCA2 mutations have up to an 85% lifetime risk of breast cancer, the majority choose to forego prophylactic mastectomy, which has been proven to markedly lower breast cancer mortality, and opt for lifelong intensive surveillance. Whether surveillance lowers breast cancer mortality in these women is unknown. However, in a formal survey of 34 of these women, 82% indicated a strong belief in the ability of surveillance to find breast cancer at a stage when it is still curable. Since 1997 we have been conducting a study to compare the sensitivity of breast magnetic resonance imaging (MRI), ultrasound, mammography and clinical breast examination (CBE) in women at high risk for hereditary breast cancer. Breast cancer incidence rates have been even higher than predicted for this population. The addition of MRI and ultrasound to conventional surveillance with mammography and CBE significantly improves sensitivity, but at the expense of decreased specificity. Two years ago we began a formal study of distress and breast cancer anxiety. A sample of 25 new and ongoing participants in the surveillance study have completed the Hospital Anxiety and Depression Scale together with the Breast Cancer Worry Scale, up to six times per year over a 2-year period. To date there has been no evidence of any impact of intensive surveillance, including false-positive studies, on anxiety, depression or breast cancer worry.