Breast MRI use uncommon among U.S. women

Rates of high-risk screening prior to a breast cancer diagnosis in patients under age 40

BACKGROUND

NCCN Guidelines recommend screening young women with an increased breast cancer risk (>20 ​% lifetime risk). We sought to evaluate our institutional rates of high-risk screening in young breast cancer patients prior to their diagnoses."

METHODS

A single-institution retrospective review (2013-2018) was performed investigating risk scores (Tyrer-Cuzick model) and characteristics of breast cancer patients (age <40 ​y) prior to diagnosis.

RESULTS

92 breast cancer patients age <40 ​y were identified (average age 34.5). Only 3.3 ​% (n ​= ​3) underwent appropriate screening, despite 35.8 ​% meeting high-risk criteria. Nearly all patients underwent genetic testing (98.9 ​%) with pathogenic mutations identified in 36.5 ​%, including 15.3 ​% with BRCA1/2 mutations.

CONCLUSIONS

This analysis highlights a significant discrepancy between those meeting criteria for high-risk screening and those who underwent appropriate screening. We identified that this cohort carries significant genetic burden. Future analysis should investigate these findings on a broader scale and strategies to improve screening.

Breast Cancer Risk Assessment and Screening Practices Reported Via an Online Survey

BACKGROUND

Breast cancer screening guidelines differ between organizations, and significant variations in practice patterns exist. Previous evidence suggests that provider-level factors are the greatest contributors to risk assessment and screening practice variability. This study aimed to characterize provider factors associated with breast cancer risk assessment and screening practice patterns, and to assess perceived barriers to providing risk assessment.

METHODS

An online survey was distributed to providers at a single academic institution and to providers publicly via social media (January to August 2022). Respondents in the United States who care for adult women at risk for the development of breast cancer were included.

RESULTS

Most of the respondents in the 143 completed surveys were white/Caucasian (79%) females (90%) age 50 years or younger (79%), and whereas 97% discuss breast cancer screening with their patients, only 90% order screening mammograms. Risk factor assessment was common (93%), typically performed at the first visit (51%). Additional training in genetics or risk assessment was uncommon (17%), although the majority were interested but did not have the time or resources (55%). Although most (64%) did not perceive barriers to providing risk assessment or appropriate screening, the most common barriers were time (77%) and education (55%). Barriers were more common among family practice or obstetrics and gynecology (OB/GYN) providers and those who worked in an academic setting (all p < 0.05).

CONCLUSIONS

Breast cancer risk assessment and screening practices are highly variable. Although time is the major barrier to providing risk assessment, providers also need education. Primary care organizations could partner with breast cancer-focused societies for additional resources.

Recent Trends in Screening Breast MRI

OBJECTIVE

The objective of this study was to assess trends in screening breast MRI utilization among privately insured women in the U.S. from 2007 to 2017.

METHODS

The utilization of screening breast MRI among women aged 25-64 years from January 1, 2007, to December 31, 2017, was obtained using the MarketScan Commercial Database. We used Current Procedural Terminology codes to exclude breast MRI exams performed in women with a new breast cancer diagnosis and in women imaged to assess response to neoadjuvant therapy in the preceding 90 days. During the 11-year study, 351 763 study-eligible women underwent 488 852 MRI scans.

RESULTS

An overall 55.0% increase in screening breast MRI utilization was observed over the study period, with a steadily increasing trend. The greatest annual increase in percent utilization was from 2007 to 2008 at 16.6%. The highest utilization rate was in 2017, in which 0.4% of women aged 25-64 years underwent screening breast MRI. Of the women who underwent screening MRI with sufficient follow-up, 76.5% underwent only one examination during the study period.

CONCLUSION

Utilization of screening breast MRI has increased steadily in the past decade to a peak of 0.4% of adult women. However, an estimated 9% of U.S. women are eligible for high-risk breast MRI screening; thus, utilization falls short of optimal compliance. Further studies to evaluate the barriers to screening compliance may help optimize utilization.

Magnetic Resonance Imaging in Screening of Breast Cancer

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.

Potential of using mammography screening appointments to identify high-risk women: cross sectional survey results from the national health interview survey

PURPOSE

Mammography screening encounters may represent ideal opportunities to identify high-risk women for risk-based screening. During mammography appointments, radiology practices evaluate breast density and ascertain known breast cancer risk factors. Our purpose was to evaluate the potential for mammographic screening encounters to identify high-risk women by estimating the (1) proportion of high-risk women who report that they have undergone mammographic screening and the (2) proportion of high-risk women who receive recommendations for breast MRI screening.

METHODS

Women ages 30-85 without breast cancer histories were included from the 2015 National Health Interview Survey, a nationally representative cross-sectional household survey (response rate 80%). Breast Cancer Risk Assessment Tool was used to determine high-risk (lifetime risk>20%). Among high-risk women, primary outcome was proportion reporting mammography screening, secondary outcome was receipt of a breast MRI recommendation after recent mammogram, accounting for complex survey design.

RESULTS

14,958 women were included. 1.0% were high-risk of whom: 91.9% ever had a mammogram, 68.0% had a mammogram within the last year, 81.5% had a mammogram within the last 2 years. 6.4% were recommended to undergo breast MRI. Among high-risk women, women with dense breast tissue were more likely (OR 496.0, 95%CI 52.6,4674.0) and older women were less likely (OR 0.91, 95%CI 0.84,0.99) to receive recommendations for breast MRI.

CONCLUSIONS

Among high-risk women, 92% reported undergoing at least one mammogram in their lives. 94% did not receive recommendations for breast MRI screening and 32% did not have a mammogram within the last year. To identify high-risk women, breast imaging centers should consider determining lifetime breast cancer risk during mammography screening visits.

Sporadic implementation of UK familial mammographic surveillance guidelines 15 years after original publication

The National Institute of health and Care Excellence issued guidelines on familial breast cancer screening in 2004. Such guidelines should be uniformly implemented to ensure that members of the same family with the same level of risk, but living in different areas, have the same access to screening. We assessed uptake by creating a short, six question online survey designed to assess compliance in each regional area. We used this to conduct a survey of all 22 regional genetics services. There was a 100% response to the survey allowing a complete map to be created. The devolved nations had near complete compliance with the sole exception of SW Scotland, but in England the picture was fragmented with regions representing a combined population of 26.6 million (48%) not implementing the full NICE recommendations. Fifteen years after the publication of the original guidelines, major inequity in provision for screening still occurs and a postcode lottery exists for the management of women from families with a history of breast cancer. We estimate that up to 73 preventable breast cancer deaths occur each year due to the current inequity of access. It may be time to consider alternative funding and implementation models to ensure consistent access across the country.

Population-Based Assessment of the Association Between Magnetic Resonance Imaging Background Parenchymal Enhancement and Future Primary Breast Cancer Risk

PURPOSE

To evaluate comparative associations of breast magnetic resonance imaging (MRI) background parenchymal enhancement (BPE) and mammographic breast density with subsequent breast cancer risk.

PATIENTS AND METHODS

We examined women undergoing breast MRI in the Breast Cancer Surveillance Consortium from 2005 to 2015 (with one exam in 2000) using qualitative BPE assessments of minimal, mild, moderate, or marked. Breast density was assessed on mammography performed within 5 years of MRI. Among women diagnosed with breast cancer, the first BPE assessment was included if it was more than 3 months before their first diagnosis. Breast cancer risk associated with BPE was estimated using Cox proportional hazards regression.

RESULTS

Among 4,247 women, 176 developed breast cancer (invasive, n = 129; ductal carcinoma in situ,n = 47) over a median follow-up time of 2.8 years. More women with cancer had mild, moderate, or marked BPE than women without cancer (80% v 66%, respectively). Compared with minimal BPE, increasing BPE levels were associated with significantly increased cancer risk (mild: hazard ratio [HR], 1.80; 95% CI, 1.12 to 2.87; moderate: HR, 2.42; 95% CI, 1.51 to 3.86; and marked: HR, 3.41; 95% CI, 2.05 to 5.66). Compared with women with minimal BPE and almost entirely fatty or scattered fibroglandular breast density, women with mild, moderate, or marked BPE demonstrated elevated cancer risk if they had almost entirely fatty or scattered fibroglandular breast density (HR, 2.30; 95% CI, 1.19 to 4.46) or heterogeneous or extremely dense breasts (HR, 2.61; 95% CI, 1.44 to 4.72), with no significant interaction (P = .82). Combined mild, moderate, and marked BPE demonstrated significantly increased risk of invasive cancer (HR, 2.73; 95% CI, 1.66 to 4.49) but not ductal carcinoma in situ (HR, 1.48; 95% CI, 0.72 to 3.05).

CONCLUSION

BPE is associated with future invasive breast cancer risk independent of breast density. BPE should be considered for risk prediction models for women undergoing breast MRI.

Factors associated with breast MRI use among women with a family history of breast cancer

Although annual breast magnetic resonance imaging (MRI) is recommended for women at high risk for breast cancer as an adjunct to screening mammography, breast MRI use remains low. We examined factors associated with breast MRI use in a cohort of women with a family history of breast cancer but no personal cancer history. Study participants came from the Sister Study cohort, a nationwide, prospective study of women with at least 1 sister who had been diagnosed with breast cancer but who themselves had not ever had breast cancer (n = 17 894). Participants were surveyed on breast cancer beliefs, cancer worry, breast MRI use, provider communication, and genetic counseling and testing. Logistic regression was used to assess factors associated with having a breast MRI overall and for those at high risk. Breast MRI was reported by 16.1% and was more common among younger women and those with higher incomes. After adjustment for demographics, ever use of breast MRI was associated with actual and perceived risk. Odds ratios (OR) were 12.29 (95% CI, 8.85-17.06), 2.48 (95% CI, 2.27-2.71), and 2.50 (95% CI, 2.09-2.99) for positive BRCA1/2 test, lifetime breast cancer risk ≥ 20%, and being told by a health care provider of higher risk, respectively. Women who believed they had much higher risk than others or had higher level of worry were twice as likely to have had breast MRI; OR = 2.23 (95% CI, 1.82-2.75) and OR = 1.76 (95% CI, 1.52-2.04). Patterns were similar among women at high risk. Breast cancer risk, provider communication, and personal beliefs were determinants of breast MRI use. To support shared decisions about the use of breast MRI, women could benefit from improved understanding of the chances of getting breast cancer and increased quality of provider communications.

Informing Women and Their Physicians about Recommendations for Adjunct Breast MRI Screening: A Cohort Study

It is unclear how best to communicate recommendations for breast cancer screening with MRI as an adjunct to mammography for women at high risk. This study compares the rates of breast MRI screening for two different methods of communication. The retrospective IRB-approved cohort study was conducted at Invision Sally Jobe Breast Centers (ISJBC). ISJBC provided Gail model risk assessment to all women presenting for screening mammography. Women with scores ≥ 19.6% were considered to be high risk. Over 2 years, ISJBC used two different methods to inform women at elevated lifetime risk and their physicians about recommendations for adjunct MRI screening (N = 561, mean age = 52 years, s.d. = 8.7). During Window A, information was sent to referring physicians as a part of the dictated imaging report, while later, in Window B, the information was sent to referring physicians as well as to the women themselves in a letter. Analyses were stratified by mammography screening frequency. One-time screeners presented in only Window A or Window B. Repeat screeners came both in Window A and in Window B. Breast MRI screening rates were significantly higher in Window B than in Window A (one-time screeners, N = 459, 9.8% vs. 14.4%, p = 0.047; repeat screeners, N = 102, 0% vs. 6.9%, p = 0.016). Although an observational study cannot assess causality, direct communication of risk-based recommendations for adjunct breast MRI screening to women and to their referring physicians was associated with an increased rate of screening breast MRI completion at the same clinic at which the women underwent mammography.

Underutilization of Supplemental Magnetic Resonance Imaging Screening Among Patients at High Breast Cancer Risk

BACKGROUND

Women at high lifetime breast cancer risk may benefit from supplemental breast magnetic resonance imaging (MRI) screening, in addition to routine mammography screening for earlier cancer detection.

MATERIALS AND METHODS

We performed a cross-sectional study of 422,406 women undergoing routine mammography screening across 86 Breast Cancer Surveillance Consortium (BCSC) facilities during calendar year 2012. We determined availability and use of on-site screening breast MRI services based on woman-level characteristics, including >20% lifetime absolute risk using the National Cancer Institute risk assessment tool. Multivariate analyses were performed to determine sociodemographic characteristics associated with on-site screening MRI use.

RESULTS

Overall, 43.9% (2403/5468) of women at high lifetime risk attended a facility with on-site breast MRI screening availability. However, only 6.6% (158/2403) of high-risk women obtained breast MRI screening within a 2-year window of their screening mammogram. Patient factors associated with on-site MRI screening use included younger (<40 years) age (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.34-4.21), family history (OR = 1.72, 95% CI: 1.13-2.63), prior breast biopsy (OR = 2.09, 95% CI: 1.22-3.58), and postsecondary education (OR = 2.22, 95% CI: 1.04-4.74).

CONCLUSIONS

While nearly half of women at high lifetime breast cancer risk undergo routine screening mammography at a facility with on-site breast MRI availability, supplemental breast MRI remains widely underutilized among those who may benefit from earlier cancer detection. Future studies should evaluate whether other enabling factors such as formal risk assessment and patient awareness of high lifetime breast cancer risk can mitigate the underutilization of supplemental screening breast MRI.

Disparities in the use of screening magnetic resonance imaging of the breast in community practice by race, ethnicity, and socioeconomic status

BACKGROUND

Uptake of breast magnetic resonance imaging (MRI) coupled with breast cancer risk assessment offers the opportunity to tailor the benefits and harms of screening strategies for women with differing cancer risks. Despite the potential benefits, there is also concern for worsening population-based health disparities.

METHODS

Among 316,172 women aged 35 to 69 years from 5 Breast Cancer Surveillance Consortium registries (2007-2012), the authors examined 617,723 negative screening mammograms and 1047 screening MRIs. They examined the relative risks (RRs) of MRI use by women with a <20% lifetime breast cancer risk and RR in the absence of MRI use by women with a ≥20% lifetime risk.

RESULTS

Among women with a <20% lifetime risk of breast cancer, non-Hispanic white women were found to be 62% more likely than nonwhite women to undergo an MRI (95% confidence interval, 1.32-1.98). Of these women, those with an educational level of some college or technical school were 43% more likely and those who had at least a college degree were 132% more likely to receive an MRI compared with those with a high school education or less. Among women with a ≥20% lifetime risk, there was no statistically significant difference noted with regard to the use of screening MRI by race or ethnicity, but high-risk women with a high school education or less were less likely to undergo screening MRI than women who had graduated from college (RR, 0.40; 95% confidence interval, 0.25-0.63).

CONCLUSIONS

Uptake of screening MRI of the breast into clinical practice has the potential to worsen population-based health disparities. Policies beyond health insurance coverage should ensure that the use of this screening modality reflects evidence-based guidelines.

Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011

IMPORTANCE

Breast magnetic resonance imaging (MRI) is highly sensitive for detecting breast cancer. Low specificity, cost, and little evidence regarding mortality benefits, however, limit recommendations for its use to high-risk women. How breast MRI is actually used in community settings is unknown.

OBJECTIVE

To describe breast MRI trends and indications in a community setting.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study at a not-for-profit health plan and multispecialty group medical practice in New England of 10,518 women aged 20 years and older enrolled in the health plan for at least 1 year who had at least 1 breast MRI between January 1, 2000, and December 31, 2011.

MAIN OUTCOMES AND MEASURES

Breast MRI counts were obtained from claims data. Clinical indication (screening, diagnostic evaluation, staging or treatment, or surveillance) was determined using a prediction model developed from electronic medical records on a subset of participants. Breast cancer risk status was assessed using claims data and, for the subset, also through electronic medical record review. RESULTS; Breast MRI use increased more than 20-fold from 6.5 per 10,000 women in 2000 to 130.7 per 10,000 in 2009. Use then declined and stabilized to 104.8 per 10,000 by 2011. Screening and surveillance, rare indications in 2000, together accounted for 57.6% of MRI use by 2011; 30.1% had a claims-documented personal history and 51.7% a family history of breast cancer, whereas 3.5% of women had a documented genetic mutation. In the subset of women with electronic medical records who received screening or surveillance MRIs, only 21.0% had evidence of meeting American Cancer Society (ACS) criteria for breast MRI. Conversely, only 48.4% of women with documented deleterious genetic mutations received breast MRI screening.

CONCLUSIONS AND RELEVANCE

Breast MRI use increased steeply over 10 years and then stabilized, especially for screening and surveillance among women with family or personal history of breast cancer; most women receiving screening and surveillance breast MRIs lacked documented evidence of meeting ACS criteria, and many women with mutations were not screened. Efforts are needed to ensure that breast MRI use and documentation are focused on those women who will benefit most.

Patterns of breast magnetic resonance imaging use in community practice

IMPORTANCE

Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer screening, diagnostic evaluation, and surveillance. However, we lack data on national patterns of breast MRI use in community practice.

OBJECTIVE

To describe patterns of breast MRI use in US community practice during the period 2005 through 2009.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using data collected from 2005 through 2009 on breast MRI and mammography from 5 national Breast Cancer Surveillance Consortium registries. Data included 8931 breast MRI examinations and 1,288,924 screening mammograms from women aged 18 to 79 years.

MAIN OUTCOMES AND MEASURES

We calculated the rate of breast MRI examinations per 1000 women with breast imaging within the same year and described the clinical indications for the breast MRI examinations by year and age. We compared women screened with breast MRI to women screened with mammography alone for patient characteristics and lifetime breast cancer risk.

RESULTS

The overall rate of breast MRI from 2005 through 2009 nearly tripled from 4.2 to 11.5 examinations per 1000 women, with the most rapid increase from 2005 to 2007 (P = .02). The most common clinical indication was diagnostic evaluation (40.3%), followed by screening (31.7%). Compared with women who received screening mammography alone, women who underwent screening breast MRI were more likely to be younger than 50 years, white non-Hispanic, and nulliparous and to have a personal history of breast cancer, a family history of breast cancer, and extremely dense breast tissue (all P < .001). The proportion of women screened using breast MRI at high lifetime risk for breast cancer (>20%) increased during the study period from 9% in 2005 to 29% in 2009.

CONCLUSIONS AND RELEVANCE

Use of breast MRI for screening in high-risk women is increasing. However, our findings suggest that there is a need to improve appropriate use, including among women who may benefit from screening breast MRI.