Multimodality breast cancer screening in women with a familial or genetic predisposition

Clinical breast exam contribution to breast cancer diagnosis in BRCA mutation carriers vs. average to intermediate risk women

PURPOSE

The contribution of clinical breast exam (CBE) to breast cancer diagnosis in average risk women undergoing regular screening mammography is minimal. To evaluate the role of CBE in high-risk women, we compared BC diagnosis by CBE in BRCA mutation carriers undergoing regular BC surveillance to average to intermediate risk women undergoing regular breast cancer screening.

METHODS

A retrospective chart review of all consecutive screening visits of BRCA mutation carriers (January 2012-October 2022) and average to intermediate risk women (November 2016-December 2022) was completed. Women with histologically confirmed BC diagnosis were included. Additional CBE yield for BC diagnosis, defined as the percentage of all BC cases detected by CBE alone, was assessed in both groups.

RESULTS

Overall, 12,997 CBEs were performed in 1,328 BRCA mutation carriers in whom 134 BCs were diagnosed. In 7,949 average to intermediate risk women who underwent 15,518 CBEs, 87 BCs were diagnosed. CBE contributed to BC diagnosis in 3 (2%) BRCA mutation carriers and 3 (4%) non-carriers. In both groups, over 4,000 CBEs were needed in order to diagnose one cancer. In all 3 BRCA mutation carriers BC was palpated during the surveillance round that did not include MRI. In the average to intermediate risk group, 2 of 3 cancers diagnosed following CBE findings were in a different location from the palpable finding.

CONCLUSIONS

The contribution of CBE to BC diagnosis is marginal for all women including BRCA mutation carriers. In BRCA mutation carriers, CBE appears redundant during the MRI surveillance round.

Revisiting Screening in Women With a Family History of Breast Cancer

Women with a family history (FH) of breast cancer and without known genetic susceptibility represent a unique population whose lifetime probability of developing breast cancer varies widely depending on familial factors, breast density, and the risk assessment tool used. Recently updated guidelines from the American College of Radiology recommend supplemental annual screening with contrast-enhanced MRI or contrast-enhanced mammography for women with an FH who are high risk (≥20% lifetime risk) or have dense breasts. To date, most screening studies addressing outcomes in women with FH have largely included those also with confirmed or suspected gene mutations, in whom the lifetime risk is highest, with limited data for women at average to intermediate risk who are not known to be genetically susceptible and may not benefit as much from the same screening approaches. Further research focusing specifically on women with FH as the only breast cancer risk factor is warranted to refine risk assessment and optimize a multimodality personalized screening approach.

The value of clinical breast examination in a breast cancer surveillance program for women with germline BRCA1 or BRCA2 mutations

OBJECTIVE

To assess the sensitivity and specificity of clinical breast examination for detecting breast cancer in asymptomatic women with predisposing germline mutations enrolled in a cancer risk management program that includes radiologic screening.

DESIGN, SETTING

Retrospective, longitudinal cohort study of women with BRCA1/2 mutations who attended the Breast and Ovarian Cancer Risk Management Clinic at the Peter MacCallum Cancer Centre, a tertiary referral centre in Melbourne, during 1 September 2001 - 31 December 2019.

PARTICIPANTS

Consecutive women with BRCA1/2 mutations who did not have personal histories of cancer and had not undergone bilateral risk-reducing mastectomy, and who had visited the clinic at least twice during the study period. Participants had generally undergone breast examination at 6- or 12-month intervals, and annual breast imaging (mammography; and magnetic resonance imaging [MRI] for women aged 50 years or younger).

MAIN OUTCOME MEASURES

Sensitivity (proportion of all biopsy-confirmed breast cancers detected by breast examination alone) and specificity of breast examination for detecting breast cancer.

RESULTS

Of 414 eligible women (mean age, 35.5 years; SD, 11.2 years), 35 were diagnosed with breast cancer during 1761 woman-years of follow-up. Only two were diagnosed based on breast examination alone (ie, without radiologic evidence), neither of whom was undergoing MRI screening. The sensitivity of breast examination was 6% (95% CI, 1-19%), the specificity 97% (95% CI, 95-98%); the positive predictive value was 14% (95% CI, 2-43%), the negative predictive value 92% (95% CI, 89-94%).

CONCLUSION

Clinical breast examination did not increase the number of breast cancers detected in MRI-screened women with BRCA1/2 mutations. Removing breast examination from surveillance programs that include MRI may be reasonable for these women.

The Effect of Prior Comparison MRI on Interpretive Performance of Screening Breast MRI

OBJECTIVE

To evaluate the effect of prior comparison MRI on interpretive performance of screening breast MRI.

METHODS

After institutional review board approval, all screening breast MRI examinations performed from January 2011 through December 2014 were retrospectively reviewed. Screening performance metrics were estimated and compared for exams with and without a prior comparison MRI, using logistic regression models to adjust for age and screening indication (BRCA mutation or thoracic radiation versus breast cancer history versus high-risk lesion history versus breast cancer family history).

RESULTS

Most exams, 4509 (87%), had a prior comparison MRI (incidence round), while 661 (13%) did not (prevalence round). Abnormal interpretation rate (6% vs 20%, P < 0.01), biopsy rate (3% vs 9%, P < 0.01), and false-positive biopsy recommendation rate per 1000 exams (21 vs 71, P < 0.01) were significantly lower in the incidence rounds compared to the prevalence rounds, while specificity was significantly higher (95% vs 81%, P < 0.01). There was no difference in cancer detection rate (CDR) per 1000 exams (12 vs 20, P = 0.1), positive predictive value of biopsies performed (PPV3) (35% vs 23%, P = 0.1), or sensitivity (86% vs 76%, P = 0.4).

CONCLUSION

Presence of a prior comparison significantly improves incidence round screening breast MRI examination performance compared with prevalence round screening. Consideration should be given to updating the BI-RADS breast MRI screening benchmarks and auditing prevalence and incidence round examinations separately.

The Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2018 Edition

This article updates readers as to what is new in the Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2018 Edition. Breast cancer screening issues are covered, including matters of breast density and possible supplemental modalities, along with appropriate pre-operative/follow-up diagnostic breast imaging tests. Up-to-date clinical practice guidelines for breast cancer screening and diagnosis should help to provide patients and clinicians with not only evidence-based breast imaging options, but also accurate and balanced information about the benefits and harms of intervention, which ultimately enables shared decision making about imaging test plans.

Prospective blinded surveillance screening of Swedish women with increased hereditary risk of breast cancer

Purpose

To evaluate the sensitivity and specificity of different screening modalities in women with a family history of breast cancer.

Methods

Our blinded, prospective, comparative cohort analysis included three types of screening, mammography, ultrasound, and clinical breast examination once per year for 6 years. Eligible patients for this study were healthy women with ≥ 17% lifetime risk of breast cancer or with a mutation in BRCA1 or BRCA2.

Results

A total of 632 women were screened between 2002 and 2012 (each for 6 years). During the study, 30 women were diagnosed with breast cancer, with 10 of these diagnoses occurring between screening visits, and six of the 10 diagnosed women were gene carriers. The clinical presentation for the women diagnosed with breast cancer was followed until 2017. No consistent patterns for the diagnostic capacity of the different screening modalities were found, although mammography showed low sensitivity, whereas ultrasound showed better sensitivity in three of the six rounds. The specificity was high in mammography and improved in ultrasound over time. Most importantly, clinical breast examination provided no additional information toward the diagnosis of breast cancer.

Conclusion

Neither mammography nor ultrasound performed yearly were sensitive enough as standalone modalities, although high specificity was confirmed. Our findings indicate that high risk (> 29% life time risk) individuals and gene carriers can be screened biannually, using the same protocol as used in mutation carriers. Our results also suggest that low-risk groups (< 20%) may continue to be referred to population mammography screening program, while clinical breast examination may be omitted in all risk groups, and could be optional in gene carriers.

Electronic supplementary material

The online version of this article (10.1007/s10549-017-4639-0) contains supplementary material, which is available to authorized users.

Accuracy of screening women at familial risk of breast cancer without a known gene mutation: Individual patient data meta-analysis

INTRODUCTION

Women with a strong family history of breast cancer (BC) and without a known gene mutation have an increased risk of developing BC. We aimed to investigate the accuracy of screening using annual mammography with or without magnetic resonance imaging (MRI) for these women outside the general population screening program.

METHODS

An individual patient data (IPD) meta-analysis was conducted using IPD from six prospective screening trials that had included women at increased risk for BC: only women with a strong familial risk for BC and without a known gene mutation were included in this analysis. A generalised linear mixed model was applied to estimate and compare screening accuracy (sensitivity, specificity and predictive values) for annual mammography with or without MRI.

RESULTS

There were 2226 women (median age: 41 years, interquartile range 35-47) with 7478 woman-years of follow-up, with a BC rate of 12 (95% confidence interval 9.3-14) in 1000 woman-years. Mammography screening had a sensitivity of 55% (standard error of mean [SE] 7.0) and a specificity of 94% (SE 1.3). Screening with MRI alone had a sensitivity of 89% (SE 4.6) and a specificity of 83% (SE 2.8). Adding MRI to mammography increased sensitivity to 98% (SE 1.8, P < 0.01 compared to mammography alone) but lowered specificity to 79% (SE 2.7, P < 0.01 compared with mammography alone).

CONCLUSION

In this population of women with strong familial BC risk but without a known gene mutation, in whom BC incidence was high both before and after age 50, adding MRI to mammography substantially increased screening sensitivity but also decreased its specificity.

Determination of recall rates for assessment in high-risk women undergoing annual surveillance breast MRI

AIM

To review all surveillance breast magnetic resonance imaging (MRI) examinations performed over a 6-year period at an Irish national centre to determine the recall rate, biopsy rate, and cancer-detection rates.

MATERIALS AND METHODS

All breast MRI examinations performed for surveillance purposes in women at high risk of developing breast cancer between January 2009 and December 2014 were reviewed. The Breast Imaging-Reporting and Data System (BI-RADS) score for each MRI examination was determined, the type of additional imaging performed, and the method of biopsy, if performed, was recorded. Histology of the biopsy specimens was reviewed.

RESULTS

Data for 715 women undergoing 1445 surveillance MRI examinations were identified. Of the examinations, 10.9% (157/1445) had MRI BI-RADS scores that required recall for further imaging and 6.3% (91/1445) required a biopsy. Recall rates were 14.2% (86/607) and 8.5% (71/838) in the prevalent and incident rounds, respectively. The overall cancer detection rate was 17 per 1000.

CONCLUSION

The current UK guideline was not achieved and no studies to date have achieved the target of <7%. Aiming for this target could risk lowering the cancer-detection rate. The authors would suggest a target rate of <15% and <10% for the prevalent round and incident rounds, respectively.

Contribution of mammography to MRI screening in BRCA mutation carriers by BRCA status and age: individual patient data meta-analysis

BACKGROUND

We investigated the additional contribution of mammography to screening accuracy in BRCA1/2 mutation carriers screened with MRI at different ages using individual patient data from six high-risk screening trials.

METHODS

Sensitivity and specificity of MRI, mammography and the combination of these tests were compared stratified for BRCA mutation and age using generalised linear mixed models with random effect for studies. Number of screens needed (NSN) for additional mammography-only detected cancer was estimated.

RESULTS

In BRCA1/2 mutation carriers of all ages (BRCA1 = 1,219 and BRCA2 = 732), adding mammography to MRI did not significantly increase screening sensitivity (increased by 3.9% in BRCA1 and 12.6% in BRCA2 mutation carriers, P > 0.05). However, in women with BRCA2 mutation younger than 40 years, one-third of breast cancers were detected by mammography only. Number of screens needed for mammography to detect one breast cancer not detected by MRI was much higher for BRCA1 compared with BRCA2 mutation carriers at initial and repeat screening.

CONCLUSIONS

Additional screening sensitivity from mammography above that from MRI is limited in BRCA1 mutation carriers, whereas mammography contributes to screening sensitivity in BRCA2 mutation carriers, especially those ⩽ 40 years. The evidence from our work highlights that a differential screening schedule by BRCA status is worth considering.

Magnetic resonance imaging improves breast screening sensitivity in BRCA mutation carriers age ≥ 50 years: evidence from an individual patient data meta-analysis

PURPOSE

There is no consensus on whether magnetic resonance imaging (MRI) should be included in breast screening protocols for women with BRCA1/2 mutations age ≥ 50 years. Therefore, we investigated the evidence on age-related screening accuracy in women with BRCA1/2 mutations using individual patient data (IPD) meta-analysis.

PATIENTS AND METHODS

IPD were pooled from six high-risk screening trials including women with BRCA1/2 mutations who had completed at least one screening round with both MRI and mammography. A generalized linear mixed model with repeated measurements and a random effect of studies estimated sensitivity and specificity of MRI, mammography, and the combination in all women and specifically in those age ≥ 50 years.

RESULTS

Pooled analysis showed that in women age ≥ 50 years, screening sensitivity was not different from that in women age < 50 years, whereas screening specificity was. In women age ≥ 50 years, combining MRI and mammography significantly increased screening sensitivity compared with mammography alone (94.1%; 95% CI, 77.7% to 98.7% v 38.1%; 95% CI, 22.4% to 56.7%; P < .001). The combination was not significantly more sensitive than MRI alone (94.1%; 95% CI, 77.7% to 98.7% v 84.4%; 95% CI, 61.8% to 94.8%; P = .28). Combining MRI and mammography in women age ≥ 50 years resulted in sensitivity similar to that in women age < 50 years (94.1%; 95% CI, 77.7% to 98.7% v 93.2%; 95% CI, 79.3% to 98%; P = .79).

CONCLUSION

Addition of MRI to mammography for screening BRCA1/2 mutation carriers age ≥ 50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age ≥ 50 years should be reconsidered.

The additional cancer yield of clinical breast examination in screening of women at hereditary increased risk of breast cancer: a systematic review

Women at hereditary increased risk of breast cancer are subjected to frequent clinical breast examination (CBE) and radiological evaluation of the breasts. This review appraises the additional cancer yield by CBE in screening of women at increased risk of breast cancer who are also subjected to frequent radiological evaluation. A literature search was conducted to identify all prospective studies on the additional value of CBE in screening of women at increased risk of breast cancer. Quality appraisal of included studies was performed using the QUADAS-2 tool. A total of 514 citations were identified. Relevant literature was scarce and highly heterogeneous. Seven prospective studies were included for review of which two studies reported additional cancer yield of CBE (3 and 5 % of total cancer cases). These two studies reported lower screen detection (77 and 80 %) compared to the studies in which no additional cases were detected by CBE (screen detection ≥94 %). Current literature on CBE in screening of women at increased risk of breast cancer is insufficient. However, it suggests that the additional cancer yield by performing CBE is minimal or absent. Reconsideration of the role of CBE in intensified screening might be warranted.

Re. Multimodality breast cancer screening in women with a familial or genetic predisposition

Earlier this year in Current Oncology, Trop and colleagues added new information to support the claim that screening with magnetic resonance imaging (MRI) for breast cancer is superior—in terms of sensitivity— to routine mammography [...]