Transcript High-Risk Screening Evidence-based Clinical Indications

Breast MR Imaging Workshop 2014
13th September 2014
High-Risk Screening
Evidence-based Clinical Indications
for Breast MRI
Dr. Muhamad Zabidi Ahmad, AMDI
Introduction
1.
2.
• Worldwide in 2010, estimated
1,643,000 new cases of breast
cancer1.
• 60% of breast cancer deaths
are from less developed
nations2.
• Increased screening program in
1990’s has led to early
detection.
• Mainly by mammogram and/or
ultrasound.
Jemal et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.
World Health Organization. Breast cancer: Prevention and Control
Strategies for
Screening
• Take into account the
combined evidence for risk of
breast cancer and effectiveness
and harms of breast cancer
screening.
• Mammogram is mainstay.
• Role of MRI is emerging
– In combination with
mammography, targeted to
high-risk patients.
The Important Points
Who are the
high-risk
group?
What are the
experts say?
In context of
our
population
Who Are The High-risk
Group?
Risk Factors for Developing Breast Cancer
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Age – risks increases with age
Family history
Early menarche, late menopause
Oral contraceptive use
Age at first birth >30
Breast density on mammogram
BRCA mutation carrier
Alcohol
ACS
• American Cancer Society
(2007)3 recommends annual
MRI, in addition to
mammogram, to women in
these groups:
– Known BRCA mutation
carriers
– First degree relatives of
known BRCA carriers
– Approximate lifetime risk of
breast cancer from 20 to 25
percent based on risk
prediction model
3. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as
an adjunct to mammography. CA Cancer J Clin 2007; 57:75.
NCCN
• National Comprehensive Cancer
Network (NCCN)4 recommended
annual breast MRI in adjunct to
mammography in these groups:
– BRCA1 and BRCA2 mutation
carriers
– First degree relative with
BRCA1 or BRCA2 mutation
– Family history of breast or
ovarian cancer
– Received radiation treatment
to the chest between ages 10
and 30
– TP53 or PTEN genes mutation
4. Bevers TB, Anderson BO, Bonaccio E, et al. NCCN clinical practice guidelines in oncology: breast cancer
screening and diagnosis. J Natl Compr Canc Netw 2009; 7:1060.
Carriers of BRCA1, BRCA2, or TP53 mutation
First degree relative of someone who carries
BRCA1, BRCA2, or TP53 mutation
Strong family history of breast or ovarian
cancer; or both
Family history consistent with Li-Fraumeni
syndrome*
Received radiation treatment to the chest
between ages 10 and 30
*Li-Fraumeni syndrome – extremely rare AD hereditary disorder. Classical
malignancy – sarcomas, cancers of the breast, brain and adrenal glands
What Are The Experts Say
A look into published literatures
No data from randomized control trials that show a
benefit of screening by MRI in women with low to
average risk of breast cancer.
Contributed partly by higher cost of MRI compared
to mammography5.
Screening breast MRI is more sensitive but less
specific than mammography for detection of
invasive breast cancer in high-risk women in both
retrospective and prospective studies.
5. http://www.uptodate.com/contents/screening-for-breast-cancer-evidence-for-effectiveness-andharms?topicKey=PC%2F87311&elapsedTimeMs=0&source=machin%E2%80%A6
Morris et al.
• Retrospective study involving
367 women with high-risk
developing breast cancer.
• Normal mammography
findings.
• Screening MRI performed
during 2 year period.
Morris et al.
• Among high-risk women, MRI
led to biopsy in 17%.
• Cancer found in 24% of women
undergoing biopsy.
• 4% from women who had MRI
screening.
Warner et al.
• Retrospective study involving
236 high-risk women with
BRCA1 and BRCA2 mutation.
• Underwent mammogram, MRI
and ultrasound as well as
clinical breast examination.
• From 1997 – 2003.
Warner et al.
• MRI is more sensitive in
detecting breast cancer
compared to mammography,
ultrasound or clinical breast
examination alone in BRCA1
and BRCA2 mutation women.
Stoutjesdijk
et al.
• Retrospective study of all MRI
and mammographic study
between 1994 to 2001.
• 179 women.
• MRI more accurate than
mammography in annual
screening in women with
hereditary risk of breast cancer.
Lehman et
al.
• Prospective study involving 195
women over 6-month period.
• BRCA1/BRCA2 carrier in
women 25 years old and older.
Lehman et
al.
• Screening MR imaging had
higher biopsy rate.
• Helped detect more cancers
than either mammography or
ultrasound alone.
Berg et al.
• Prospective study to determine
cancer detection yield by
ultrasound and MRI in women
with elevated risk for breast
cancer.
• 2809 women at 21 sites from
2004 to 2006.
• MRI resulted in higher detection
rate.
• Reviewed 11 studies comparing
test performance of screening
MRI with mammography in
high-risk women.
• Age ranging 40 to 47 years old.
• Sensitivity of MRI higher than mammography:
0.77 (95% CI 0.70 – 0.84) versus 0.39 (CI 0.37
– 0.41).
• Specificity of MRI lower than mammography:
0.86 (CI 0.81 – 0.92) versus 0.95 (CI 0.93 –
0.97).
• Sensitivity of MRI and mammography
together was 0.94 (CI 0.90 – 0.97) and
specificity was 0.77 (CI 0.75 – 0.80).
• However, the cost of running MRI for
screening is higher
• Take longer time
• Studies looking into more effective and faster
MRI acquisition
• Takes 3 minutes instead of 40
minutes
• T1 followed by contrast
• Images substracted into individual
first postcontrast subtracted
images (FAST) and fused into
single MIP image
In Context of Our
Population
• Incidence of breast cancer
published in National Cancer
Registry 2006 was 39.3 per
100,000 population.
• Most present at late stage.
• Mammogram prevalence rate
of 7.6% (National Health
Morbidity Survey 2006).
• MRI not used widely.
CPG 2nd Edition
2010 on
management of
breast cancer
CPG on Management of Breast Cancer, 2nd Edition 2010
American Cancer
Society
recommendation
for breast MRI
screening.
Conclusion
• MRI as a screening tool for high-risk women
• Valuable adjunct when used together with
mammogram
• Limited resources for large scale screening
program
Thank you