March 8, 2009

ACS Guidelines for Breast Screening with MRI May Be Excluding Some High-risk Women


ACS Guidelines for Breast Screening with MRI May Be Excluding Some High-risk Women

The American Cancer Society (ACS) has developed a set of guidelines to recommend which high-risk women need to undergo screening with breast magnetic resonance imaging (MRI); however, these guidelines may unwittingly exclude some women who are at a high risk of carrying the BRCA mutation yet still don’t meet the limitations set by the ACS. The results of this study were published in the journal Cancer.[1]

Breast cancer is the second leading cause of cancer death in women in the United States, with approximately 180,000 cases diagnosed each year. Women with a family history of breast cancer are at an increased lifetime risk of developing the disease, as are women who carry a BRCA mutation. These women are encouraged to undergo more vigilant screening to allow for earlier detection and higher cure rates.

MRI uses radio waves and a magnet to create detailed images of the inside of the body. The American Cancer Society has recommended annual breast MRI for the following high-risk groups:

  • Women with a BRCA1 or BRCA2 mutation
  • Women who have a first-degree relative with a BRCA mutation (even if they have not yet been tested themselves)
  • Women who have a 20-25% or greater risk of breast cancer based on risk assessment tools (which utilize family history)

Researchers evaluated 18,190 patients who underwent breast cancer screening mammography at Massachusetts General Hospital Avon Comprehensive Breast Evaluation Center between 2003 and 2005. The primary objectives of the study were to determine the number of patients who met the ACS criteria for MRI screening based on their lifetime breast cancer risk and also to identify the number of high-risk patients who may be systematically excluded from MRI screening based on the ACS guidelines.

The women completed a questionnaire regarding their breast cancer risk factors, and the researchers then used BRCAPRO, a computerized breast cancer risk-assessment model, to determine their lifetime breast cancer risk and their risk of BRCA mutation.

The researchers observed that 0.43% of the screening population met the ACS MRI screening criteria; however, 1.01% of the population was comprised of mutation carriers. By following the ACS guidelines, only 14.75% (27 of 183 patients) would be eligible for MRI screening. This discrepancy was further magnified among the Jewish subset in the study, where only 23 of 1,035 women qualified for MRI based on the ACS criteria, but 96 more women had a 10% or greater risk of mutation. The researchers estimated that 40% of mutation carriers in the Jewish population may not meet the criteria for more intensive surveillance with MRI.

Based on the results of this study, the researchers expressed concern that the ACS guidelines may exclude some high-risk women from MRI screening. They suggest that “a more effective approach may be to encourage genetic testing on women who are identified as high-risk, thus providing a better definition of the MRI target population.”


[1] Murphy CD, Lee JM, Drohan B, et al. The American Cancer Society guidelines for breast screening with magnetic resonance imaging. Cancer. 2008;113:3116-3120.

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