MRI screening for breast cancer in high-risk patients

Abstract

Mrs. R is a healthy 53-year-old female. She is married with two daughters and is of Ashkenazi Jewish descent. She believed that she was at high risk for the development of breast cancer and scheduled an appointment to discuss this with her nurse practitioner (NP). She was concerned because her mother was diagnosed with breast cancer at age 32 and died from the disease. Her maternal grandmother passed away from ovarian cancer at age 50. The NP orders a BRCA1 and BRCA2 testing. In the United States, BRCA mutations are more common in those of Ashkenazi Jewish descent than other ethnic groups. 1 Results of the tests were positive for the BRCA1 deleterious mutation. During her follow-up visit, the NP discussed the results of the BRCA testing and referred Mrs. R for genetic counseling. Mrs. R also requested information about a breast magnetic resonance imaging (MRI). ■ Breast cancer overviewBreast cancer is currently the most common cause of cancer in women in the United States. 2 The American Cancer Society (ACS) estimates that in 2014, 232,670 women will be diagnosed with invasive breast cancer in the United States, another 62,570 women will be diagnosed with in situ cases, and 40,000 will die from breast cancer. 2 The ACS has established recommendations for breast cancer screening depending on a woman's calculated lifetime risk for developing breast cancer. Screening for high-risk individuals includes an annual mammogram in addition to an annual MRI. 3 ■ High-risk determination The determination of risk assessment for patients directs recommendations for screening. High-risk patients can be predisposed to the development of breast cancer through a variety of factors. A personal history or family history in women with fi rst-degree relatives affected with breast cancer are at an increased risk for developing breast cancer themselves. 1-3 Genetic predisposition with regard to mutations of the BRCA1 and BRCA2 genes increases risk for breast cancer. 1,2,4 Women who were treated with radiation in the chest area for a previous cancer (Hodgkin Disease or non-Hodgkin lymphoma) between 10 and 30 years of age are also at increased risk for breast cancer. [1][2][3] Several breast cancer risk prediction models (such as the Gail, Tyrer-Cuzick, Claus, and BRCAPRO) are available for healthcare providers to assess for breast cancer risk or the possibility that a BRCA mutation is present. 3 MRI screening is recommended as an adjunct to mammography when the risk prediction model projects a 20% to 25% greater lifetime risk. 3,5 The ACS takes a neutral stance on the use of an annual MRI screening for patients with a 15% to 20% lifetime risk of breast cancer. 3 A patient with a 15% or less lifetime risk is not recommended for annual MRI screening by the ACS at this time. 3 Annual MRI screening in conjunction with an annual mammogram is recommended for women over age 30 who have specifi c risk factors, including the BRCA mutation, a 20% to 25% or greater lifetime risk of breast cancer determined by the appropriate prediction model, or a ...