High-risk women–What breast screening is appropriate?

Article Type

Article

Changed

Mon, 01/31/2022 - 10:29

Author(s)

Robin Seitzman, PhD, MPH

Wendie Berg, MD, PhD

_{Text copyright DenseBreast-info.org.}

Answer

B. For a 28-year-old woman, herself untested, with a known pathogenic BRCA1 or BRCA2 mutation in a first-degree relative (mother/ father, sister/brother, daughter/son), screening annual magnetic resonance imaging (MRI) alone is recommended until age 30, followed by screening annual MRI and mammography/tomosynthesis at age 30 and beyond. If MRI is not an option, ultrasonography or contrast-enhanced mammography should be considered.

Most medical societies in the United States recommend mammography screening beginning at age 40 if a woman is at average risk. If a woman is determined to be at high risk, breast cancer screening may be recommended to begin by age 30. Breast cancer risk assessment, with a risk model based largely on family history, should begin by age 30 for all women.

The American College of Radiology (ACR),¹ National Comprehensive Cancer Network (NCCN),^2,3and American Society of Breast Surgeons recommend annual MRI screening for the following high-risk subgroups of women:

Women with known disease-causing BRCA1 or BRCA2 mutations, or other disease-causing mutations, or their untested first-degree relatives. (Age to begin screening MRI and screening mammography/tomosynthesis varies by mutation).^1,3 Women with known pathogenic BRCA1 or BRCA2 mutations, or their untested first-degree relatives, should begin annual screening with MRI only between ages 25-29, adding annual digital mammography/tomosynthesis at age 30 and beyond (unless the woman has had bilateral mastectomy). Note: There is emerging evidence that the benefit of mammography is relatively small in pathogenic BRCA1 carriers prior to the age of 40; therefore, the ACR suggests BRCA1 mutation carriers may consider delaying mammography until age 40 only if they receive contrast-enhanced MRI annually starting at age 25.¹ Annual mammography is of benefit beginning at age 30 in those with BRCA2 or other disease-causing mutations.
Age to begin annual MRI screening and mammography/tomosynthesis in women who are known to carry or are first-degree untested relatives of individuals with less common disease-causing mutations (such as those associated with Li-Fraumeni syndrome [TP53]; Bannayan-Riley-Ruvalcaba syndrome or Cowden syndrome [PTEN]; hereditary diffuse gastric cancer [CDH1]; Peutz-Jeghers syndrome [STK11]; neurofibromatosis type 1 [NF1]; PALB2; ATM; CHEK2; or BARD1) ranges from 20-40 years depending on the mutation and family history.³ (See https://densebreast-info.org/providers-faqs /what-is-the-screening-management-for -various-other-mutation-carriers/.)

Women who received chest/mantle radiation therapy by age 30 (such as for Hodgkin disease) and at least 8 years prior. Women with prior chest radiation therapy (such as for Hodgkin disease) between ages 10 and 30 are at high risk for developing breast cancer,^1,2,4,5 with risk similar in magnitude to BRCA1 or BRCA2 carriers, and are recommended for annual screening MRI starting at age 25 or 8 years after the chest radiation therapy, whichever is later.
Women with a calculated lifetime risk of breast cancer of ≥20% are recommended to begin annual screening MRI by age 25-30.^1,2,5 Any of the models that include detailed family history such as the Tyrer-Cuzick (IBIS, which now includes breast density as a risk factor); BRCAPRO; BOADICEA; Claus; or Penn II; but not the Gail or Breast Cancer Surveillance Consortium (BCSC) models, can be used to estimate lifetime risk for the purposes of screening MRI guidelines. (See https://densebreast -info.org/for-providers/risk-model-tutorial/ for a summary table with live links.)
Women with a personal history of breast cancer and dense breasts or diagnosis by age 50, regardless of breast density. A personal history of breast cancer is not included in risk models, but all women diagnosed with breast cancer at or before age 50 and treated with breast-conserving therapy have a ≥20% lifetime risk for a new breast cancer.^1,2 Annual MRI may be considered in addition to annual mammography or tomosynthesis in women with a personal history of breast cancer diagnosed after age 50 and without dense breasts, and/or a history of lobular carcinoma in situ (LCIS) or prior atypia (eg, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or atypical papilloma).^1,2

Supplemental MRI screening should continue until age 75, after which management should be considered on an individual basis. If MRI screening is not an option, ultrasound or contrast-enhanced mammography (where available) should be considered as an alternative.^6-8 ●

RESOURCES

For more information, visit medically sourced DenseBreastinfo.org. Comprehensive resources include a free CME opportunity, Dense Breasts and Supplemental Screening.

References

Monticciolo DL, Newell MS, Moy L, et al. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018;15 (3 Pt A):408-414. doi: 10.1016/j.jacr.2017.11.034.
National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis (Version 1.2021). https://www .nccn.org/professionals/physician_gls/pdf/breast-screening .pdf. Accessed November 18, 2021.
National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version 1.2020). https://www.nccn.org/professionals/physician_gls/pdf /genetics_bop.pdf. Accessed July 31, 2020.
Oeffinger KC, Ford JS, Moskowitz CS, et al. Breast cancer surveillance practices among women previously treated with chest radiation for a childhood cancer. JAMA. 2009;301(4):404-414. DOI: 10.1001/jama.2008.1039.
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;57:75-89. doi: 10.3322/canjclin.57.2.75.
Sorin V, Yagil Y, Yosepovich A, et al. Contrast-enhanced spectral mammography in women with intermediate breast cancer risk and dense breasts. AJR Am J Roentgenol. 2018;211:W267-W274. doi: 10.2214/AJR.17.19355.
Sung JS, Lebron L, Keating D, et al. Performance of dualenergy contrast-enhanced digital mammography for screening women at increased risk of breast cancer. Radiology. 2019;293:81-88. doi: 10.1148/radiol.2019182660.
Xiang W, Rao H, Zhou L. A meta-analysis of contrastenhanced spectral mammography versus MRI in the diagnosis of breast cancer. Thorac Cancer. 2020;11:1423-1432. doi: 10.1111/1759-7714.13400.

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obgm0340117_wyd_dbi.pdf

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Dr. Seitzman is Director of Education and Epidemiology Research, DenseBreast-info.org.

Dr. Berg is Professor of Radiology, University of Pittsburgh School of Medicine and Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, and Chief Scientific Advisor, DenseBreast-info.org.

The authors report that DenseBreast-info, Inc. is a 501(c)(3) nonprofit organization which receives unrestricted educational grants from GE Healthcare, Bayer, Volpara Health, Hologic, Siemens Healthineers, Beekley Medical, iCAD, and CMR Naviscan. Dr. Berg also reports being principal investigator for research from Koios Medical, Inc. for which her department receives a grant.

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OBG Management - 34(1)

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OBG Management

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17, 22

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GYN Image Quiz

Author(s)

Robin Seitzman, PhD, MPH

Wendie Berg, MD, PhD

Author(s)

Robin Seitzman, PhD, MPH

Wendie Berg, MD, PhD

Author and Disclosure Information

Dr. Seitzman is Director of Education and Epidemiology Research, DenseBreast-info.org.

Dr. Berg is Professor of Radiology, University of Pittsburgh School of Medicine and Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, and Chief Scientific Advisor, DenseBreast-info.org.

The authors report that DenseBreast-info, Inc. is a 501(c)(3) nonprofit organization which receives unrestricted educational grants from GE Healthcare, Bayer, Volpara Health, Hologic, Siemens Healthineers, Beekley Medical, iCAD, and CMR Naviscan. Dr. Berg also reports being principal investigator for research from Koios Medical, Inc. for which her department receives a grant.

Author and Disclosure Information

Dr. Seitzman is Director of Education and Epidemiology Research, DenseBreast-info.org.

Dr. Berg is Professor of Radiology, University of Pittsburgh School of Medicine and Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, and Chief Scientific Advisor, DenseBreast-info.org.

The authors report that DenseBreast-info, Inc. is a 501(c)(3) nonprofit organization which receives unrestricted educational grants from GE Healthcare, Bayer, Volpara Health, Hologic, Siemens Healthineers, Beekley Medical, iCAD, and CMR Naviscan. Dr. Berg also reports being principal investigator for research from Koios Medical, Inc. for which her department receives a grant.

Article PDF

obgm0340117_wyd_dbi.pdf

Article PDF

obgm0340117_wyd_dbi.pdf

_{Text copyright DenseBreast-info.org.}

Answer

B. For a 28-year-old woman, herself untested, with a known pathogenic BRCA1 or BRCA2 mutation in a first-degree relative (mother/ father, sister/brother, daughter/son), screening annual magnetic resonance imaging (MRI) alone is recommended until age 30, followed by screening annual MRI and mammography/tomosynthesis at age 30 and beyond. If MRI is not an option, ultrasonography or contrast-enhanced mammography should be considered.

Most medical societies in the United States recommend mammography screening beginning at age 40 if a woman is at average risk. If a woman is determined to be at high risk, breast cancer screening may be recommended to begin by age 30. Breast cancer risk assessment, with a risk model based largely on family history, should begin by age 30 for all women.

The American College of Radiology (ACR),¹ National Comprehensive Cancer Network (NCCN),^2,3and American Society of Breast Surgeons recommend annual MRI screening for the following high-risk subgroups of women:

Women with known disease-causing BRCA1 or BRCA2 mutations, or other disease-causing mutations, or their untested first-degree relatives. (Age to begin screening MRI and screening mammography/tomosynthesis varies by mutation).^1,3 Women with known pathogenic BRCA1 or BRCA2 mutations, or their untested first-degree relatives, should begin annual screening with MRI only between ages 25-29, adding annual digital mammography/tomosynthesis at age 30 and beyond (unless the woman has had bilateral mastectomy). Note: There is emerging evidence that the benefit of mammography is relatively small in pathogenic BRCA1 carriers prior to the age of 40; therefore, the ACR suggests BRCA1 mutation carriers may consider delaying mammography until age 40 only if they receive contrast-enhanced MRI annually starting at age 25.¹ Annual mammography is of benefit beginning at age 30 in those with BRCA2 or other disease-causing mutations.
Age to begin annual MRI screening and mammography/tomosynthesis in women who are known to carry or are first-degree untested relatives of individuals with less common disease-causing mutations (such as those associated with Li-Fraumeni syndrome [TP53]; Bannayan-Riley-Ruvalcaba syndrome or Cowden syndrome [PTEN]; hereditary diffuse gastric cancer [CDH1]; Peutz-Jeghers syndrome [STK11]; neurofibromatosis type 1 [NF1]; PALB2; ATM; CHEK2; or BARD1) ranges from 20-40 years depending on the mutation and family history.³ (See https://densebreast-info.org/providers-faqs /what-is-the-screening-management-for -various-other-mutation-carriers/.)

Women who received chest/mantle radiation therapy by age 30 (such as for Hodgkin disease) and at least 8 years prior. Women with prior chest radiation therapy (such as for Hodgkin disease) between ages 10 and 30 are at high risk for developing breast cancer,^1,2,4,5 with risk similar in magnitude to BRCA1 or BRCA2 carriers, and are recommended for annual screening MRI starting at age 25 or 8 years after the chest radiation therapy, whichever is later.
Women with a calculated lifetime risk of breast cancer of ≥20% are recommended to begin annual screening MRI by age 25-30.^1,2,5 Any of the models that include detailed family history such as the Tyrer-Cuzick (IBIS, which now includes breast density as a risk factor); BRCAPRO; BOADICEA; Claus; or Penn II; but not the Gail or Breast Cancer Surveillance Consortium (BCSC) models, can be used to estimate lifetime risk for the purposes of screening MRI guidelines. (See https://densebreast -info.org/for-providers/risk-model-tutorial/ for a summary table with live links.)
Women with a personal history of breast cancer and dense breasts or diagnosis by age 50, regardless of breast density. A personal history of breast cancer is not included in risk models, but all women diagnosed with breast cancer at or before age 50 and treated with breast-conserving therapy have a ≥20% lifetime risk for a new breast cancer.^1,2 Annual MRI may be considered in addition to annual mammography or tomosynthesis in women with a personal history of breast cancer diagnosed after age 50 and without dense breasts, and/or a history of lobular carcinoma in situ (LCIS) or prior atypia (eg, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or atypical papilloma).^1,2

Supplemental MRI screening should continue until age 75, after which management should be considered on an individual basis. If MRI screening is not an option, ultrasound or contrast-enhanced mammography (where available) should be considered as an alternative.^6-8 ●

RESOURCES

For more information, visit medically sourced DenseBreastinfo.org. Comprehensive resources include a free CME opportunity, Dense Breasts and Supplemental Screening.

_{Text copyright DenseBreast-info.org.}

Answer

B. For a 28-year-old woman, herself untested, with a known pathogenic BRCA1 or BRCA2 mutation in a first-degree relative (mother/ father, sister/brother, daughter/son), screening annual magnetic resonance imaging (MRI) alone is recommended until age 30, followed by screening annual MRI and mammography/tomosynthesis at age 30 and beyond. If MRI is not an option, ultrasonography or contrast-enhanced mammography should be considered.

Most medical societies in the United States recommend mammography screening beginning at age 40 if a woman is at average risk. If a woman is determined to be at high risk, breast cancer screening may be recommended to begin by age 30. Breast cancer risk assessment, with a risk model based largely on family history, should begin by age 30 for all women.

The American College of Radiology (ACR),¹ National Comprehensive Cancer Network (NCCN),^2,3and American Society of Breast Surgeons recommend annual MRI screening for the following high-risk subgroups of women:

Women with known disease-causing BRCA1 or BRCA2 mutations, or other disease-causing mutations, or their untested first-degree relatives. (Age to begin screening MRI and screening mammography/tomosynthesis varies by mutation).^1,3 Women with known pathogenic BRCA1 or BRCA2 mutations, or their untested first-degree relatives, should begin annual screening with MRI only between ages 25-29, adding annual digital mammography/tomosynthesis at age 30 and beyond (unless the woman has had bilateral mastectomy). Note: There is emerging evidence that the benefit of mammography is relatively small in pathogenic BRCA1 carriers prior to the age of 40; therefore, the ACR suggests BRCA1 mutation carriers may consider delaying mammography until age 40 only if they receive contrast-enhanced MRI annually starting at age 25.¹ Annual mammography is of benefit beginning at age 30 in those with BRCA2 or other disease-causing mutations.
Age to begin annual MRI screening and mammography/tomosynthesis in women who are known to carry or are first-degree untested relatives of individuals with less common disease-causing mutations (such as those associated with Li-Fraumeni syndrome [TP53]; Bannayan-Riley-Ruvalcaba syndrome or Cowden syndrome [PTEN]; hereditary diffuse gastric cancer [CDH1]; Peutz-Jeghers syndrome [STK11]; neurofibromatosis type 1 [NF1]; PALB2; ATM; CHEK2; or BARD1) ranges from 20-40 years depending on the mutation and family history.³ (See https://densebreast-info.org/providers-faqs /what-is-the-screening-management-for -various-other-mutation-carriers/.)

Women who received chest/mantle radiation therapy by age 30 (such as for Hodgkin disease) and at least 8 years prior. Women with prior chest radiation therapy (such as for Hodgkin disease) between ages 10 and 30 are at high risk for developing breast cancer,^1,2,4,5 with risk similar in magnitude to BRCA1 or BRCA2 carriers, and are recommended for annual screening MRI starting at age 25 or 8 years after the chest radiation therapy, whichever is later.
Women with a calculated lifetime risk of breast cancer of ≥20% are recommended to begin annual screening MRI by age 25-30.^1,2,5 Any of the models that include detailed family history such as the Tyrer-Cuzick (IBIS, which now includes breast density as a risk factor); BRCAPRO; BOADICEA; Claus; or Penn II; but not the Gail or Breast Cancer Surveillance Consortium (BCSC) models, can be used to estimate lifetime risk for the purposes of screening MRI guidelines. (See https://densebreast -info.org/for-providers/risk-model-tutorial/ for a summary table with live links.)
Women with a personal history of breast cancer and dense breasts or diagnosis by age 50, regardless of breast density. A personal history of breast cancer is not included in risk models, but all women diagnosed with breast cancer at or before age 50 and treated with breast-conserving therapy have a ≥20% lifetime risk for a new breast cancer.^1,2 Annual MRI may be considered in addition to annual mammography or tomosynthesis in women with a personal history of breast cancer diagnosed after age 50 and without dense breasts, and/or a history of lobular carcinoma in situ (LCIS) or prior atypia (eg, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or atypical papilloma).^1,2

Supplemental MRI screening should continue until age 75, after which management should be considered on an individual basis. If MRI screening is not an option, ultrasound or contrast-enhanced mammography (where available) should be considered as an alternative.^6-8 ●

RESOURCES

For more information, visit medically sourced DenseBreastinfo.org. Comprehensive resources include a free CME opportunity, Dense Breasts and Supplemental Screening.

References

Monticciolo DL, Newell MS, Moy L, et al. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018;15 (3 Pt A):408-414. doi: 10.1016/j.jacr.2017.11.034.
National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis (Version 1.2021). https://www .nccn.org/professionals/physician_gls/pdf/breast-screening .pdf. Accessed November 18, 2021.
National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version 1.2020). https://www.nccn.org/professionals/physician_gls/pdf /genetics_bop.pdf. Accessed July 31, 2020.
Oeffinger KC, Ford JS, Moskowitz CS, et al. Breast cancer surveillance practices among women previously treated with chest radiation for a childhood cancer. JAMA. 2009;301(4):404-414. DOI: 10.1001/jama.2008.1039.
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;57:75-89. doi: 10.3322/canjclin.57.2.75.
Sorin V, Yagil Y, Yosepovich A, et al. Contrast-enhanced spectral mammography in women with intermediate breast cancer risk and dense breasts. AJR Am J Roentgenol. 2018;211:W267-W274. doi: 10.2214/AJR.17.19355.
Sung JS, Lebron L, Keating D, et al. Performance of dualenergy contrast-enhanced digital mammography for screening women at increased risk of breast cancer. Radiology. 2019;293:81-88. doi: 10.1148/radiol.2019182660.
Xiang W, Rao H, Zhou L. A meta-analysis of contrastenhanced spectral mammography versus MRI in the diagnosis of breast cancer. Thorac Cancer. 2020;11:1423-1432. doi: 10.1111/1759-7714.13400.

References

Monticciolo DL, Newell MS, Moy L, et al. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018;15 (3 Pt A):408-414. doi: 10.1016/j.jacr.2017.11.034.
National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis (Version 1.2021). https://www .nccn.org/professionals/physician_gls/pdf/breast-screening .pdf. Accessed November 18, 2021.
National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version 1.2020). https://www.nccn.org/professionals/physician_gls/pdf /genetics_bop.pdf. Accessed July 31, 2020.
Oeffinger KC, Ford JS, Moskowitz CS, et al. Breast cancer surveillance practices among women previously treated with chest radiation for a childhood cancer. JAMA. 2009;301(4):404-414. DOI: 10.1001/jama.2008.1039.
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;57:75-89. doi: 10.3322/canjclin.57.2.75.
Sorin V, Yagil Y, Yosepovich A, et al. Contrast-enhanced spectral mammography in women with intermediate breast cancer risk and dense breasts. AJR Am J Roentgenol. 2018;211:W267-W274. doi: 10.2214/AJR.17.19355.
Sung JS, Lebron L, Keating D, et al. Performance of dualenergy contrast-enhanced digital mammography for screening women at increased risk of breast cancer. Radiology. 2019;293:81-88. doi: 10.1148/radiol.2019182660.
Xiang W, Rao H, Zhou L. A meta-analysis of contrastenhanced spectral mammography versus MRI in the diagnosis of breast cancer. Thorac Cancer. 2020;11:1423-1432. doi: 10.1111/1759-7714.13400.