Comment on Screening by MRI Mentioned in the Reviews by Narod and Møller
- 926 Downloads
KeywordsBreast Cancer Mutation Carrier BRCA2 Mutation Mammography Screening Breast Cancer Mortality
Currently many women from families with a high risk of breast cancer due to a familial or genetic predisposition, including carriers of a BRCA1/2 germline mutation, opt for intensive surveillance . Several guidelines advise screening by mammography and clinical breast examination. However, the value of this screening scheme in women that often start screening under the age of 40 has never been proven. There are indications that the sensitivity of mammography is especially low in carriers of a BRCA1 or BRCA2 mutation [2, 3]. This is the main reason why the value of MRI screening is being investigated in various family cancer clinics worldwide. To date only preliminary data from small studies are available about the effectiveness of this MRI screening [4, 5, 6].
In these preliminary studies, MRI appears to be a more sensitive screening method than mammography, but this does not mean that it detects breast cancer at an earlier stage. It might be expected that MRI can detect breast cancer at an earlier stage than mammography. However, no study has been published that compares the tumour stage of patients detected within an MRI screening programme with that of comparable symptomatic patients. As stated by Narod, the main goal of screening is a stage shift towards earlier breast cancer diagnosis that might lead to a reduction in breast cancer mortality, against acceptable side effects. While the high financial costs are mentioned by Narod, many other negative effects of MRI screening have been described. For instance, some studies described a specificity much lower as compared to mammography, causing unnecessary additional investigations. These negative effects should be taken into account when making a decision to use a new screening tool.
To date no longer-term prospective studies with data about the potential of MRI to diagnose breast cancer at an earlier stage, the possible reduction of breast cancer mortality and the cost-effectiveness are available. These data can be expected from several ongoing studies in the near future [7, 8]. In this respect we agree with Møller that only when these data are available definitive and evidence-based advice about screening in high risk women can be given.
In the meantime we advise, as Narod and Møller, to consider MRI screening in high risk women in addition to the routine screening program, especially in women where mammography screening has the smallest effect, such as mutation carriers, until we have results from large prospective studies.
- 1.Meijers-Heijboer EJ, Verhoog LC, Brekelmans CT, Seynaeve C, Tilanus-Linthorst MM, Wagner A, Dukel L, Devilee P, Ouweland AM, van Geel AN, Klijn JG: Presymptomatic DNA testing and prophylactic surgery in families with a BRCA 1 or BRCA 2 mutation. Lancet 2000, 355: 2015–2020. 10.1016/S0140-6736(00)02347-3CrossRefPubMedGoogle Scholar
- 2.Brekelmans CT, Seynaeve C, Bartels CC, Tilanus-Linthorst MM, Meijers-Heijboer EJ, Crepin CM, van Geel AA, Menke M, Verhoog LC, Ouweland A, Obdeijn IM, Klijn JG, Rotterdam Committee for Medical and Genetic Counseling: Effectiveness of breast cancer surveillance in BRCA1/2 gene mutation carriers and women with high family risk. J Clin Oncol 2001, 19: 924–930.PubMedGoogle Scholar
- 3.Scheuer L, Kauff N, Robson M, Kelly B, Barakat R, Satagopan J, Ellis N, Hensley M, Boyd J, Borgen P, Norton L, Offit K: Outcome of Preventive Surgery and Screening for Breast and Ovarian Cancer in BRCA Mutation Carriers. J Clin Oncol 2002, 20: 1260–1268. 10.1200/JCO.20.5.1260CrossRefPubMedGoogle Scholar
- 4.Kuhl CK, Schmutzler RK, Leutner CC, Kempe A, Wardelmann E, Hocke A, Maringa M, Pfeifer U, Krebs D, Schild HH: Breast MR Imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene: preliminary results. Radiology 2000, 215: 267–279.CrossRefPubMedGoogle Scholar
- 5.Warner E, Plewes DB, Shumak RS, Catzavelos GC, Di Prospero LS, Yaffe MJ, Goel V, Ramsay E, Chart PL, Cole DE, Taylor GA, Cutrara M, Samuels TH, Murphy JP, Murphy JM, Narod SA: Comparison of breast magnetic resonance imaging, mammography, and ultrasound for surveillance of women at high risk for hereditary breast cancer. J Clin Oncol 2001, 19: 3524–3531.PubMedGoogle Scholar
- 6.Stoutjesdijk MJ, Boetes C, Jager GJ, Beex L, Bult P, Hendriks JH, Laheij RJ, Massuger L, van Die LE, Wobbes T, Barentsz JO: Magnetic resonance imaging and mammography in women with a hereditary risk of breast cancer. J Natl Cancer Inst 2001, 93: 1095–1102. 10.1093/jnci/93.14.1095CrossRefPubMedGoogle Scholar
- 7.Kriege M, Brekelmans CT, Boetes C, Rutgers EJ, Oosterwijk JC, Tollenaar RA, Manoliu RA, Holland R, de Koning HJ, Klijn JG: MRI screening for breast cancer in women with familial or genetic predisposition: design of the Dutch National Study. Familial Cancer 2001, 1: 163–168. 10.1023/A:1021135809870CrossRefPubMedGoogle Scholar