Mammography Still Best for Screening After Breast Cancer

Pam Harrison

April 28, 2015

TORONTO — For women with a personal history of breast cancer, surveillance is better with mammography than with MRI because more cancers are detected with mammography in these patients, new research suggests.

"We know that screening MRI is appropriate in women with a strong history of breast cancer or who are BRCA-positive because their cancers are more likely to be mammographically occult," said Linda Moy, MD, associate professor of radiology at the New York University Langone Medical Center in New York City.

For the many women with a personal history of breast cancer, "some experts are recommending a screening MRI as well," she told Medscape Medical News. However, "insurance companies don't always cover them and they are expensive."

"We're trying to figure out how best to manage these women who really want to have any recurrence of another cancer detected early," she explained. "Our study suggests that new cancers in this group of women are more likely to be detected on a mammogram, so it questions the use of routine breast MRI surveillance."

Dr Moy presented the study results here at the American Roentgen Ray Society 2015 Annual Meeting.

The retrospective review involved women who underwent breast MRI from January 2008 to December 2009. They were followed until December 2013.

Of the 57 women who developed a new breast cancer during the follow-up period, 33 had mammographically occult cancers and 24 cancers were evident on mammography.

There was no significant difference in age, in mammographic density, or in the use of antiestrogens between women with mammographically occult cancer and those with mammographically evident cancer.

In addition, the number of invasive and in situ cancers was similar in the two groups, Dr Moy reported.

In women with a strong family history or a BRCA mutation, mammographically occult cancers were more common than mammographically evident cancers (45% vs 21%; P = .02).

However, in women with a personal history of breast cancer only, mammographically evident cancers were more common than mammographically occult cancers (71% vs 33%).

For the 24 women whose cancers were evident on mammography, 19 had a personal history of breast cancer. Of these, 12 of the cancers were ductal carcinoma in situ (DCIS) and seven were invasive carcinomas (three of which were clinically evident as palpable lesions).

The other five women whose cancers were evident on mammography had a strong family history, and three of the cancers were DCIS.

The researchers "also went back to look at the original breast cancer, thinking that if the original cancer was more aggressive, women might need to be followed with an MRI as well [as with mammography]," Dr Moy reported.

The findings suggest that women whose first cancer was HER2-positive or triple-negative were more likely to experience a recurrence and that it might be prudent to follow these women with MRI, but because the data were limited, the researchers could not draw a firm conclusion.

"I wish our data were cleaner, but we're still trying to find a subset of women with a personal history of breast cancer who will benefit from MRI screening," Dr Moy said.

"All we can say right now is that our data support current guidelines recommending MRI in women who have a strong family history or who are BRCA-positive, because cancers in this population are more likely to be mammographically occult," she explained.

Controversy Persists

There is still a lot of controversy over the best way to follow women with a personal history of breast cancer, said Emily Sedgwick, MD, section head of breast imaging at the Baylor College of Medicine in Houston.

"Intuitively, you'd think if a woman has a personal history of breast cancer, she would be more likely to have a cancer recur," she told Medscape Medical News.

However, if the original cancer was estrogen-receptor-positive, women could be taking an antiestrogen, which would decrease the likelihood of a recurrent cancer, she pointed out.

"Women with a personal history of breast cancer are a very heterogeneous group of patients and we don't really know how intensive we should be in our surveillance," Dr Sedgwick said.

"This study is saying that breast MRI surveillance may not be appropriate for all women who have a personal history of breast cancer in the absence of other risk factors," she reiterated.

"It really comes down to developing an accurate risk profile to help guide management for individual patients," she said. "You really need to look at all risk factors [for recurrence], including features of the original tumor, family history, whether a woman is on a preventative treatment, and, of course, personal preference."

This study was funded by the National Institutes of Health. Dr Moy and Dr Sedgwick have disclosed no relevant financial relationships.

American Roentgen Ray Society (ARRS) 2015 Annual Meeting: Abstract 3828. Presented April 23, 2015.

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