Get annual breast MRI, experts tell many women

The American Cancer Society is recommending that women whose close relatives have had breast cancer should be screened annually with an MRI as well as a mammogram — part of new guidelines that could affect as many as 1.4 million women.

The recommendation, prompted by advice from an expert panel, even includes some women whose aunts and grandmothers have had the disease — in addition to those with mothers and sisters who had breast cancer.

It is the first time the cancer society has urged the use of magnetic resonance imaging (MRI) — which detects the tiniest tumors — for breast-cancer screening, in addition to mammograms.

"One truth about breast cancer is that when it's detected early, we can cure it," said Dr. Connie Lehman, director of breast imaging at the Seattle Cancer Care Alliance and a member of the expert panel.

"Mammograms are a great tool, but they are imperfect. MRI has been established as a great complement to mammograms."

In 2003, the cancer society issued guidelines that stopped short of recommending MRIs for women at high risk for the disease. More research evidence on MRI effectiveness now warrants it, the society said.

Insurance implications

New American Cancer Society guidelines

Who should have MRIs? Women with a strong family history of breast cancer are at high risk of getting the disease. The American Cancer Society says careful analysis of family history by a physician is needed. But the recommendation may include women who have had:

• Two or more close relatives with breast or ovarian cancer, which is genetically linked to breast cancer. Close relatives include a mother, sister, grandmother, aunt and half-sister.

• A close relative who got breast cancer before menopause.

• A family history of both breast and ovarian cancer.

• One or more relatives who have had two cancers — two separate breast cancers or breast and ovarian cancer.

• Male relatives with breast cancer.

For more information:

American Cancer Society guidelines for breast-cancer screening with MRI: http://caonline.amcancersoc.org

American Cancer Society home page: www.cancer.org

The new recommendations could have significant implications for medical insurers because they use such guidelines, along with scientific studies, in deciding whether to cover certain diagnostic procedures and treatments.

MRIs use magnetic fields to detect tumors, while mammography uses X-rays. The costs vary, but MRIs generally are much more expensive: $1,000 or more, compared with about $100 to $150 for mammograms.

The cancer-society guidelines say women whose lifetime risk related to family history is more than 20 to 25 percent should have the additional MRI screening. Overall, women have about a 13 percent lifetime risk of the disease, though that is changed by factors such as family history and age.

The guidelines also recommend annual MRIs, in addition to mammograms, for women who have mutations in known breast-cancer genes (called BRCA 1 and 2) and for the daughters and sisters of those women. The tests are also urged for women who have had radiation treatments in the chest between ages 10 and 30 and for those with certain rare syndromes or who are at genetic risk for those syndromes.

For years, the society has recommended yearly mammograms for women with no increased risk of breast cancer, beginning at age 40. The society estimates about 178,000 new cases of the disease will be diagnosed this year, and 40,000 women will die.

In the new guidelines for women at high risk, calculation of the lifetime risk related to family history is based on complex models used by physicians. But generally they include women with two or more close relatives who had breast cancer or ovarian cancer, which is genetically linked to breast cancer. And it may include women with close relatives who had breast cancer before menopause.

"Very careful family history analysis is required," the guidelines say. They add that physicians should be careful to use the most current risk-assessment models.

The guidelines, published in the March-April edition of the journal Cancer and released today, also give several examples using three different risk models.

One example is a 35-year-old woman whose mother had breast cancer at age 33 and whose maternal aunt had breast cancer at age 42. Depending on the model used, the woman would have either a 19 percent, 36 percent or 28 percent lifetime risk.

While the new guidelines will affect more than a million women, they don't go so far as to recommend annual MRIs for certain other high-risk women, such those who have already had breast cancer or have very dense breast tissue, which can obscure some tumors from being detected by mammograms. The cancer society said there is still not enough evidence to recommend MRIs for those women.

Still, the experts said factors such as these may influence individual decisions to have an MRI screen when family history alone does not warrant it.

Lehman, who is a radiology professor at the University of Washington, predicted the cancer society will continue to watch the research and could change its recommendations to include other women in the future.

Meanwhile, Lehman directed a separate study, reported in this week's New England Journal of Medicine, that found an MRI also can detect cancers in the second breast of women who have been newly diagnosed with breast cancer.

In the study of nearly 1,000 patients, the scientists found cancers had been missed by mammograms in 3 percent of the women.

One concern about MRIs has been the fact that they have about a 10 percent false-positive rate, about twice the rate of mammograms. False positives can lead to unnecessary biopsies and worry on the part of patients.

But Lehman said there is now no question that MRI use can save the lives of many high-risk women by catching cancers earlier.

"We know what happens when they are left untreated," she said. "No one is safe when they are left untreated."

Warren King: 206-464-2247 or wking@seattletimes.com