Imaging screening and surveillance

Abstract

BRCA mutation carriers, who have not undergone risk-reducing mastectomy by age 25-30, require annual screening with magnetic resonance imaging (MRI). Sensitivity of screening MRI in this population is 90-95%, more than twice that of mammography, with a specificity of over 90% after the first round of screening. Ten-year breast cancer-free survival, though likely somewhat lower than that with risk-reducing mastectomy, is at least 90%. The incremental benefit of adding mammography to MRI is small, particularly for BRCA1 mutation carriers under age 40, and there is no proven role for adding clinical breast examination. Screening ultrasound, in conjunction with mammography, is only beneficial for women who are unable to undergo MRI. The upper age at which MRI can safely be stopped and annual mammography continued is not yet known. Intensive screening does not appear to have any significant negative psychological consequences. There is no role for screening with any imaging modality in asymptomatic women who have undergone risk-reducing mastectomy. For BRCA mutation carriers who have not undergone risk-reducing salpingo-oophorectomy by the recommended age, there is no evidence to date that ovarian cancer screening reduces mortality.