Mantle Field Radiation / MRI in Women at High Risk for Breast Cancer

• Receipt of mantle field radiation before the age of 30:
  • Is associated with a significantly increased risk of breast cancer compared to the general population
• Patients with a history of Hodgkin’s lymphoma treated with mantle field radiation therapy:
  • Are more likely to be diagnosed with:
    • Breast cancer at a younger age
    • Have hormone receptor negative breast cancer
    • And have a second breast cancer
• Because the increased risk of breast cancer has been seen as early as 8 years following receipt of radiation therapy:
  • High risk screening after mantle field radiation therapy:
    • Should begin at the age of 25 or
    • 8 years after radiation therapy
      • Whichever occurs later
• The estimated cumulative incidence of breast cancer by the age of 50 among patients with a history of Hodgkin’s lymphoma treated with mantle field radiation therapy is:
  • 35%
• Among all women at high risk for breast cancer (lifetime risk greater than 20%):
  • Annual screening MRI:
    • Has been associated with 77% to 100% sensitivity for detecting a new cancer
    • While mammography is associated with 16% to 40% sensitivity
• In 2007, the American Cancer Society convened an expert panel to review the evidence on MRI screening as an adjunct to annual mammography for women at high risk of developing breast cancer:
  • Annual screening MRI is recommended for patients with:
    • A clinical history of chest radiation between the ages of 10 and 30 years
  • As well as women with a known BRCA mutation
  • Untested first-degree relatives of BRCA mutation carriers
  • Those with other genetic mutations increasing breast cancer risk
  • Women with a greater than 20% lifetime risk secondary to family history
• The addition of bilateral breast ultrasound to a screening regimen of mammography and MRI:
  • Is associated with a substantial increase in false positives:
    • Leading to additional biopsies with no incremental benefit over mammography and MRI alone
• There is insufficient evidence to recommend for or against:
  • Annual screening breast MRI:
    • In women who have a history of:
      • Lobular carcinoma in situ
      • Atypical lobular hyperplasia
      • Atypical ductal hyperplasia
• There is no evidence to support MRI:
  • In women with a less than 15% lifetime risk of breast cancer
  • In women with dense breast tissue
  • In women with a personal history of breast cancer
• References:
  • Veit-Rubin N, Rapiti E, Massimo U, Benhamou S, Vinh-Hung V, Vlastos G, et al. Risk, characteristics, and prognosis of breast cancer after Hodgkin’s lymphoma. Oncologist. 2012;17(6):783-791.
  • Henderson TO, Amsterdam A, Bhatia S, Hudson MM, Meadows AT, Neglia JP, et al. Systematic review: surveillance for breast cancer in women treated with chest radiation for childhood, adolescent, or young adult cancer. Ann Intern Med. 2010;152(7):444-455; w144-454.
  • Moskowitz CS, Chou JF, Wolden SL, Bernstein JL, Malhotra J, Novetsky Friedman D, et al. Breast cancer after chest radiation therapy for childhood cancer. J Clin Oncol. 2014; 32(21):2217-2223.
  • Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.
  • National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis, Version 1.2019. https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf. Accessed February 23, 2020.
  • Riedl CC, Luft N, Bernhart C, Weber M, Bernathova M, Tea MK, et al. Triple-modality screening trial for familial breast cancer underlines the importance of magnetic resonance imaging and questions the role of mammography and ultrasound regardless of patient mutation status, age, and breast density. J Clin Oncol. 2015;33(10):1128-1135.
  • van Zelst JCM, Mus RDM, Woldringh G, et al. Surveillance of Women with the BRCA1 or BRCA2 Mutation by Using Biannual Automated Breast US, MR Imaging, and Mammography. Radiology. 2017;285(2):376-388.

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