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Is Mammography Adequate for Screening Women with Inherited BRCA Mutations and Low Breast Density?

Divisions of ¹ Medical Oncology, ² Imaging Research, ³ Clinical Trials and Epidemiology, and ⁴ Preventive Oncology and Departments of ⁵ Medical Imaging and ⁶ Medical Biophysics, Sunnybrook Health Sciences Centre and ⁷ Centre for Research in Women's Health, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada

Requests for reprints: Ellen Warner, Toronto-Sunnybrook Regional Cancer Center, Toronto, Ontario M4N 3M5, Canada. Phone: 416-480-4617; Fax: 416-480-6002. E-mail: ellen.warner{at}sunnybrook.ca

Background: Several observational studies have shown that magnetic resonance imaging (MRI) is significantly more sensitive than mammography for screening women over age 25 at high risk for hereditary breast cancer; however, MRI is more costly and less specific than mammography. We sought to determine the extent to which the low sensitivity of mammography is due to greater breast density.

Methods: Breast density was evaluated for all patients on a high-risk screening study who were diagnosed with breast cancer between November 1997 and July 2006. Density was measured in two ways: qualitatively using the four categories characterized by the Breast Imaging Reporting and Data System and quantitatively using a computer-aided technique and classified as (a) 10%, (b) 11% to 25%, (c) 26% to 50%, and (d) >50% density. Comparison of sensitivity of mammography (and MRI) for each individual density category and after combining the highest two and lowest two density categories was done using Fisher's exact test.

Results: A total of 46 breast cancers [15 ductal carcinoma in situ (DCIS) and 31 invasive] were diagnosed in 45 women (42 with BRCA mutations). Mean age was 48.3 (range, 32-68) years. Overall, sensitivity of mammography versus MRI was 20% versus 87% for DCIS and 26% versus 90% for invasive cancer. There was a trend towards greater mammographic sensitivity for invasive cancer in women with fattier breasts compared with those with greater breast density (37-43% versus 8-12%; P = 0.1), but this trend was not seen for DCIS.

Conclusion: It is necessary to add MRI to mammography for screening women with BRCA mutations even if their breast density is low. (Cancer Epidemiol Biomarkers Prev 2008;17(3):706–11)

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