Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer

Abstract

Importance: There is little evidence on population-based harms and benefits of screening breast magnetic resonance imaging (MRI) in women with and without a personal history of breast cancer (PHBC).

Objective: To evaluate biopsy rates and yield in the 90 days following screening (mammography vs magnetic resonance imaging with or without mammography) among women with and without a PHBC.

Design, setting, and participants: Observational cohort study of 6 Breast Cancer Surveillance Consortium (BCSC) registries. Population-based sample of 812 164 women undergoing screening, 2003 through 2013.

Exposures: A total of 2 048 994 digital mammography and/or breast MRI screening episodes (mammogram alone vs MRI with or without screening mammogram within 30 days).

Main outcomes and measures: Biopsy intensity (surgical greater than core greater than fine-needle aspiration) and yield (invasive cancer greater than ductal carcinoma in situ greater than high-risk benign greater than benign) within 90 days of a screening episode. We computed age-adjusted rates of biopsy intensity (per 1000 screening episodes) and biopsy yield (per 1000 screening episodes with biopsies). Outcomes were stratified by PHBC and by BCSC 5-year breast cancer risk among women without PHBC.

Results: We included 101 103 and 1 939 455 mammogram screening episodes in women with and without PHBC, respectively; MRI screening episodes included 3763 with PHBC and 4673 without PHBC. Age-adjusted core and surgical biopsy rates (per 1000 episodes) doubled (57.1; 95% CI, 50.3-65.1) following MRI compared with mammography (23.6; 95% CI, 22.4-24.8) in women with PHBC. Differences (per 1000 episodes) were even larger in women without PHBC: 84.7 (95% CI, 75.9-94.9) following MRI and 14.9 (95% CI, 14.7-15.0) following mammography episodes. Ductal carcinoma in situ and invasive biopsy yield (per 1000 episodes) was significantly higher following mammography compared with MRI episodes in women with PHBC (mammography, 404.6; 95% CI, 381.2-428.8; MRI, 267.6; 95% CI, 208.0-337.8) and nonsignificantly higher, but in the same direction, in women without PHBC (mammography, 279.3; 95% CI, 274.2-284.4; MRI, 214.6; 95% CI, 158.7-280.8). High-risk benign lesions were more commonly identified following MRI regardless of PHBC. Higher biopsy rates and lower cancer yield following MRI were not explained by increasing age or higher 5-year breast cancer risk.

Conclusions and relevance: Women with and without PHBC who undergo screening MRI experience higher biopsy rates coupled with significantly lower cancer yield findings following biopsy compared with screening mammography alone. Further work is needed to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio.

Figure 1.. Screening Examinations^a With Follow-up Time and Associated Screening Episode^b Definitions

^aOnly examinations with radiologist indication of screening were considered. For women without a personal history of breast cancer (PHBC), a screening examination (mammogram or magnetic resonance imaging [MRI]) was defined as a bilateral examination and without imaging of the same type (mammogram or MRI) in the prior 9 months. For women with a PHBC, a screening examination was defined as an examination without the following: a prior bilateral mastectomy, imaging of the same type (mammogram or MRI) within the prior 60 days, or a diagnosis of cancer within 6 months before the screen. ^bAll analyses were conducted at the level of a screening episode. Each screening examination was turned into a screening episode. Each examination was followed for 90 days, unless there was another screening examination in the 90-day follow-up. When a screening examination was followed within 30 days, these were rolled up to the first index screening examination and followed for 90 days from the index examination. ^cScreening examination occurred 31 to 90 days after index examination. The second screening examination started another screening episode with 90 days’ follow-up.

Figure 2.. Age-Adjusted Rate of Core and Surgical Breast Biopsies by Screening Modality and Breast Cancer Surveillance Consortium 5-Year Breast Cancer Risk Among 783 522 Women Without a Personal History of Breast Cancer