Beyond Mammograms: When Women May Need Breast MRI Screening

October is Breast Cancer Awareness Month, a reminder that breast cancer affects about one in eight women in the United States. While routine mammograms are a key part of screening, some women may need a more personalized plan based on their risk.

Roshani Patel, M.D., FACS, medical director of breast surgical oncology at Hackensack Meridian Jersey Shore University Medical Center, explained how breast specialists assess risk, when genetic testing makes sense and what patients should discuss with their doctors.

A risk assessment looks at more than breast cancer history

Women with a strong family history of breast cancer, chest radiation before age 30 or a biopsy showing high-risk breast changes should be seen by a comprehensive breast team, Patel said. That may include an accredited radiology facility or breast program, or a fellowship-trained breast surgeon.

A risk assessment considers hormonal factors, such as age at first childbirth and menopause, breast density, and family history of breast and ovarian cancer. Patel noted that some inherited mutations show up in families as pancreatic or prostate cancer rather than breast cancer, which is why a genetics referral may still be appropriate.

When MRI is added to screening

Women with a lifetime breast cancer risk greater than 20% to 25% may qualify for screening MRI in addition to mammography. Patel said those with dense breasts typically get a mammogram and ultrasound together, followed by an MRI six months later. Women without very dense breasts may get a mammogram alone, then an MRI six months later.

For women who carry a mutation that raises breast cancer risk, MRI screening typically starts at age 25, with mammography added at 30.

Why the relative with cancer should be tested first

Patel recommends starting genetic testing with the family member who had cancer. If that person tests negative, other relatives may not need testing. If a parent has a mutation but the patient doesn’t, the patient’s risk is “actually the same as mine,” Patel said, meaning the same as an average woman her age.

She also highlighted CHEK2, a lesser-known mutation that comes in several variants, some linked to colon cancer and a higher chance of a second breast cancer, which can shape surgical decisions.

How stage and size guide surgery

A lumpectomy removes the cancer with a margin of healthy tissue, which Patel compared to removing an egg yolk with some of the white around it. Larger areas of disease may require removing the breast. Radiation or chemotherapy may still be needed, since “the surgery that we do does not obviate the need for other treatment,” she said.

Stage 0, or ductal carcinoma in situ (DCIS), means cancer cells remain inside the milk-producing glands. Stages 1 through 4 describe invasive cancer, from disease that hasn’t reached the lymph nodes to cancer that has spread elsewhere in the body.

Most breast cancers aren’t inherited

Patel stressed that women who carry gene mutations aren’t the ones who most commonly get breast cancer. “Any one of us could get breast cancer,” she said.

She encourages women to ask about their breast density and to report a lump in the breast or under the arm, or a focused area of pain that isn’t improving.