Updated Recommendations by the American College of Radiology for Breast Cancer Screening in Individuals at Higher-Than-Average Risk

Take-Away Points

• ■ Major Focus: To assess recent evidence and provide updates to the prior 2018 American College of Radiology (ACR) guidelines for breast cancer screening in individuals at higher-than-average risk.

• ■ Key Results: Breast cancer risk assessment should be performed by age 25, particularly for Black individuals and those of Ashkenazi Jewish descent. For most individuals at higher-than-average risk, the supplemental breast cancer screening modality of choice is breast MRI.

• ■ Impact: Breast cancer risk assessment by age 25 identifies high-risk individuals who would benefit from earlier and more intensive screening.

Early detection of breast cancer decreases breast cancer mortality. Individuals at higher-than-average risk should begin digital mammography screening at an earlier age than those at average risk and consider supplemental screening. The ACR Commission on Breast Imaging published an update to the 2018 breast cancer screening guideline for individuals at higher-than-average risk. This update considers new data on digital breast tomosynthesis (DBT), contrast-enhanced mammography (CEM), and contrast-enhanced breast MRI. Key topics include breast cancer risk assessment, supplemental screening modality of choice, and individuals who would benefit from supplemental screening.

The ACR now recommends breast cancer risk assessment by age 25 (previously age 30) for all individuals, particularly Black individuals and those of Ashkenazi Jewish descent. Those of Ashkenazi Jewish descent are at higher risk for genetic mutations, and Black individuals younger than 50 years have significantly higher rates of advanced-stage breast cancer and breast cancer mortality compared with non-Hispanic White individuals or other racial minority groups. Early breast cancer risk assessment guides personalized screening strategies and identifies individuals at higher-than-average risk who can benefit from supplemental screening.

The ACR recommends MRI as the supplemental screening modality of choice for most higher-than-average risk individuals. MRI demonstrates higher sensitivity than mammography, US, or mammography plus US. Cancers detected at MRI are more likely to be smaller, lower stage, and node-negative. CEM or US could be considered in those who would qualify for but cannot undergo supplemental MRI screening. Individuals at increased risk due to dense breast tissue who desire supplemental screening should receive annual MRI beginning at age 40 in addition to annual digital mammography with or without DBT. In individuals with dense breasts, MRI demonstrates higher cancer detection rates and positive predictive values than either US or DBT. In addition, interval cancer rates in those with dense breasts are reduced by MRI screening. In mutation carriers aged 30 to 39 years old, screening with MRI alone demonstrates comparable sensitivity and higher specificity than MRI plus mammography. Therefore, the ACR recommends that mutation carriers can delay mammographic screening until age 40 if annual breast MRI is performed as recommended.

Highlighted Article

• Monticciolo DL, Newell MS, Moy L, et al. Breast cancer screening for women at higher-than-average risk: updated recommendations from the ACR. J Am Coll Radiol 2023. doi: https://doi.org/10.1016/j.jacr.2023.04.002