MRI In Breast Cancer Screening Rapid Review Case Study 2022

Running head: MRI IN BREAST CANCER SCREENING RAPID REVIEW 1
MRI In Breast Cancer Screening Rapid Review
Ishtiaq Karim
Student Id: 5024122

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Is MRI Imaging Effective In Early Diagnosis of Breast Cancer among Young Women?
A Rapid Review of Evidence
Executive Summary
Background
There are high prevalence and incidence of breast cancer amongst females, primarily
amongst females with breast carcinoma history in their families or females who have endured
chest radiation therapies prior to 30 years of age, or with predisposing genetic mutations like
BRCA1/2. These groups of women show high likelihood (20-65 percent) of breast
malignancy development relative to general population (11 percent). The main aim of this
study is to undertake rapid systematic review of literature to establish the effectiveness of
breast MRI in breast cancer diagnosis amongst young women.
Objective
To carry out a rapid review study and recapitulate most recent and suitable evidence
from systematic review alongside meta-analysis or a combination of the two designs
published between 2009 and 2019 to comprehend the breast MRI effectiveness in early breast
cancer diagnosis amongst high-risk females with particular focus on determining whether
breast MRI can assist enhance likelihood of detecting breast cancer amongst this population.
Criteria for considering studies
Any meta-analysis and systematic reviews with breast MRI screening for breast cancer stood
included. The studies were restricted to English and period between 2009 and 2019.
Types of Participants
Young women with breast carcinoma history in their families or females who have
experienced chest radiation therapies prior to 30 years of age, or with predisposing genetic

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mutations like BRCA1/2. These groups of women show high likelihood (20-65 percent) of
breast malignancy development relative to general population (11 percent).
Types of intervention
Any meta-analysis and systematic reviews which evaluated the effectiveness of breast
MRI in breast diagnosis cancer amongst young females.
Types of Studies
Any meta-analysis and systematic reviews which assess the MRI effectiveness in screening
breast cancer amongst young women.
Outcomes
The primary outcomes stood effectiveness of breast MRI on screening of breast cancer.
Search Strategy
The search strategy was performed on five databases including MEDLINE, PubMed,
Cochrane, EMBASE and CINAHL. The best existing evidences stood acknowledged
considering the PICO elements. The exclusion and inclusion criteria stood taken into account
for reviews’ selection.
Methodological Quality
Seven articles chosen were appraised for the reliability of methodology prior to inclusion in
the final review utilizing AMSTAR as a reliable and effective instrument utilized in assessing
meta-analysis and systematic reviews methodological quality. AMSTAR contains eleven
criteria with scores ranging from zero to eleven (0-lowest; 11-highest).
Data extraction and Data Synthesis
The extraction tool was used to extract data. The info gathered included author, population of
study, year of publication, design of study, searched databases, interventions, quality score as

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well as outcome measures. The findings and results of revues were also presented in narrative
form and encompasses figures and facts alongside tables to help in desired presentation.
Results
After reviewing and analyzing the seven reviews included, it was discovered that breast MRI
is highly sensitivity to detect breast cancer and must always be used in conjunction with
mammography to boost detection potentials.
Conclusion
From the gathered evidence, it is concluded that breast MRI is an effective screening and
diagnosing technique for breast cancer amongst young women.
Keywords
Keywords: MRI in cancer screening, systematic reviews, breast cancer, MRI imaging, Breast
ailments and detecting breast carcinoma

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Table of Contents
Executive Summary...................................................................................................................2
Background.............................................................................................................................2
Objective.................................................................................................................................2
Criteria for considering studies..............................................................................................2
Types of Participants..............................................................................................................2
Types of intervention..............................................................................................................3
Types of Studies.....................................................................................................................3
Outcomes................................................................................................................................3
Search Strategy.......................................................................................................................3
Methodological Quality..........................................................................................................3
Data extraction and Data Synthesis........................................................................................3
Results....................................................................................................................................4
Conclusion..............................................................................................................................4
Keywords................................................................................................................................4
1. Background............................................................................................................................8
2. Objectives...............................................................................................................................9
3. Criteria for Considering Studies...........................................................................................10
3.1 Types of Studies.............................................................................................................10
3.2. Types of Participants.....................................................................................................10
3.3. Types of Interventions...................................................................................................10

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3.4. Types of Outcomes........................................................................................................11
4. Search Strategy.....................................................................................................................11
5. Methods of Review..............................................................................................................12
5.1 Assessment of methodological quality...........................................................................12
5.2 Data Extraction...............................................................................................................12
5.3. Data Synthesis...............................................................................................................13
6. Results..................................................................................................................................13
6.1. Description of Search Results.......................................................................................13
Figurer: PRISMA Flow diagram for search strategy...........................................................14
6.2. Description of Included Reviews..................................................................................14
8. Discussion............................................................................................................................18
8.1. Summary of Findings....................................................................................................18
MRI Effectiveness............................................................................................................18
MRI in Breast Cancer Screening Amongst Young Women.............................................20
8.2. Quality of Evidence.......................................................................................................23
8.3. Potential Biases in Review Process...............................................................................23
9. Conclusion............................................................................................................................24
9.1. Implication for Practitioners..........................................................................................24
9.2 Implication for Researchers............................................................................................24
References................................................................................................................................25
Appendices...............................................................................................................................28
Appendix A: PRISMA Flow Diagram.................................................................................28
Appendix B: Search Strategy for PubMed...........................................................................29

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Appendix C: Data extraction Form......................................................................................30
Appendix D: AMSTAR 2 Critical Appraisal Form.............................................................32
Appendix E: Time Frame.....................................................................................................37

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1. Background
The most prevalent malignancy occurring among the women is Breast cancer. Women
with the strong history of breast carcinomas in their family or women, who have undergone
any kind of chest radiation therapy before 30 years of age, or have the predisposing genetic
mutation (e.g., BRCA1 or BRCA2 mutation) (20% to 65%) possess a higher chance of
developing breast malignancy in comparison to general population (11%) (Wang, 2017). The
effective diagnosis of breast cancer at the early stage can significantly help in reducing the
breast cancer related mortality and morbidities.
Most of the techniques used for the screening of breast carcinomas have some
limitations, such as some are expensive, prolonged and not suitable for younger women
(Roganovic et al, 2015). Magnetic resonance imaging is being considered as the most
effective screening modality for early detection of breast lesions. Therefore, this study will
conduct a critical review of the existing evidences from the literature in order to understand
the effectiveness of MRI Imaging in early diagnosis of breast cancer in women with high-risk
of cancer.
The purpose of this research is to inspect and analyse the effectiveness of MRI breast
for the early diagnosis of breast cancer among the women, who are at the higher risk. The
main objective is to understand the significance of early diagnosis of the breast cancer, as the
prevalence and incidences of breast cancer is significantly increasing among young women.
Memon et al (2015) have informed that the exposure to radiations and family history of
breast cancer can result in increasing the risk of the cancer among young women and a
delayed diagnosis of the disease can increase the mortality rates (Paluch-Shimon et al, 2016).
Therefore, there is a substantial need of appropriate and effective screening tools for the early
detection of the breast cancer among young women.

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Various forms of diagnostic approaches for breast cancer have been studied by the
investigators, such as computerised tomography, mammography, positron emission
tomography, biopsy, and ultrasound (Roganovic et al, 2015). Garber (2009) and Roganovic et
al (2015) identified that MRI imaging could be highly significant in early detection of breast
cancer. Mammography is the most popular and current standard used for the diagnosis and
detection of breast carcinomas.
However, studies have identified that, this screening tool is not effective for women
below the age of40 (Onega et al, 2016). Hassan & El-Shenawee (2011) informed that MRI
imaging could be more effective in detecting the small lesions among young women that
could not be detected through mammography. However, a gap has been identified in the
literature towards understanding the significance of MRI in early diagnosis of breast cancer
specifically in the case of young women who are at higher risk. This study will help in filling
this gap by informing about the effectiveness of MRI for early detection of breast cancer
among younger women.
2. Objectives
We will analyse and summarise the most appropriate evidences from the literature in
this rapid review study, in order to understand the effectiveness of MRI Imaging in early
diagnosis of breast cancer in high-risk women. The primary focus of this rapid review study
will be the following question specifically:
How MRI imaging can help in enhancing the possibility of detection of breast cancer
among young and high-risk women?

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3. Criteria for Considering Studies
3.1 Types of Studies
The identification of an effectiveness of MRI imaging in early diagnosis of breast
carcinoma among young and high-risk women will be evaluated in this rapid review study.
Systematic reviews are considered to be most significant in developing evidence-based
knowledge (Edwards, 2014). Breast cancer has been recognized as the most prevailing
malignancy in different studies that is identified among 6.6% cases diagnosed among the
young women (Assi et al, 2013). According to Australian Government Cancer Statistics, in
the year 2019, 23% of all accounted new cancer cases among the women aged between 20
and 39 are of breast cancer. Breast cancer also resulted in 21% deaths among the women
aged 20-39 (Cancer Australia, 2019). Therefore, breast carcinoma is being identified as the
most prevalent malignancy resulting in higher rate of mortality among young women.
3.2. Types of Participants
This study will comprise the studies that have the appropriate context and have
included ‘young women’ who are at high risk of breast cancer, or screening and imaging for
early diagnosis of breast cancer. Breast carcinoma diagnosis and treatment among young
women require special consideration, because of the various complexities associated with
cancer diagnosis in young age (Houssami & Cho, 2018). Therefore, the context of the
research is to focus on wider literature and conduct a critical analysis of the studies that
mainly discuss the significance of early detection of breast cancer in younger women by
using MRI imaging.
3.3. Types of Interventions
Different studies have identified that diagnosis of breast cancer among young women
is more challenging than in older women, as the cancer symptoms may present differently
and may be difficult to be detected (Houssami & Cho, 2018). Stuckey & Onstad, (2015)

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espoused that MRI is highly effective in detecting invasive carcinoma as well as carcinoma in
situ, which is not visible through other screening modalities and thus considered as highly
significant in high risk patients. Therefore, the main intervention included in this study will
be significance and effectiveness of MRI screening in early diagnosis of breast carcinoma.
3.4. Types of Outcomes
The significance of high sensitivity and rapid detection techniques for early diagnosis
of breast cancer among young and high risk women (Sheila Cristina Rocha-Brischiliari,
2017) and the role of Magnetic resonance imaging for the rapid early detection of breast
cancer in younger women, who are at higher risk of developing this disease (Cho et al, 2017)
will be indicated in this study.
4. Search Strategy
The identification of the peer reviewed systematic review studies will be the principle
search strategy. All the studies that will be explored through online search would be assessed,
based on their relevance to the study problem, provided in their title, abstract and the other
description. The search of the studies will also be based on the appropriate PRISMA Flow.
Therefore, the main medical databases will be searched with appropriate use of keywords.
The five important data bases that would be utilized for conducting search are:
 CINAHL
 Cochrane
 EMBASE
 MEDLINE
 PubMed
According to eligibility criteria, all the studies that are published between 2009 and
2019 would be eligible for the inclusion in this rapid review study. The time period of 10

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years is identified to be significant for this research, as it will help in obtaining the recent
evidences. The studies published in English language will only be eligible for inclusion in the
study. The detailed search strategy can be accessed in Appendix B.
5. Methods of Review
5.1 Assessment of methodological quality
The methodological validity and quality of the studies will be analysed on the basis
of critical appraisal instruments called as Assessment of Multiple Systematic Reviews
(AMSTAR 2). According to Shea et al (2017) that main aim of AMSTAR is to evaluate the
systematic review of the randomised control trials. AMSTAR 2 has been developed in order
to improve the process of reviewing systematic reviews (Lorenz et al, 2019). This tool
contains 16 different items that help in assessing the validity and reliability of the systematic
review studies. The domain specific questions will be answered in this tool under which ‘yes’
denotes positive response and in case of some missing information ‘no’ is used (Shea et al,
2017). In AMSTAR 2, the ‘partial yes’ has also been provided as an additional response for
some specific instances, where the researcher identifies any kind of partial response to the
review standard (Lorenz et al, 2019).
5.2 Data Extraction
The data collection for this review will be based on the appropriate information
collection. The specific information about outcomes, study method, interventions and study
population will be provided by the data extraction. MRI has been identified as a highly
sensitive technique that helps in effective detection of malignant breast lesion in young
women, who have dense breast tissues in comparison to older women (Paluch-Shimon et al,
2016). In this study, the extracted data will reveal about the study population (young women)
that are at high risk or not, including the effectiveness of MRI imaging in early diagnosis of
breast cancer in young women.

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5.3. Data Synthesis
The finding of this rapid review will be presented using a narrative approach. The
tables and figures will be used to hand over the finding of the review.
6. Results
6.1. Description of Search Results
Utilizing the searches in the database, 1437 studies in total got recognised whereby
300 papers stood retrieved from MEDLINE, 247 from PubMed, 321 from Cochrane, 301
from EMBASE and 268 from CINAHL. A total of 482 articles were removed for being
duplicate and 955 articles remained for detailed examination. A total of 922 papers were
further acknowledged as not being relevant following the review of their abstract and were
excluded leading to total of 33 full papers being retrieved for additional examination. Further,
14 studies unmet the criteria for inclusion and stood subsequently excluded leaving us with a
total of 19 full papers being retrieved for additional examination. The remaining 19 papers
were further subjected to assessment of quality which resulted in 12 more articles being
omitted for never meeting the quality assessment criteria. Thus, 7 full articles in total met the
quality assessment criteria premised on AMSTAR score which ranged from medium to high
qualities. Out of the 7 articles, two were of medium quality with scores of 7, 6 and five were
of high quality (AMSTAR score: 9, 10, 10, 9, 11) were subsequently included in the review
and ten. The beneath flow diagram shows the search strategy.

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Figurer: PRISMA Flow diagram for search strategy
6.2. Description of Included Reviews
In the systematic review undertaken by Menezes et al. (2014), the authors performed
a search of literature on PubMed in articles issued between years 1990 and 2013 utilizing
such keywords as “MRI”, “staging,” “breast,” “diffusion-weighted imaging,” “spectroscopy,”
as well as “high-field breast MRI”. The investigators included the papers printed in English
relating to mature humans with existing abstracts and also comprised of the references at the
bottom of each paper’s reference list. The authors initially presented the major guidelines on
the utilization of MRI in both breast cancer’s diagnosis and staging, and consequently
discussed the novel technologies then available for research. The authors concluded that
major evidence in support of MRI is anchored on the breast MRI’s grander capability in the

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detection on ispsilateral as well as contralateral illness, when contrasted with ultrasound as
well as mammography.
In other systematic review by Salem et al. (2013), the authors discussed the role of
MRI in screening, diagnosis as well as following-up of breast cancer in young individuals.
The keywords used included magnetic resonance imaging (MRI); breast cancer, and young
females. The authors reviewed various articles published on the topic. The authors reviewed
the papers published by European Society of Breast Cancer Specialist (EUSOMA) and
American Cancer Society and highlighted their suggestions on the use of MRI in detection of
breast cancer. The authors reviewed the findings from 8 major clinical trials in the previous
years that explored breast MRI as tool for screening have been published. These authors
cumulatively reviewed studies which encompassed 4271 patients and discovered one-
hundred and forty-four breast cancer detected by MRI, for the general cancer yield of three
percent. It was concluded in this article that contrast-enhanced breast MRI remains a
powerful technique in breast imaging diagnostic workup specifically in highly exposed young
women.
A combined meta-analysis and systematic review study by Nelson et al. (2016) came
in the backdrop of a recommendation in the year 2009 by the United States Preventive
Services Task Force of the biennial mammography screen for females aged fifty to seventy-
four as well as selective screening for the people aged between 40 and 49 years. The main
purpose of this review was mainly to determine effectiveness of breast cancer screening in
average-risk females. The data was obtained from MEDLINE and Cochrane databases to
4/06/2015. The reviewers selected the studies which were published in English and were
RCT as well as observational studies about screening breast cancer with mammography, MRI
and ultrasound which had reported mortality of breast cancer, all-cause mortalities or even
advanced outcomes of breast cancer. The reviewers extracted data as well as confirmed the

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same data alongside dual-rated quality and also solved discrepancies via consensus. The
reviewers synthesized data to show that fair-qualities proof from the meta-analysis of trials
on mammography which showed a relative risk (RR) for breast cancer mortalities of 0.920
for females aged between 39 and 49 years. The risk reduction stood at 25 percent to 31
percent for females aged between 50 and 69 years in mammographic observational studies.
Another systematic review research by Lee et al. (2010) likened the use of ultrasound,
MRI and mammography in screening breast cancer amongst the young women. The
keywords for the search included screening, breast cancer, recommendations, breast
ultrasound, breast MRI, and mammography. The reviewers focused on reviewing the
recommendations and guidelines of Society of Breast Imagining (SIB) and ACR on the
utilization of Mammography, Breast Ultrasound as well as additional technologies for
detecting clinical occult breast cancer. This was premised on the notion that breast cancer
screening with mammography is subject to various limitations leading to the recent use of
MRI and ultrasound as adjunctive screening techniques for mammography, primarily for
females who might be at augmented breast cancer development risk.
In another shared systematic review and meta-analysis study by Sun (2013), the
reviewers’ main purpose was to appraise the breast-specific gamma imaging (BSGI)
diagnostic performance as assistant modality to mammographic screening for the detection of
breast cancer. The investigators used all-inclusive searches of EMBASE (1994 to August
2012) as well as MEDLINE (1984 to August 2012). The authors used search keywords as
breast neoplasm, meta-analysis, breast-specific gamma imaging and mammography. They
constructed a summary receive operating characteristic curve (SROC) which effectively
summarized the general BSGI test performance. The authors also pooled the sensitivities for
detection of sub-centimetre cancer alongside DCIS (ductal carcinoma in situ). They also
evaluated the BSGI’s potential in complementing mammography via the identification of

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mammography-occult breast cancer. The result showed that MRI demonstrated comparable
sensitivity as well as enhanced specificity of diagnosis of breast cancer by BSGI over the
MRI.
In another systematic review study by Mann (2015), the main purpose was to
summarize the info regarding the breast MRI to be given to women as well as referring
physicians. The keywords used by the reviewers included breast; MRI, patient advocacy,
breast cancer and access to information. The investigators listed all the contraindications and
subsequently described the procedure details, emphasizing the need for right scheduling as
well as not moving in the course of examination. The reviewers provided 17 notes and 5
FAQs which they framed for utilization as straight communication to females and reviewed
the text by Europa Donna-The European Breast Cancer Coalition hence ensuring that it can
be understood straightforwardly by females who are enduring MRI. Their report included a
discussion on BI-BADS categories alongside additional actions following the examination of
a breast MRI. The review acknowledged that MRI remains a highly sensitive modality, and
primarily enhancing high-risk women screening. The review further revealed that MRI plays
a significant role in clinical diagnosis, solving of problems, as well as staging hence
impacting on the management of patients. Nonetheless, the review showed that MRI has
certain limitations and sometimes misses breast cancer.
Another meta-analysis study by Brenner 2015) was based on the background that no
consensus existed on whether MRI needs to be integrated into protocols for screening of
breast for females with BRCA1/2 mutations aged greater or equal to 50 years. Hence, the
reviewers probed the existing evidence on the aged-linked screening accurateness in females
with BRCA1/2 mutation based on IPD or individual patient data meta-analysis. The
investigators pooled the IPD from 6 screening trials (high-risk) which included females with
BRCA1/2 mutations that had finished at least 1 screening rotund with mammography and

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MRI. They used a comprehensive linear-mixed model of studies to estimate sensitivity as
well as specificity of mammography, MRI, as well as a blend of the two modalities in women
and particularly in those females from age fifty and above. The result showed that inclusion
of MRI to mammography to screen BRCA1/2 mutation carriers from age 50 years enhances
sensitivity of screening by a magnitude identical to that evident in younger women. Thus,
restricting screening MRI in BRCA1 or 2 carriers’ age from fifty years needed to be
reassessed.
8. Discussion
8.1. Summary of Findings
A wide array of systematic review remain available which probed the use of breast
MRI in screening breast cancer amongst young females. Indeed, most of the studies have
concluded reviews that summarize the findings from the systematic reviews to acknowledge
whether breast MRI is furthermost effective screening instrument for detecting breast cancer
amongst young women. Indeed such studies have concluded that breast MRI is effective and
mores so when used alongside mammography. This rapid review remains a detailed summary
of the systematic reviews alongside metal-analyses which have acknowledged breast MRI as
most effective tool in screening breast cancer amongst young women than mammography.
The summary from the chosen reviews has recognized breast MRI as the most effective tool
for screening breast cancer in fledgling women.
MRI Effectiveness
The MRI uses magnetic fields to generate comprehensive cross-sectional tissue
structure’s image, providing extremely good contrast of soft issue. MRI creates breast images
via the measurement of vicissitudes in protons’ movements in water and fat with altering
magnetic fields’ application and via the use of variation in tissue relaxation characteristics.

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The dissimilarity between breast tissue (lesions, fat and glandular) relies on mobility
alongside magnetic atmosphere of atoms of hydrogen in fat alongside water contributing to
measured signals which regulates the brightness of tissue in an image. Such leads to images
in the breast which show primarily fat and parenchyma, alongside lesions, whenever existing.
The utilization of MRI for detection of breast cancer is premised on neo-vascularity or
angiogenesis concept of tumor. Tumor linked vessels of blood have enhanced penetrability
that results in immediate take-up as well as gadolinium release within the 1st 1-2 minutes
following the administration, culminating in a speedy enhancement alongside washout
pattern on MRI. Such vibrant pattern assist in distinguishing benign lesion from breast
cancers. Therefore, MRI (contrast-enhanced) has been demonstrated to show an extremely
greater sensitivity for the detection of breast cancer in the asymptomatic (high-risk) as well as
symptomatic females, even though specificity highlights have been increasingly inconstant.
Such a great signal arising from enhancing-lesions might be challenging to distinguish
from fat, culminating in the utilization of images subtraction or suppression of fat, or even the
two, for cancer assessment. Since parenchymal tissue further enhances, yet generally
increasingly gradually than malignant lesion; and further due to contrast might rapidly wash
out from certain tumors, it remains imperative to examine the images at the earliest possible
time point following the injection of contrast (often 1-3 minutes). Examination of MRI might
entail examining images a specific time point, or even usually, shall gather an image of pre-
injection with consecutive image sets following injection of contrast (DCE-MRI or dynamic
contrast enhanced). The appearance of lesion, and where possible, the washout and uptake
pattern might be utilized in the identification of malignant illness, and differentiate it from
conditions of benign. Such tools that have been broadly deployed for symptomatic illness
assessment, have lately been demonstrated to give desirable sensitivities as the technique for
screening breast cancer in females at amplified risk premised on family history.

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MRI in Breast Cancer Screening Amongst Young Women
Globally, diagnosis of breast cancer is in more than 1M females each year. Till this
illness might be deterred, detection at early stages provides best opportunity for treatment.
For screening procedure (in generic terms), to get regarded useful, it has must not solely
detect lesions at the earlier phase possible, but also it needs to showcase that earlier diagnosis
culminates in certain clinical benefits, favorably, a decrease in mortality of breast cancer.
Even though mammography screening remains offered often to young females with the
genetic breast cancer predisposition, its efficacy remains yet to be proven.
The preliminary outcome in such females showcased that mammographic screening
has extremely low sensitivities for the detection of tumors, specifically in the BRCA mutation
carriers. Such females have a collective lifespan risks of breast cancer development of
twenty-one to sixty-five percent. Female genetically predisposed to frequently develop this
illness at young ages where thick breast tissue lowers the mammographic sensitivities.
Additional feasible rationale encompass alterations observed on mammography in BRCA
mutation carriers as opposed to non-carriers of similar age.
Owing to the deliberations about the MRI role as test for screening, the American
Cancer Society (ACS) has highlighted suggestions for the utilization of breast MRI for
screening breast cancer. It must be emphasized that where MRI is utilized, it needs to be
alongside, not in place of, a screening mammogram. This is due to the fact that though the
MRI remains increasingly sensitive test (it remains more probably to identify cancer as
opposed to mammogram), it might still miss certain cancers which a mammogram might
capture.
For many highly exposed females, the ACS suggested that MRI screening together
with mammograms need to commence at age of thirty years and last for so long as a female
remains in better health. However, due to restricted evidence regarding the desired age at

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which to begin screening, such a decision needs to be premised on collective decision-making
amongst healthcare providers and patients, considering personal preferences and
circumstances.
The ASC suggested screening with breast MRI as the mammography adjunct for the
carriers of BRCA mutation and respective 1st-degree relations; females with the lifespan risk
of breast cancer greater/equal to twenty-twenty-five percent; females with radiation of chest
history between 10 and 30 years of age; and females with Cowden and Li-Fraumeni
(predisposing genetic syndrome). The ASC felt that limited evidence existed for and against
MRI screening amongst females with the duct carcinoma in situ or personal invasive breast
cancer history.
The European Society of Breast Cancer Specialist (EUSOMA) in the year 2010
published an article which evaluated the existing evidence about clinical value of as well as
suggestions for breast MRI. Such an article highlighted the outcomes of each cohort study
probing the diagnostic effectiveness of a range of modalities for imagining in the extremely
exposed female surveillance. EUSOMA suggested that females with the family history
recommending a hereditary predisposition to breast cancer need to have their respective risks
properly evaluated by suitably trained expert cluster like hereditary counselling.
Where a female is discovered to be highly exposed (20 to 30 percent lifetime
risk/greater), such women need to be provided oral as well as written info about their risk as
well as benefits and risks of MRI and mammography screening or alternate risk-lessening
mechanisms. If such women accept screening by MRI, they need to get informed regarding
the logistics and intervals of the screening. This need to be established based on national or
regional considerations displaying an area-particular cumulative risk in overall populace,
obtainability of resource as well as practical feasibility. It was suggested that yearly MRI
screening must be available beginning at age of thirty years.

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Premised on the observational studies which have generated consistent findings;
combining MRI and mammographic screening is presently the care standard for BRCA
mutations females that reject risk-lessening mastectomy. Due to MRI’s great sensitivities,
manifold researchers have probed the MRI’s prospective role in screening females at
augmented risks. The findings from 8 major clinical trials in the previous years that explored
breast MRI as tool for screening have already been printed.
Cumulatively, these articles encompassed 4271 patients and discovered one-hundred
and forty-four breast cancer discovered by MRI, for the general cancer-yield of three percent.
The MRI sensitivities fluctuated from seventeen-one percent to a hundred percent crossways
the articles. Even though their reported specificity stood variable; rates of call-back alongside
benign biopsies risk remained within desirable limits. Generally, patient that experienced
breast screening with MRI showed a ten percent risk of getting called back; as well as a five
percent risk of undergoing a biopsy of benign.
A research stood performed to recapitulate sensitivity, specificity and likelihood
ratios, alongside post-test probabilities linked to addition of MRI to yearly mammography
screening of females susceptible to breast cancer in 11 relevant, prospective, and non-
randomized researches ranging from small single-center studies with solely 1 round of
screening of patient to large multicenter researches with recurrent annual screening rounds
being identified. Women’s characteristics ranged crossway the samples including age range,
breast cancer history, and either BRCA2 or BRCA1.
Research utilized dynamic MRI (contrast-enhanced) along with coronal or axial plane
images for European studies or sagittal images for studies in North American which stood
often understood with no mammography findings’ knowledge of. A summary adverse
possibility ratio along with a BI-RADS-suspicious lesion probability (provided adverse test
results as well as assuming two percent pre-test disease probabilities) stood 0.7 (95% CI,

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0.59-0.82) alongside 1.4% (CI, 1.2%-1.6%) for mammography only and 0.14 (CI, 0.5-0.42)
as well as 0.3% (CI, 0.1%-0.80%) for MRI+ mammography combined; utilizing a BI-RADS
score of four or greater as positive definition. The investigators summed up that screen with
both mammography and MRI could detect cancerous lesions better as opposed to only
mammography amongst females extremely susceptible or probably to have genetic breast
cancer predisposition.
8.2. Quality of Evidence
The utilization of AMSTAR technique for guaranteeing the methodological quality of
the reviews assisted in overcoming the challenges in the course of the study quality selection.
A total of seven systematic reviews alongside meta-analysis stood included for review which
ranged from medium (six articles) to high quality (10 articles). The findings from such
reviews quality would assist the both researchers and practitioners in the future.
8.3. Potential Biases in Review Process
The review availed a summary of the breast MRI as the most effective screening
technique or tool in breast cancer amongst young women. Nonetheless, there are a range of
shortcomings. The first limitation is that only five databases were utilized for search strategy
and hence the publication bias might be inevitable in the review. The second limitation was
on limiting the time period between 2009 and 2019 thereby restricting the inclusion of all
studies published before 2009 which would otherwise be beneficial for future practice. The
third shortcoming is that only English papers were included as the inclusion of papers written
in other languages was infeasible yet they could have provided extra info regarding the
effectiveness of breast MRI for screening breast cancer amongst young women in the future.
Finally, a large proportion of meta-analyses and systematic reviews entailed several had
sparse data for comparing breast MRI technique with mammography; and yet such could
have improved the understanding of breast MRI effectiveness.

MRI IN BREAST CANCER SCREENING RAPID REVIEW 24
9. Conclusion
Breast MRI remains an effective technique for screening breast cancer amongst the
young women since it has a higher sensitivity to cancerous lesions than mammography.
However, the rapid review of literature has shown that this should not mean that we stop the
use of mammography since they both MRI and mammography are supplementary and work
best together to detect the breast cancer among young women. This review has thus
summarized the existing evidence with respect to breast MRI as the most effective technique
in screening breast cancer amongst young women. It is concluded from the discussion that
breast MRI will work alongside mammography to properly detect breast cancer in young
women and hence they should always be used together. Therefore, this rapid review of
literature recommends that breast MRI is effective technique and should be used to screen
breast cancer amongst young women.
9.1. Implication for Practitioners
From the findings of this rapid review of literature, it is demonstrated that
practitioners should use breast MRI alongside mammography to screen and detect breast
cancer among young women. The nurses should always ensure that mammography is
replaced by breast MRI since though MRI is more effective that mammography, there is
evident that mammography can sometimes detect breast cancer which have not been detected
by breast MRI.
9.2 Implication for Researchers
As shown under discussion, there is a need for additional studies that specifically
focused on the comparison between breast MRI and other interventions like mammography
to help provided a more vivid picture on the effectiveness of breast MRI in detecting breast
cancer than other interventions. Also, additional research is required on how best breast MRI
and mammography should be integrated for effective outcomes.

MRI IN BREAST CANCER SCREENING RAPID REVIEW 25
References
Assi, H. A., Khoury, K. E., Dbouk, H., Khalil, L. E., Mouhieddine, T. H., & El Saghir, N. S.
(2013). Epidemiology and prognosis of breast cancer in young women. Journal of
thoracic disease, 5(Suppl 1), S2.
Brenner, R. J. (2015). Magnetic Resonance Imaging Improves Breast Screening Sensitivity in
BRCA Mutation Carriers Age≥ 50 Years: Evidence From an Individual Patient Data
Meta-Analysis: Phi XA, Houssami N, Obdeijn IM, et al (Univ Med Ctr Groningen,
Netherlands; Erasmus Univ Med Ctr Rotterdam, Netherlands; Univ of Sydney, New
South Wales, Australia; et al) J Clin Oncol 33: 349-356, 2015 §. Breast Diseases: a
YB Quarterly, 26(3), 219-220.
Cancer Australia. (2019). Breast Cancer in Young Women. Australian Government.
Retrieved from:
https://breast-cancer-in-young-women.canceraustralia.gov.au/statistics
Cho, N., Han, W., Han, B. K., Bae, M. S., Ko, E. S., Nam, S. J., ... & Song, B. J. (2017).
Breast cancer screening with mammography plus ultrasonography or magnetic
resonance imaging in women 50 years or younger at diagnosis and treated with breast
conservation therapy. JAMA oncology, 3(11), 1495-1502.
Edwards, T. B. (2014). What is the value of a systematic review?. Journal of shoulder and
elbow surgery, 23(1), 1-2.
Garber, J. E. (2009). Identifying and assessing women at high risk for breast cancer. Breast
Cancer Research, 11(1), S1.
Hassan, A. M., & El-Shenawee, M. (2011). Review of electromagnetic techniques for breast
cancer detection. IEEE Reviews in Biomedical Engineering, 4, 103-118.

MRI IN BREAST CANCER SCREENING RAPID REVIEW 26
Houssami, N., & Cho, N. (2018). Screening women with a personal history of breast cancer:
overview of the evidence on breast imaging surveillance. Ultrasonography, 37(4),
277.
Lee, C. H., Dershaw, D. D., Kopans, D., Evans, P., Monsees, B., Monticciolo, D., ... &
Hendrick, E. (2010). Breast cancer screening with imaging: recommendations from
the Society of Breast Imaging and the ACR on the use of mammography, breast MRI,
breast ultrasound, and other technologies for the detection of clinically occult breast
cancer. Journal of the American college of radiology, 7(1), 18-27.
Lorenz, R. C., Matthias, K., Pieper, D., Wegewitz, U., Morche, J., Nocon, M., ... & Jacobs,
A. (2019). A psychometric study found AMSTAR 2 to be a valid and moderately
reliable appraisal tool. Journal of clinical epidemiology.
Mann, R. M., Balleyguier, C., Baltzer, P. A., Bick, U., Colin, C., Cornford, E., ... & Gilbert,
F. J. (2015). Breast MRI: EUSOBI recommendations for women’s
information. European radiology, 25(12), 3669-3678.
Memon, Z. A., Kanwal, N., Sami, M., Larik, P. A., & Farooq, M. Z. (2015). Risk of breast
cancer among young women and importance of early screening. Asian Pac J Cancer
Prev, 16(17), 7485-9.
Menezes, G. L., Knuttel, F. M., Stehouwer, B. L., Pijnappel, R. M., & van den Bosch, M. A.
(2014). Magnetic resonance imaging in breast cancer: a literature review and future
perspectives. World journal of clinical oncology, 5(2), 61.
Nelson, H. D., Fu, R., Cantor, A., Pappas, M., Daeges, M., & Humphrey, L. (2016).
Effectiveness of breast cancer screening: systematic review and meta-analysis to
update the 2009 US Preventive Services Task Force recommendation. Annals of
internal medicine, 164(4), 244-255.

MRI IN BREAST CANCER SCREENING RAPID REVIEW 27
Onega, T., Goldman, L. E., Walker, R. L., Miglioretti, D. L., Buist, D. S., Taplin, S., ... &
Smith-Bindman, R. (2016). Facility mammography volume in relation to breast
cancer screening outcomes. Journal of medical screening, 23(1), 31-37.
Paluch-Shimon, S., Pagani, O., Partridge, A. H., Bar-Meir, E., Fallowfield, L., Fenlon, D., ...
& Harbeck, N. (2016). Second international consensus guidelines for breast cancer in
young women (BCY2). The Breast, 26, 87-99.
Rocha-Brischiliari, S. C., de Oliveira, R. R., Andrade, L., Brischiliari, A., Gravena, A. A. F.,
de Barros Carvalho, M. D., & Pelloso, S. M. (2017). The rise in mortality from breast
cancer in young women: trend analysis in Brazil. PloS one, 12(1), e0168950.
Roganovic, D., Djilas, D., Vujnovic, S., Pavic, D., & Stojanov, D. (2015). Breast MRI, digital
mammography and breast tomosynthesis: comparison of three methods for early
detection of breast cancer. Bosnian journal of basic medical sciences, 15(4), 64.
Salem, D. S., Kamal, R. M., Mansour, S. M., Salah, L. A., & Wessam, R. (2013). Breast
imaging in the young: the role of magnetic resonance imaging in breast cancer
screening, diagnosis and follow-up. Journal of thoracic disease, 5(Suppl 1), S9.
Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., ... & Henry, D. A.
(2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include
randomised or non-randomised studies of healthcare interventions, or both, Bmj, 358,
j4008.
Sun, Y., Wei, W., Yang, H. W., & Liu, J. L. (2013). Clinical usefulness of breast-specific
gamma imaging as an adjunct modality to mammography for diagnosis of breast
cancer: a systemic review and meta-analysis. European journal of nuclear medicine
and molecular imaging, 40(3), 450-463.
Wang, L. (2017). Early diagnosis of breast cancer. sensors, 17(7), 1572.

MRI IN BREAST CANCER SCREENING RAPID REVIEW 28
Appendices
Appendix A: PRISMA Flow Diagram

MRI IN BREAST CANCER SCREENING RAPID REVIEW 29
Appendix B: Search Strategy for PubMed
1. ‘Breast cancer’
2. ‘Breast cancer and young women’ or ‘breast cancer prevalence’
3. ‘Cancer Screening’
4. ‘MRI imaging and cancer screening’
5. ‘MRI’ or ‘mammography’
6. ‘cancer in women’
7. ‘High risk women and breast cancer’
8. ‘MRI imaging in high risk women’
9. ‘Cancer diagnosis among women’
10. ‘Breast carcinoma detection and young women’
11. ‘systematic review’
12. ‘meta-analysis’ and ‘breast cancer’
13. ‘Language – English
14. Year 2009- current

MRI IN BREAST CANCER SCREENING RAPID REVIEW 30
Appendix C: Data extraction Form
Author
Year
Country
Focus
Search
Details
Quality
Score
Number
of
Studies
Designs of
the studies
Intervention
s
Study
Outcomes
Menezes
et al.
(2014)
Searched
Pubmed
(1990 to
2013),
English
papers
9 95 Systematic
review
Breast MRI Breast
MRI
effective
Salem et
al(2013)
Searched
PubMed
English
articles
10 41 Systematic Breast MRI Breast
MRI
effective
Nelson et.
(2016)
Searched
MEDLINE
and
10 38 Combined
systematic
review and
Breast MRI Breast
MRI

MRI IN BREAST CANCER SCREENING RAPID REVIEW 31
Cochrane
databases
to 4 June
2015,
English
language,
meta-
analysis
effective
Lee et al.
(2010)
SIB and
ACR
9 82 Systematic
review
Breast MRI Breast
MRI
effective
Sun et al.
(2013)
Searched
MEDLINE
(1984 to
August
2012 and
EMBASE
(1994 to
August
2012),
English
language
articles
11 19 systematic
review and
meta-
analysis
Breast MRI Breast
MRI
effective

MRI IN BREAST CANCER SCREENING RAPID REVIEW 32
Appendix D: AMSTAR 2 Critical Appraisal Form
AMSTAR 2 Items Menezes et
al. (2014)
Salem et
al(2013)
Nelson et.
(2016)
Lee et al.
(2010)
Sun et al.
(2013
Were the PICO
components added in
research questions
and inclusion criteria
for review?
Yes Yes Yes Yes Yes
Did a Justification Yes Yes Yes Yes Yes

MRI IN BREAST CANCER SCREENING RAPID REVIEW 33
for any significant
deviations from the
protocols is given in
the report and a
declaration is
included in the report
of review regarding
“the review methods
were established
prior to the conduct
of the review”?
Did a selection
process of study
design for review is
explained by review
author?
Yes Yes Yes Yes Yes
Did a comprehensive
strategy for literature
search is adopted by
review author?
Yes Yes Yes Yes Yes
Did a duplication in
study selection is
performed by the
review author?
Yes Yes Yes Yes Yes
Did a duplication of Yes Yes Yes Yes Yes

MRI IN BREAST CANCER SCREENING RAPID REVIEW 34
data extraction is
done by review
author?
Did a list of studies
not included and the
justification for their
rejection is given by
the author?
Yes Yes Yes Yes Yes
Did the included
studies are mentioned
with adequate details
by the review author?
Yes Yes Yes Yes Yes
Did a risk of bias
(RoB) is assessed by
a satisfactory
technique in selected
individual studies by
the review author?
Yes Yes Yes Yes Yes
If the review author
has carried out meta-
analysis, did the
statistical
combination of
results are performed
by an appropriate
Yes Yes Yes Yes Yes

MRI IN BREAST CANCER SCREENING RAPID REVIEW 35
method?
Did an assessment of
the possible effects of
individual study’s
ROB on the outcomes
of evidence synthesis
or meta-analysis, is
done by review
author?
Yes Yes Yes Yes Yes
Did the ROB in
primary studies is
being considered in
interpretation or
discussion of the
outcome of the
review, by the review
author?
Yes Yes Yes Yes Yes
Did a satisfactory
explanation
regarding non-
uniformity seen in the
outcome of the
review, is provided by
review author?
Yes Yes Yes Yes Yes
In case of the Yes Yes Yes Yes Yes

MRI IN BREAST CANCER SCREENING RAPID REVIEW 36
application of
quantitative
synthesis, did a
thorough inquiry of
publication bias and
its possible effects
on the outcome of the
review are carried
out by review
authors?
Did a report of
plausible conflict of
interest is registered
by review author,
while conducting
review?
Yes Yes Yes Yes Yes

MRI IN BREAST CANCER SCREENING RAPID REVIEW 37
Appendix E: Time Frame
Time Frame Week 1 Week 2 Week 3 Week 4 Week 5
Formulation
of PICO
Question
Formulation
of search
terms
Preliminary
Search
Application
to search
strategy to
retrieve
articles
Title and
Abstract
screening
Checking for
relevance of

MRI IN BREAST CANCER SCREENING RAPID REVIEW 38
articles
Summarising
evidences