NICE wants women aged 30–49 years with known mutations in the BRCA1 or BRCA2 genes or a high risk of carrying BRCA1 mutations to undergo annual MRI scans instead of, or in addition to, mammography. Scanning will begin as early as 20 years of age for carriers of the high risk TP53 mutation.
Previously, NICE only recommended MRI to resolve anomalies on mammograms, but a U-turn was been made after three studies that showed using MRI to screen young women at high risk of breast cancer boosted early detection rates.
Using MRI in high-risk cases was considered cost-effective by NICE even though an MRI scan costs an average £224, compared with £33.50 per mammogram.
But Dr Robert Bailey, a GP in Peterborough with an interest in breast cancer, said local MRI services may struggle to cope with the additional workload.
‘At the moment it would be a considerable drain on MRI time which is already stretched to
the limit,’ he said. ‘This has resource implications even if you are talking about these high-risk patients, because they’re a small but significant group.’
An MRI breast scan takes an estimated 40–50 minutes, but mammography has a turnaround of less than four minutes, explained Dr Bailey.
NICE recommended that women under 50 with a family history of BRCA1, BRCA2 or TP53 mutations should undergo digital mammography because this improves sensitivity.
However, Dr James Mackay, a consultant genetic oncologist at University College London, said: ‘This guideline is not helping with equity of access and fairness. There are fewer digital mammography machines across the country than MRI scanners.’
Dr Mackay also criticised the NICE definition of risk and the decision that women with a family risk of BRCA2 mutations would not be eligible for MRI.
‘There’s an attempt to provide a different level of clinical services to someone with a BRCA1 mutation in the family from someone with a BRCA2 mutation, which would be divisive,’ he said.
‘This guideline has made it difficult for someone in primary care to make the distinction.’
But RCGP chairman Professor Mayur Lakhani urged ‘clinicians to note the recommendation for yearly MRI screening for women between the ages of 20 and 49 if they have a high risk.’