虽然钼靶为目前唯一有证据可以减少乳腺癌死亡率的筛查方法，但是其假阳性结果较多。由于磁共振的分辨率和敏感性较高，故指南推荐磁共振用于辅助钼靶对乳腺癌高风险女性进行筛查，但是反对磁共振用于乳腺癌中低风险女性。不过，磁共振筛查对于有、无乳腺癌个人史女性人群的利弊尚不明确。 2018年2月12日，《美国医学会杂志》内科学分册在线发表凯泽永久华盛顿卫生研究院、华盛顿大学、麻省总医院、哈佛医学院、哈佛皮尔格林医疗卫生研究所、布列根和波士顿妇女医院、北卡罗来纳大学教堂山总校、新墨西哥大学、达特茅斯学院、旧金山加利福尼亚大学的人群队列研究报告，利用10年癌症登记数据对有或无乳腺癌个人史女性接受钼靶或磁共振±钼靶筛查后90天内的活检率和癌检出率进行了比较。 该队列观察研究利用乳腺癌监测联盟6个登记处（北卡罗来纳州、华盛顿州、大芝加哥区、新罕布什尔州、大旧金山区、佛蒙特州）2003～2013年81万2164例接受筛查女性人群样本，总共204万8994次数字化钼靶±磁共振筛查（单用钼靶、磁共振±30天内钼靶）。主要结局衡量指标：筛查后90天内的活检率（手术＞粗针＞细针穿刺）和癌检出率（浸润癌＞导管原位癌＞高风险良性＞良性）。根据年龄对活检率（每1000次筛查）和癌检出率（每1000次筛查伴活检）进行校正。根据乳腺癌个人史、无乳腺癌个人史女性的乳腺癌监测联盟登记处5年乳腺癌风险对结局进行分层。 结果发现，有、无乳腺癌个人史女性接受钼靶筛查10万1103次、193万9455次，接受磁共振筛查3763次、4673次。 磁共振与钼靶相比，根据年龄校正后的粗针和手术活检率：
钼靶与磁共振相比，经过活检确诊的导管原位癌和浸润癌：
无论有、无乳腺癌个人史，磁共振与钼靶相比，高风险良性病变都较多。随着年龄增加或5年乳腺癌风险增加，磁共振与钼靶相比，活检率增加而癌检出率减少。 因此，磁共振与钼靶相比，有、无乳腺癌个人史女性接受筛查后的活检率都较高，活检后癌检出率都较低。有必要开展进一步研究，确定磁共振筛查能够获益的女性，以权衡其利弊。 相关阅读 JAMA Intern Med. 2018 Feb 12. [Epub ahead of print] Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer. Buist DSM, Abraham L, Lee CI, Lee JM, Lehman C, O'Meara ES, Stout NK, Henderson LM, Hill D, Wernli KJ, Haas JS, Tosteson ANA, Kerlikowske K, Onega T; Breast Cancer Surveillance Consortium. Kaiser Permanente Washington Health Research Institute, Seattle; University of Washington School of Medicine, Seattle; Massachusetts General Hospital, Boston; Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; University of North Carolina, Chapel Hill; University of New Mexico, Albuquerque; Brigham and Women's Hospital, Boston, Massachusetts; Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; University of California, San Francisco. This population-based cohort study uses cancer registry data to examine the biopsy rates and yield in the 90 days following screening (mammography vs MRI with or without mammography) among women with and without a personal history of breast cancer. QUESTION: What are biopsy rates and yield in the 90 days following screening among women with and without a personal history of breast cancer (PHBC)? FINDINGS: In this population-based cohort including 812164 women undergoing screening (mammography vs magnetic resonance imaging [MRI] with or without mammography), there were 2-fold higher and 5-fold higher core and surgical biopsy rates following MRI compared with mammography among women with and without a PHBC, respectively, resulting in lower invasive cancer and ductal carcinoma in situ yield for both groups. MEANING: Women with and without PHBC who undergo screening MRI experience higher biopsy rates coupled with significantly lower cancer yield compared with mammography alone. 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 812164 women undergoing screening, 2003 through 2013. EXPOSURES: A total of 2048994 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 101103 and 1939455 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. PMID: 29435556 DOI: 10.1001/jamainternmed.2017.8549
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