Annals of Internal MedicineOutcomes of Density-Targeted Supplemental Breast Magnetic Resonance Imaging Screening by Breast Cancer Risk: Long-Term Health and Economic Considerations

A lifetime simulation of women 40 and older finds supplemental breast MRI for extremely dense breasts benefits women with 2 times or greater average breast cancer risk, with harm-benefit ratios comparable to standard DBT in average-risk women. However, cost-effectiveness remains unfavorable at current MRI pricing, and biennial DBT starting at 45 outperforms biennial supplemental MRI starting at 50 across all risk groups.

Clinical Considerations

• Supplemental MRI averted 0.1 to 0.8 additional breast cancer deaths per 1,000 women beyond DBT alone, with benefit concentrated in women at 2 times or higher average risk.
• False-positive biopsy burden is significant, ranging from 22 to 186 additional biopsy recommendations per 1,000 women, a critical shared decision-making data point.
• Starting DBT at 45 outperformed supplemental MRI starting at 50 on cost-effectiveness across every risk group, reinforcing earlier screening initiation over modality escalation.
• MRI cost and false-positive rates are the primary levers determining cost-effectiveness, meaning institutional pricing directly shapes whether supplemental MRI is defensible for your patient panel.

Practice Applications

• Reserve supplemental MRI recommendations for extremely dense breast patients with confirmed relative risk of 2.0 or higher.
• Counsel eligible patients on the false-positive biopsy tradeoff before ordering supplemental MRI as routine density follow-up.
• Prioritize earlier DBT initiation at 40 to 45 over delayed supplemental MRI strategies for average and moderately elevated-risk patients.
• Review your institution’s MRI cost structure to determine whether supplemental screening crosses the cost-effectiveness threshold for your population.

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