Cost effectiveness analysis of prostate cancer screening strategies in Germany: A microsimulation study.

Objective: The objective of this study is to describe how the use of digital rectal exam to triage patients to standard transrectal ultrasound (TRUS) biopsies or magnetic resonance imaging (MRI) then MRI fusion biopsies impacts cancer detection rates, departmental resources and the diagnostic journey. Patients and methods: A retrospective analysis of all patients undergoing prostate biopsies in a 15-month period following the introduction of triage digital rectal exam (DRE) and MRI at Ayr University Hospital was conducted. MRI usage and patient journeys were also examined. Results: A total of 95.5% of patients proceeding directly to TRUS had malignant histology and less than 1% required further investigation. Forty-nine per cent of patients who underwent triage MRI avoided biopsy and over one-third of patients with previously benign TRUS biopsies had clinically significant malignancy on MRI fusion biopsies. The pathway eliminated repeat TRUS biopsy and the number of biopsies a month decreased. MRI usage doubled and waiting times to diagnostic biopsy increased when compared to a one-stop diagnostic clinic. Conclusion: Triaging according to DRE avoided delays in cases of overt malignancy and increased the detection rate of standard TRUS. For those patients with a benign DRE, MRI enabled half to avoid biopsy. The increase in demand on MRI was mitigated, in part, by using a shorter detection protocol but institutions must be aware of the potential for delays to diagnosis. Level of evidence: 4

Objectives To investigate the influencing factors of positive rate of transrectal ultrasound(TRUS) biopsy for prostate cancer. Methods A total of 222 male patients who underwent TRUS biopsy for prostate cancer were analysed retrospectively from June 2011 to June 2014. The relevant data including age, total prostate specific antigen(TPSA), magnetic resonance imaging(MRI), prostate volume(PV) and degital rectal examination(DRE) were analysed by univariate and multivariate regression and ROC. Then the PAMD(PV+ Age+ MRI+ DRE) scoring system was used to predict the positive rate of TRUS biopsy for prostate cancer. Results 88(39.6%) cases were diagnosed with prostate cancer among the 222 patients. Multivariate regression showed that age, TPSA, PV, MRI and DRE were all significant independent predictors of prostate cancer, with OR and 95%CI of 2.539(1.156~5.576), 2.745(1.677~4.494), 0.409(0.187~0.891), 0.132(0.039~0.446) and 0.018 (0.005~0.063) respectively. Patients with the risk score of ≥4 by PAMD scoring system had a significantly higher rate(48.2%) of prostate cancer than others risk score groups. Conclusions PAMD scoring system can help to increase the positive rate of TRUS biopsy for prostate cancer. Key words: Prostatic Neoplasms; Biopsy, Needle; Rectum

BackgroundStrategies for early detection of prostate cancer aim to detect clinically significant prostate cancer (csPCa) and avoid detection of insignificant cancers and unnecessary biopsies. Swedish national guidelines (SNGs), years 2019 and 2020, involve prostate-specific antigen (PSA) testing, clinical variables, and magnetic resonance imaging (MRI). The Stockholm3 test and MRI have been suggested to improve selection of men for prostate biopsy. Performance of SNGs compared with the Stockholm3 test or MRI in a screening setting is unclear. ObjectiveTo compare strategies based on previous and current national guidelines, Stockholm3, and MRI to select patients for biopsy in a screening-by-invitation setting. Design, setting, and participantsAll participants underwent PSA test, and men with PSA ≥3 ng/ml underwent Stockholm3 testing and MRI. Men with Stockholm3 ≥11%, Prostate Imaging Reporting and Data System score ≥3 on MRI, or indication according to SNG-2019 or SNG-2020 were referred to biopsy. Outcome measurements and statistical analysisThe primary outcome was the detection of csPCa at prostate biopsy, defined as an International Society of Urological Pathology (ISUP) grade of ≥2. Results and limitationsWe invited 8764 men from the general population, 272 of whom had PSA ≥3 ng/ml. The median PSA was 4.1 (interquartile range: 3.4–5.8), and 136 of 270 (50%) who underwent MRI lacked any pathological lesions. In total, 37 csPCa cases were diagnosed. Using SNG-2019, 36 csPCa cases with a high biopsy rate (179 of 272) were detected and 49 were diagnosed with ISUP 1 cancers. The Stockholm3 strategy diagnosed 32 csPCa cases, with 89 biopsied and 27 ISUP 1 cancers. SNG-2020 detected 32 csPCa and 33 ISUP 1 cancer patients, with 99 men biopsied, and the MRI strategy detected 30 csPCa and 35 ISUP 1 cancer cases by biopsying 123 men. The latter two strategies generated more MRI scans than the Stockholm3 strategy (n = 270 vs 33). ConclusionsPrevious guidelines provide high detection of significant cancer but at high biopsy rates and detection of insignificant cancer. The Stockholm3 test may improve diagnostic precision compared with the current guidelines or using only MRI. Patient summaryThe Stockholm3 test facilitates detection of significant cancer, and reduces the number of biopsies and detection of insignificant cancer.

There is considerable debate regarding the role of magnetic resonance imaging (MRI) in the management of the breast cancer patient. MRI should not be used as a diagnostic test to exclude the presence of carcinoma. In one multi-institutional study of 1,004 women, the positive predictive value of MRI was 72%, and the overall sensitivity 88% [1]. Recognition that MRI identifies additional areas of cancer not detected by other imaging modalities in an average of 16% of breast cancer cases [2] has led to great interest in its use to select women for breast-conserving surgery (BCS). Suggested benefits of MRI include a reduction in margin positivity and conversion from BCS to mastectomy, and a decrease in local recurrence rates. Several retrospective studies and one prospective randomized [3] trial have addressed the impact of MRI on the short-term surgical outcomes. These studies have uniformly failed to demonstrate a benefit for MRI. In the prospective randomized Comparative Effectiveness of Magnetic Resonance Imaging in Breast Cancer (COMICE) trial, re-excision was required in 10% of the MRI group and 11% of the non-MRI group, with conversion to mastectomy in 6% and 8%, respectively. Most studies show that MRI approximately doubles the overall likelihood of undergoing mastectomy without decreasing unplanned mastectomy. Solin and colleagues examined the effect of MRI on local recurrence after BCS with radiation therapy (RT) and on contralateral cancer [4]. At 8 years the incidence of contralateral cancer was 6% in both the MRI and non-MRI groups, and local recurrence was seen in 3% of those with an MRI at diagnosis and in 4% of those without. The repeated observation that MRI finds two to four times as much disease as becomes evident as local recurrence indicates that the majority of this disease is controlled with RT. In addition, the existence of local recurrence after mastectomy indicates that some local recurrence is a manifestation of biologically aggressive disease (first site of metastases), which is unlikely to be influenced by the use of MRI. Current indications for the use of MRI in patients with breast cancer include: known or suspected BRCA1&2 mutation carriers who choose not to undergo bilateral mastectomy; patients presenting with metastases to the axillary nodes and no evident breast tumor; patients with Paget's disease of the nipple and no evident breast tumor; or the uncommon patient with a major discrepancy between clinical findings and the results of mammography and ultrasound. A benefit for MRI in the follow-up of the breast cancer patient is also unproven. Local recurrence after BCS and RT is uncommon, occurring in fewer than 8% of patients at 10 years. The size of the local recurrence is not a prognostic factor, and the idea that early detection will improve prognosis does not reflect the biology of local recurrence. The treatment of local recurrence regardless of size is mastectomy, and salvage mastectomy results in local control in 85 to 95% of patients. These good outcomes must be weighed against the cost of MRI, the high rate of short-interval follow-up and biopsies generated, and the lack of a clear rationale for using the examination for follow-up.

ObjectiveThis study aimed to assess the cost-effectiveness of magnetic resonance imaging (MRI) with combinations of targeted biopsy (TBx) and systematic biopsy (SBx) for early prostate cancer detection in Sweden. MethodsA cost-utility analysis was conducted from a lifetime societal perspective using a microsimulation model. Five strategies included no screening and quadrennial screening for men aged 55 to 69 years using SBx alone, TBx on positive MRI (MRI + TBx), combined TBx/SBx on positive MRI (MRI + TBx/SBx), and SBx on negative MRI with TBx/SBx on positive MRI (MRI − SBx, MRI + TBx/SBx). Test characteristics were based on a recent Cochrane review. We predicted the number of biopsies, costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios. ResultsThe screening strategies were classified in Sweden as high costs per QALY gained compared with no screening. Using MRI + TBx and MRI + TBx/SBx reduced the number of biopsy episodes across a lifetime by approximately 40% compared with SBx alone. Both strategies showed strong dominance over SBx alone and MRI − SBx, MRI + TBx. Compared with MRI + TBx, the MRI + TBx/SBx strategy had an incremental cost-effectiveness ratio of more than €200 000 per QALY gained, which was classified in Sweden as a very high cost. These predictions were robust in the probabilistic sensitivity analysis. Limitations included generalizability of the model assumptions and uncertainty regarding the health-state values and study heterogeneity from the Cochrane review. ConclusionsMRI + TBx and MRI + TBx/SBx showed strong dominance over alternative screening strategies. MRI + TBx resulted in similar or marginally lower gains in QALYs and lower costs than MRI + TBx/SBx. MRI + TBx was considered the optimal choice among the screening strategies.

To investigate the impact of implementing magnetic resonance imaging (MRI) and ultrasonography fusion technology on biopsy and prostate cancer (PCa) detection rates in men presenting with clinical suspicion for PCa in the clinical practice setting. We performed a review of 1808 consecutive men referred for elevated prostate-specific antigen (PSA) level between 2011 and 2014. The study population was divided into two groups based on whether MRI was used as a risk stratification tool. Univariable and multivariable analyses of biopsy rates and overall and clinically significant PCa detection rates between groups were performed. The MRI and PSA-only groups consisted of 1020 and 788 patients, respectively. A total of 465 patients (45.6%) in the MRI group and 442 (56.1%) in the PSA-only group underwent biopsy, corresponding to an 18.7% decrease in the proportion of patients receiving biopsy in the MRI group (P < 0.001). Overall PCa (56.8% vs 40.7%; P < 0.001) and clinically significant PCa detection (47.3% vs 31.0%; P < 0.001) was significantly higher in the MRI vs the PSA-only group. In logistic regression analyses, the odds of overall PCa detection (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.29-2.35; P < 0.001) and clinically significant PCa detection (OR 2.04, 95% CI 1.48-2.80; P < 0.001) were higher in the MRI than in the PSA-only group after adjusting for clinically relevant PCa variables. Among men presenting with clinical suspicion for PCa, addition of MRI increases detection of clinically significant cancers while reducing prostate biopsy rates when implemented in a clinical practice setting.

The aim of this study was to perform a 1-yr trial-based cost-effectiveness analysis (CEA) of tiotropium versus salmeterol followed by a 5-yr model-based CEA. The within-trial CEA, including 7,250 patients with moderate to very severe chronic obstructive pulmonary disease (COPD), was performed alongside the 1-yr international randomised controlled Prevention of Exacerbations with Tiotropium (POET)-COPD trial comparing tiotropium with salmeterol regarding the effect on exacerbations. Main end-points of the trial-based analysis were costs, number of exacerbations and exacerbation days. The model-based analysis was conducted to extrapolate results to 5 yrs and to calculate quality-adjusted life years (QALYs). 1-yr costs per patient from the German statutory health insurance (SHI) perspective and the societal perspective were €126 (95% uncertainty interval (UI) €55-195) and €170 (95% UI €77-260) higher for tiotropium, respectively. The annual number of exacerbations was 0.064 (95% UI 0.010-0.118) lower for tiotropium, leading to a reduction in exacerbation-related costs of €87 (95% UI €19-157). The incremental cost-effectiveness ratio was €1,961 per exacerbation avoided from the SHI perspective and €2,647 from the societal perspective. In the model-based analyses, the 5-yr costs per QALY were €3,488 from the SHI perspective and €8,141 from the societal perspective. Tiotropium reduced exacerbations and exacerbation-related costs, but increased total costs. Tiotropium can be considered cost-effective as the resulting cost-effectiveness ratios were below commonly accepted willingness-to-pay thresholds.

To prospectively evaluate magnetic resonance (MR) imaging and MR spectroscopy for depiction of local prostate cancer recurrence after external-beam radiation therapy, with step-section pathologic findings as the standard of reference. Study received institutional approval, and written informed consent was obtained. Study was compliant with Health Insurance Portability and Accountability Act. Sextant biopsy, digital rectal examination, MR imaging, MR spectroscopy, and salvage radical prostatectomy with step-section pathologic examination were performed in nine patients with increasing prostate-specific antigen levels after external-beam radiation therapy. MR imaging criterion for tumor was a focal nodular region of reduced signal intensity at T2-weighted imaging. MR spectroscopic criteria for tumor were voxels with choline (Cho) plus creatine (Cr) to citrate (Cit) ratio ([Cho + Cr]/Cit) of at least 0.5 or voxels with detectable Cho and no Cit in the peripheral zone. Sensitivity and specificity of sextant biopsy, digital rectal examination, MR imaging, and MR spectroscopy were determined by using a prostate sextant as the unit of analysis. For feature analysis, MR imaging and MR spectroscopic findings were correlated with step-section pathologic findings. MR imaging and MR spectroscopy showed estimated sensitivities of 68% and 77%, respectively, while sensitivities of biopsy and digital rectal examination were 48% and 16%, respectively. MR spectroscopy appears to be less specific (78%) than the other three tests, each of which had a specificity higher than 90%. MR spectroscopic feature analysis showed that a metabolically altered benign gland could be falsely identified as tumor by using MR spectroscopic criteria; further analysis of MR spectroscopic features did not lead to improved MR spectroscopic criteria for recurrent tumor. In summary, MR imaging and MR spectroscopy may be more sensitive than sextant biopsy and digital rectal examination for sextant localization of cancer recurrence after external-beam radiation therapy.

The objectives of this presentation are to discuss the clinical role of magnetic resonance (MR) in local and nodal staging of prostate cancer, and to show new developments. The clinical questions are how can we improve with new MR imaging (MRI) techniques: localization, local staging, targeted radiotherapy planning, and nodal staging? Accurate tumour localisation is important for detection of prostate cancer in patients with clinical suspicion (e.g. elevated prostate-specific antigen (PSA)) and a negative trans-rectal ultrasound biopsy. When combining anatomical (T2-weighted) high resolution techniques by applying either 1.5 T with an endorectal coil, or 3 T without an endorectal coil, with contrast enhanced dynamic MRI and MR spectroscopy, localization accuracy is ∼90%. The additional use of this technique has been shown to increase the rate of positive biopsies. In addition, when the tumour is accurately localised, local staging by inexperienced radiologists improves. These localisation techniques allow targeted radiotherapy planning (e.g. by giving 90 Gy to the dominant intraprostatic lesion), as fusion with these ‘functional’ MR images and computed tomography (CT) is feasible. Local staging at 1.5 T without using an endorectal coil results in a sensitivity of 64% and a specificity of 72%. When using an endorectal coil, specificity can improve to 98% with equal sensitivity. Advanced MRI at 3 T using an endorectal coil has resulted in a sensitivity of 88% and a specificity of 96%. When a high specificity reading is performed in patients with intermediate to high risk for extracapsular disease (PSA > 10 or Gleason > 6 or T3 at digital rectal examination (DRE)), and if prostatectomy is not performed in a stage T3 on such an MRI, the use of MRI results in a cost-saving of 2500 euros per patient. As current cross sectional imaging techniques and positron emission tomography (PET)-CT have limited sensitivity in detecting nodal metastases (CT 35%, and [18F]FDG-PET 65%), in patients with intermediate to high risk for nodal metastases (PSA > 10 or Gleason > 6 or T3 at DRE) routinely a pelvic lymph node dissection is performed. However, it has been showed that with this (obturator) dissection not all positive nodes are detected. The combination of a new MRI (lymph node specific) contrast agent (MRL) has been shown to have a sensitivity and specificity >90% and a negative predictive value of 97% in detecting even small nodes. In patients with a negative MRL a diagnostic pelvic lymph node dissection can be safely avoided. This results in a cost saving of approximately 2000 euros per patient.

To project intermediate and long-term clinical outcomes of magnetic resonance (MR) imaging screening for breast cancer in women with BRCA1 gene mutations. A microsimulation model was developed to compare three annual screening strategies versus clinical surveillance: (a) mammography, (b) MR imaging, and (c) combined MR imaging and mammography. Input parameters were obtained from the published medical literature, existing databases, and expert opinion. The model was calibrated to targets from the Surveillance Epidemiology and End Results database (1975-1980) compiled during a period prior to the onset of widespread mammographic screening. Sensitivity analysis was performed to evaluate the effect of uncertainty in parameter estimates. With clinical surveillance, the estimated median diameter of invasive breast cancers at presentation was 2.6 cm. Average life expectancy was 71.15 years. With annual screening with mammography, MR imaging, or combined mammography and MR imaging, median invasive tumor diameters at diagnosis decreased to 1.9, 1.3, and 1.1 cm, respectively. Annual screening with mammography, MR imaging, or combined mammography and MR imaging increased average life expectancy by 0.80 year, 1.10 years, and 1.38 years, respectively, and decreased relative mortality from breast cancer (16.8%, 17.2%, and 22.0%, respectively). Program sensitivity was greater than 50% only with MR imaging screening strategies. The majority of women undergoing screening had one or more false-positive screening examinations (53.8%, 80.2%, and 84.0% for mammography, MR imaging, and combined mammography and MR imaging, respectively). Many women also underwent one or more biopsies for benign disease (11.3%, 26.3%, and 30.3%, respectively). Results were sensitive to BRCA1 penetrance estimates and to MR imaging sensitivity in the detection of ductal carcinoma in situ. Annual screening with combined mammography and MR imaging provides BRCA1 mutation carriers with the greatest life expectancy gain and breast cancer mortality reduction. However, an important trade-off of this strategy is an increased rate of false-positive screening results and biopsies performed for benign disease.

Accurate staging of prostate cancer (PCa) is the basis for the risk stratification to select targeted treatment. Therefore, this study aimed to compare the diagnostic accuracy rates of magnetic resonance imaging (MRI) and digital rectal examination (DRE) for preoperative T staging of potentially resectable PCa. From March 2021 to March 2022, patients with PCa with T staging by prostate biopsy were included. All examinations used postoperative histopathologic T staging as the reference standard. All patients underwent DRE and MRI before the puncture. Two blinded urologists and radiologists independently evaluated DRE and MRI, respectively. Before the examination, patients were then divided into early- (T1, T2) and late-(T3, T4) stage cancer. Analysis of a paired sample sign test was performed to determine differences between DRE and MRI. A total of 136 study participants with PCa were evaluated histopathologically, of whom 71% (97/136) and 29% (39/136) were at the early- and late-stage cancer, respectively. MRI had a significantly higher accuracy (91.9% vs. 76.5%, P < 0.001) compared with DRE. Further, MRI showed a higher sensitivity than DRE to diagnose early PCa (92.8% vs. 74.2%; P < 0.001). However, the specificity was not significantly different between them (89.7% vs. 82.1%; P = 0.375). Area under the curve (receiver operating curve) values were calculated as 0.78 ± 0.038 (95% confidence interval [CI], 0.71-0.86), 0.91 ± 0.028 (95% CI, 0.86-0.97), and 0.872 ± 0.028 (95% CI, 0.80-0.92) for DRE-, MRI-, MRI + DRE-based PCa predictions, respectively. The prediction performance of MRI was better than that of DRE (DeLong test, z = 3.632, P = 0.0003) and MRI + DRE (DeLong test, z = 3.715, P = 0.0002). For resectable PCa, the diagnostic potential of MRI in assessing the T stage was higher than that of DRE. However, DRE is still valuable, especially for patients with locally advanced PCa.

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone (n = 11 745) or breast MRI (n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

To determine the role of magnetic resonance (MR) imaging performed with a combined endorectal body phased-array coil for patients with elevated prostate-specific antigen (PSA) levels or suspicious free-to-total PSA ratios in whom prior transrectal ultrasonographically (US) guided biopsy findings were negative for prostate cancer. Forty-four patients with PSA levels greater than 4 ng/mL or free-to-total PSA ratios lower than 15% but negative biopsy findings were examined with T1- and T2-weighted MR imaging at 1.5 T with a combined endorectal body phased-array coil. All patients underwent digital rectal examination (DRE) and transrectal US. Thirty-eight patients underwent repeat biopsy after MR imaging. The accuracy of MR imaging for detection of prostate cancer was assessed prospectively. Retrospectively, MR imaging findings were correlated with individual biopsy site findings. MR imaging and biopsy results were correlated by using a cross table to calculate sensitivity, specificity, and positive predictive value (PPV). Retrospective analysis results were evaluated with receiver operating characteristic analysis. A P value of less than.05 indicated significance (chi(2) test according to Pearson). At prospective analysis, MR imaging had a sensitivity of 83% and a PPV of 50% for detection of prostate cancer; these values were 33% and 67%, respectively, for DRE and 33% and 57%, respectively, for transrectal US. At retrospective site-by-site analysis, MR imaging results did not correlate significantly with individual biopsy site findings (P =.126); sensitivity was 65% and PPV was 12%. In this patient population, MR imaging has higher sensitivity for detection of prostate cancer than DRE or transrectal US.

Prostate MRI: Who, when, and how? Report from a UK consensus meeting

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). 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. Observational cohort study of 6 Breast Cancer Surveillance Consortium (BCSC) registries. Population-based sample of 812 164 women undergoing screening, 2003 through 2013. A total of 2 048 994 digital mammography and/or breast MRI screening episodes (mammogram alone vs MRI with or without screening mammogram within 30 days). 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. We included 101 103 and 1 939 455 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. 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.