Rethinking MRI surveillance after breast cancer in the context of persistent racial disparities in mortality.

1675 Background: Detection of asymptomatic breast cancer recurrence by imaging is associated with improved survival compared to detection after symptoms develop. Currently, both the American Cancer Society and ASCO recommend against routine MRI for patients with a history of breast cancer and no clinical findings, unless they meet specific high-risk criteria. The American College of Radiology Appropriateness Criteria similarly characterizes surveillance MRI as conditionally appropriate, supporting its use only when additional risk factors are present. Since randomized trials to address surveillance strategies in diverse populations are unlikely to be feasible, we performed an observational study comparing MRI performance in intermediate and high-risk screening populations, and women with a history of breast cancer, stratified by race. Methods: We retrospectively analyzed 41,041 breast MRI exams performed in an urban health system from 1/2/2014 to 10/29/2025. In Pennsylvania, insurance covers supplemental MRI for women with dense breasts, and in our network, screening MRI is generally performed in asymptomatic patients current with mammography. Exams were categorized as high-risk screening (n=15,682, 38%), supplemental (n=10,905, 27%), or surveillance for a personal history of breast cancer (n=11,476, 28%). Logistic regression was used to estimate odds ratio for true and false positives by indication adjusted for age and race. Results: Cancer detection rates were higher in the surveillance group compared with high risk screening (true positive [TP] rate 21.0, n=241 vs 12.4, n=194), a 53% difference after adjusting for age and race (OR 1.53 [1.26–1.86], p<0.001), with similar false-positive rates (7.5%, n=857 vs 8.7%, n=1,359; OR 1.02 [0.93–1.11], p=0.7). MRI cancer detection rate was higher for supplemental than high-risk screening (OR 1.35 [1.24–1.46], p<0.001). Notably, in a subset comparison of screening MRI in Black vs. white women (n=37,383), TP rates were higher among Black women than white women across all MRI indications. The highest TP rate was observed in Black women undergoing surveillance MRI (31.9 vs. 20.5; OR 1.62 [1.11, 2.31], p=0.010), followed by supplemental (25.6 vs. 14,5; OR 1.84 [1.17, 2.77], p=0.005), and high-risk (21.6 vs. 11.4; OR 1.97 [1.22, 3.03], p=0.003). The TP rate remained higher for Black compared with white women for first MRI as well as subsequent MRI for surveillance, high-risk, and supplemental screening. Conclusions: Black women in the U.S. have 40% higher breast cancer mortality compared to non-Hispanic white women, and early detection offers the best chance for optimal survival. Our findings suggest surveillance MRI identifies a higher burden of clinically occult cancer than high-risk screening MRI, especially among Black women. Expanding access to surveillance MRI may help address persistent racial disparities in breast cancer outcomes.