Contrast-Enhanced Mammography as an Alternative to MRI

A faster, cost-effective option for high-risk breast cancer screening

BY NICK KLENSKE October 20, 2025

Berg

Gilbert

When it comes to screening women at an increased risk for breast cancer, MRI remains the gold standard. But it does have its limitations.

“Not only is access to MRI equipment limited, but many patients with claustrophobia also cannot tolerate MRI,” said Wendie Berg, MD, PhD, professor of radiology at the University of Pittsburgh School of Medicine and Chief Scientific Advisor to DenseBreast-info.org.

A potential alternative, according to Dr. Berg, is contrast-enhanced mammography (CEM).

Following the intravenous injection of iodinated contrast material, CEM uses updated standard mammography equipment to capture both low- and high-energy images.

Subtraction images are then created, depicting enhanced findings similar to those seen with contrast-enhanced MRI. By comparison, the low-energy images resemble standard digital mammograms.

Like MRI, CEM is not limited by breast density and can be performed using adapted mammogram equipment. “It is very similar to standard mammography in terms of equipment and image acquisition, and mammography units are widespread,” Dr. Berg added.

CEM contrast is relatively inexpensive, and the exam itself can be performed at lower cost. “Because CEM is under the control of the breast imagers, it can be undertaken at the time of the breast imaging visit,” said Fiona Gilbert, MBChB, FRCR, professor of radiology at the University of Cambridge School of Clinical Medicine in England. “In general, CEM has faster acquisition time than MRI—taking as little as 15 to 20 minutes—and it takes less time to read the images.”

Benefits Outweigh the Risks

Even though the use of intravenous iodinated contrast means that CEM carries a substantial risk for allergic-type reactions (about 0.8%) that requires regular staff training and on-site physician management, about 70% of women who have had both examinations prefer CEM over MRI.

“An important factor contributing to this preference is that there is no claustrophobia with CEM,” Dr. Berg explained. “The ‘one-stop-shop’ aspect of CEM is also very attractive as women can have the benefits of the proven mammography technology with the added benefit of vascular-based cancer detection all in one examination.”

While CEM requires additional staff to handle tasks such as checking for allergies and renal function, undertaking the venous cannulation, setting up the IV, injecting the contrast and monitoring for reaction, the overall impact on staff and workflow is limited.

“Like MRI, we tend to know from the initial screening CEM images whether or not a biopsy is needed, and that can often be scheduled directly without the need for a separate diagnostic visit,” Dr. Berg added.

CEM Shown to Outperform MRI

Despite these benefits, CEM is not yet approved by the U.S. Food and Drug administration for screening, and it won’t be until more data is provided.

A new Radiology study co-authored by Dr. Berg aims to help fill this data gap.

The study evaluated whether adding CEM to digital breast tomosynthesis (DBT) improves breast cancer detection in women eligible for screening MRI.

Of the 601 women who met the criteria—87% of whom had dense breasts—12 were found to have cancer, with six being identified only by CEM (added yield of 10/1000). The cancers found by CEM were all early stage, all node negative, and with a median size of 0.7 cm for five invasive cancers identified. None of the participants developed symptomatic interval cancers in the ensuing year.

“CEM has been shown to have equivalent sensitivity and specificity to abbreviated MRI or full protocol MRI in breast screening, a fact that has been confirmed by the BRAID trial where CEM actually demonstrated slightly higher cancer detection than MRI and four times that of whole breast ultrasound,” Professor Gilbert said.

Professor Gilbert co-authored a recent article comparing supplemental breast cancer imaging techniques for The Lancet.

The Breast screening—Risk Adapted Imaging for Density (BRAID) study is a randomized controlled trial that compares supplemental imaging of abbreviated MRI, automated breast US system (ABUS), and CEM with standard mammography in women with dense breasts and a negative screening mammogram.

The trial has already shown that the invasive cancers found by CEM and abbreviated MRI were under 15 mm and half the size of those cancers detected by US.

— FIONA GILBERT, MBCHB, FRCR

A False Positive Problem

There is, however, a downside. In the Radiology study, of the 589 women without cancer, 79 (13.4%) were recalled for additional testing. This is in addition to the 48 recalled by DBT alone.

The study found that such false positives were especially common in perimenopausal women.

In the BRAID trial, the recall rate was twice as high for CEM and abbreviated MRI compared to whole breast US. Some of these false positives can be attributed to a learning curve for CEM. Several other studies have shown that when CEM is undertaken for a second time the false positive rate falls.

Dr. Berg and her colleagues are developing AI tools to help reduce CEM’s false positive rate.

Although the results of the Radiology study show great promise for screening using CEM as an alternative to MRI, more work needs to be done. “We do not yet have long-term data after multiple rounds of CEM-based screening to show a shift in stage distribution, and more data are needed to prove a reduction in symptomatic interval cancers,” Dr. Berg said.

She and her team are currently conducting several Breast Cancer Research Foundation-funded studies of multiple rounds of screening CEM in women with a personal history of breast cancer. Likewise, the ongoing BRAID trial in the U.K. and the C-MIST trial in the U.S. will include multiple rounds of screening with CEM in women with dense breasts and will help inform expected outcomes.

Researchers are also looking at whether contrast-enhanced screening would be as effective if performed every 18 months (as outlined in the BRAID trial) or every 24 months (in line with one of Dr. Berg’s trials). “This could reduce the overall burden to women and the health care system, and we are collecting the data needed to find out,” Dr. Berg concluded.