NEW STUDY ON BREAST MRIs
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March 28, 2007
Call to Increase M.R.I. Use for Breast Exam
By DENISE GRADY
Two reports being published today call for greatly expanded use of M.R.I. scans in women who have breast cancer or are at high risk for it.
The recommendations do not apply to most healthy women, who have only an average risk of developing the disease.
Even so, the new advice could add a million or more women a year to those who need breast magnetic resonance imaging a demand that radiologists are not yet equipped to meet, researchers say. The scans require special equipment, software and trained radiologists to read the results, and may not be available outside big cities.
Breast M.R.I. costs $1,000 to $2,000, and sometimes more 10 times the cost of mammography so a million more scans a year would cost at least $1 billion. It is sometimes covered by insurance and Medicare, sometimes not.
One report is a set of new guidelines for using M.R.I. in women at high risk for breast cancer, and the other is a study in The New England Journal of Medicine showing that in women who have newly diagnosed cancer in one breast, M.R.I. can find tumors in the other breast that mammograms miss.
M.R.I. has drawbacks. It is so sensitive much more so than mammography that it reveals all sorts of suspicious growths in the breast, leading to many repeat scans and biopsies for things that turn out to be benign. For women who are likely to have hidden tumors, the prospect of such false-positive findings may be acceptable. But the risk of needless biopsies and additional scans is not considered reasonable for women with just an average risk of breast cancer, and is the main reason M.R.I. is not recommended for them.
The new guidelines, from the American Cancer Society, are being published in the societys journal CA: A Cancer Journal for Clinicians. They recommend scans and mammograms once a year starting at age 30 for high-risk women.
High risk is defined as a 20 percent to 25 percent or higher chance of developing breast cancer over the course of a lifetime. (The average lifetime risk for women in the United States is 12 percent to 13 percent.)
The high-risk group includes women who are prone to breast cancer because they have certain genetic mutations, BRCA1 or BRCA2, or those whose mothers, sisters or daughters carry those mutations, even if the woman herself has not been tested. These mutations are not common they cause less than 10 percent of all breast cancers but they greatly increase a womans risk, to 36 percent to 85 percent.
Women with even rarer mutations, in genes called TP53 or PTEN, are also advised to be screened, as are women who had radiation treatment to the chest between ages 10 and 30, for disorders like Hodgkins disease.
Others at high risk include women from families in which breast cancer is common, especially in their close relatives, even if no genetic mutation has been identified. Women and their doctors can estimate their odds by using one of several online risk calculators that factor in the medical history of both the woman and her family. A simple calculator is available at http://www.cancer.gov/bcrisktool/.
But different calculators can give quite different results, and women may need help from their doctors to interpret the results, said Dr. Elizabeth Morris, a member of the expert panel that drew up the guidelines and director of Breast M.R.I. at Memorial Sloan-Kettering Cancer Center in Manhattan.
Just to figure out who should have it will be the hardest thing, Dr. Morris said. A lot of that onus is put on the referring physician. A lot of women are going to think theyre high risk, and theyre not.
The cancer society said that for women with certain conditions, there was not enough information to recommend for or against M.R.I. screening. The uncertain group includes women with very dense breast tissue on mammograms, and women who had breast cancer in the past, or growths called carcinoma in situ or atypical hyperplasia.
Dr. Robert Smith, the cancer societys director for screening, estimated that the new guidelines would add one million to two million women a year to the number who should have breast M.R.I.
Increased demand for such scans could easily outstrip the capacity, even though the number of centers offering them has increased markedly in the last five years, said Dr. Constance Lehman, another member of the panel that wrote the guidelines and a professor of radiology at the University of Washington. She said professional societies in radiology were scrambling to provide training and accreditation for the scans.
Insurers will probably cover the scans because the new guidelines are based on good evidence and promoted by a respected medical group, said Peter V. Lee, president of the Pacific Business Group on Health, a nonprofit coalition of large buyers of health care that cover about five million people. Huge amounts of money are now wasted on unnecessary M.R.I., Mr. Lee said, adding: Here we have a case where theres evidence. Hallelujah! Lets use it.
Not every imaging center is qualified to perform such scans, but some that are not up to par may offer it anyway, so patients must beware.
Special equipment is needed: a powerful, high-field magnet and a special breast coil to generate a magnetic field around the breast. The scan is done with the woman lying on her stomach on a special table with openings that let the breasts rest in wells surrounded by the coil.
And you have to make sure theyre doing enough, not one a week, and make sure they have biopsy capability, Dr. Morris said.
If the breast scan is done at a center that cannot perform biopsies, a woman with a suspicious finding may have to start all over again at another clinic.
The second new report describes a study showing that in women who had cancer in one breast, an M.R.I. scan of the other breast found tumors that mammograms had missed in 3 percent of the women. Researchers say M.R.I. can help women who already have one cancer by detecting a hidden tumor in the other breast, enabling them to have both cancers treated at once instead of having to go through treatment all over again when the second tumor is finally detected.
Research has shown that 10 percent of women who have cancer in one breast will eventually develop it in the other as well.
This study supports the recommendation that women who are diagnosed with breast cancer consider the benefits of a breast M.R., said Dr. Lehman, the senior author of the study. What we think is most important is that we understand the full extent of a womans breast cancer before her therapy is initiated.
The scans are recommended in newly diagnosed cases, but not for most women who had breast cancer treated in the past.
Currently, women with newly diagnosed cancer in one breast are given mammograms of the other, but only a minority are offered M.R.I., Dr. Lehman said. This year, about 180,000 new cases of breast cancer are expected in the United States.
Some surgeons think every woman with a new diagnosis of breast cancer should have an M.R.I. of the other breast, and some think no one should, Dr. Morris said. She said the scans were most likely to be useful in younger women with breast cancer and dense tissue that hides tumors from mammograms. In older women with small, early tumors and clear mammograms, she said, such scanning is less important.
The study findings will make it harder for insurance companies to refuse to pay for such scans of the second breast in women with breast cancer, said Dr. Etta D. Pisano, another author of the study and a professor of radiology at the University of North Carolina.
The study, conducted at 25 medical centers, included 969 women with recently diagnosed cancer in one breast and a normal mammogram on the other. All were given M.R.I. scans, which discovered cancers in the supposedly healthy breast in 30 women, 3.1 percent of the group. Nearly all the cancers were at an early stage, and were treated at the same time as the ones originally discovered.
Without the scans, Dr. Lehman said, the tumors would not have been found until later, and then the women would have had to go through surgery, and perhaps radiation and chemotherapy as well, all over again. We know cancers diagnosed later in these women dont do as well as cancers diagnosed initially, she said.
But to find 30 cancers, 121 women had biopsies, which were ordered because of abnormalities on M.R.I. That means 91 false-positive scans and biopsies of healthy tissue, and a false-positive rate of about 10 percent. Dr. Lehman said most cancer patients were willing to accept the risk of a false-positive and a biopsy in order to find out whether there was anything to worry about in the other breast.
The study was paid for by the National Cancer Institute.
Call to Increase M.R.I. Use for Breast Exam
By DENISE GRADY
Two reports being published today call for greatly expanded use of M.R.I. scans in women who have breast cancer or are at high risk for it.
The recommendations do not apply to most healthy women, who have only an average risk of developing the disease.
Even so, the new advice could add a million or more women a year to those who need breast magnetic resonance imaging a demand that radiologists are not yet equipped to meet, researchers say. The scans require special equipment, software and trained radiologists to read the results, and may not be available outside big cities.
Breast M.R.I. costs $1,000 to $2,000, and sometimes more 10 times the cost of mammography so a million more scans a year would cost at least $1 billion. It is sometimes covered by insurance and Medicare, sometimes not.
One report is a set of new guidelines for using M.R.I. in women at high risk for breast cancer, and the other is a study in The New England Journal of Medicine showing that in women who have newly diagnosed cancer in one breast, M.R.I. can find tumors in the other breast that mammograms miss.
M.R.I. has drawbacks. It is so sensitive much more so than mammography that it reveals all sorts of suspicious growths in the breast, leading to many repeat scans and biopsies for things that turn out to be benign. For women who are likely to have hidden tumors, the prospect of such false-positive findings may be acceptable. But the risk of needless biopsies and additional scans is not considered reasonable for women with just an average risk of breast cancer, and is the main reason M.R.I. is not recommended for them.
The new guidelines, from the American Cancer Society, are being published in the societys journal CA: A Cancer Journal for Clinicians. They recommend scans and mammograms once a year starting at age 30 for high-risk women.
High risk is defined as a 20 percent to 25 percent or higher chance of developing breast cancer over the course of a lifetime. (The average lifetime risk for women in the United States is 12 percent to 13 percent.)
The high-risk group includes women who are prone to breast cancer because they have certain genetic mutations, BRCA1 or BRCA2, or those whose mothers, sisters or daughters carry those mutations, even if the woman herself has not been tested. These mutations are not common they cause less than 10 percent of all breast cancers but they greatly increase a womans risk, to 36 percent to 85 percent.
Women with even rarer mutations, in genes called TP53 or PTEN, are also advised to be screened, as are women who had radiation treatment to the chest between ages 10 and 30, for disorders like Hodgkins disease.
Others at high risk include women from families in which breast cancer is common, especially in their close relatives, even if no genetic mutation has been identified. Women and their doctors can estimate their odds by using one of several online risk calculators that factor in the medical history of both the woman and her family. A simple calculator is available at http://www.cancer.gov/bcrisktool/.
But different calculators can give quite different results, and women may need help from their doctors to interpret the results, said Dr. Elizabeth Morris, a member of the expert panel that drew up the guidelines and director of Breast M.R.I. at Memorial Sloan-Kettering Cancer Center in Manhattan.
Just to figure out who should have it will be the hardest thing, Dr. Morris said. A lot of that onus is put on the referring physician. A lot of women are going to think theyre high risk, and theyre not.
The cancer society said that for women with certain conditions, there was not enough information to recommend for or against M.R.I. screening. The uncertain group includes women with very dense breast tissue on mammograms, and women who had breast cancer in the past, or growths called carcinoma in situ or atypical hyperplasia.
Dr. Robert Smith, the cancer societys director for screening, estimated that the new guidelines would add one million to two million women a year to the number who should have breast M.R.I.
Increased demand for such scans could easily outstrip the capacity, even though the number of centers offering them has increased markedly in the last five years, said Dr. Constance Lehman, another member of the panel that wrote the guidelines and a professor of radiology at the University of Washington. She said professional societies in radiology were scrambling to provide training and accreditation for the scans.
Insurers will probably cover the scans because the new guidelines are based on good evidence and promoted by a respected medical group, said Peter V. Lee, president of the Pacific Business Group on Health, a nonprofit coalition of large buyers of health care that cover about five million people. Huge amounts of money are now wasted on unnecessary M.R.I., Mr. Lee said, adding: Here we have a case where theres evidence. Hallelujah! Lets use it.
Not every imaging center is qualified to perform such scans, but some that are not up to par may offer it anyway, so patients must beware.
Special equipment is needed: a powerful, high-field magnet and a special breast coil to generate a magnetic field around the breast. The scan is done with the woman lying on her stomach on a special table with openings that let the breasts rest in wells surrounded by the coil.
And you have to make sure theyre doing enough, not one a week, and make sure they have biopsy capability, Dr. Morris said.
If the breast scan is done at a center that cannot perform biopsies, a woman with a suspicious finding may have to start all over again at another clinic.
The second new report describes a study showing that in women who had cancer in one breast, an M.R.I. scan of the other breast found tumors that mammograms had missed in 3 percent of the women. Researchers say M.R.I. can help women who already have one cancer by detecting a hidden tumor in the other breast, enabling them to have both cancers treated at once instead of having to go through treatment all over again when the second tumor is finally detected.
Research has shown that 10 percent of women who have cancer in one breast will eventually develop it in the other as well.
This study supports the recommendation that women who are diagnosed with breast cancer consider the benefits of a breast M.R., said Dr. Lehman, the senior author of the study. What we think is most important is that we understand the full extent of a womans breast cancer before her therapy is initiated.
The scans are recommended in newly diagnosed cases, but not for most women who had breast cancer treated in the past.
Currently, women with newly diagnosed cancer in one breast are given mammograms of the other, but only a minority are offered M.R.I., Dr. Lehman said. This year, about 180,000 new cases of breast cancer are expected in the United States.
Some surgeons think every woman with a new diagnosis of breast cancer should have an M.R.I. of the other breast, and some think no one should, Dr. Morris said. She said the scans were most likely to be useful in younger women with breast cancer and dense tissue that hides tumors from mammograms. In older women with small, early tumors and clear mammograms, she said, such scanning is less important.
The study findings will make it harder for insurance companies to refuse to pay for such scans of the second breast in women with breast cancer, said Dr. Etta D. Pisano, another author of the study and a professor of radiology at the University of North Carolina.
The study, conducted at 25 medical centers, included 969 women with recently diagnosed cancer in one breast and a normal mammogram on the other. All were given M.R.I. scans, which discovered cancers in the supposedly healthy breast in 30 women, 3.1 percent of the group. Nearly all the cancers were at an early stage, and were treated at the same time as the ones originally discovered.
Without the scans, Dr. Lehman said, the tumors would not have been found until later, and then the women would have had to go through surgery, and perhaps radiation and chemotherapy as well, all over again. We know cancers diagnosed later in these women dont do as well as cancers diagnosed initially, she said.
But to find 30 cancers, 121 women had biopsies, which were ordered because of abnormalities on M.R.I. That means 91 false-positive scans and biopsies of healthy tissue, and a false-positive rate of about 10 percent. Dr. Lehman said most cancer patients were willing to accept the risk of a false-positive and a biopsy in order to find out whether there was anything to worry about in the other breast.
The study was paid for by the National Cancer Institute.
Comments
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One flaw in what the repoters talk about and it is still a common misconception:
Quote:
The high-risk group includes women who are prone to breast cancer because they have certain genetic mutations, BRCA1 or BRCA2, or those whose mothers, sisters or daughters carry those mutations, even if the woman herself has not been tested.
The BRCA 1 and 2 gene mutation is not linked to the sex chromosomes. So, if there is breast or ovarian or prostate cancer on the father's side, it can be a red flag for those mutations. It is not just close relatives on the mother's side to worry about. The breast surgeon reminded me of this when I saw her last week during my friend's appt. -
What are the implications for women who have had cancer in both breasts and been treated surgically and with chemotherapy? Do we need to have yearly MRI's to look for recurrence of tumors in the chest area? By the way, mammgraphy picked up the LCIS in my left breast (calcificaitons) but did not pick up the three invasive tumors buried deep in my dense right breast. MRI saved my life. Without it, my cancer would have progressed to a point where cure was not possible.
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dst--that is exactly what I've heard and read: that mammos are better are detecting the non-invasive in-situ breast cancers (DCIS and LCIS), while MRIs are better at detecting the invasive bc's. That's why I'm now alternating MRIs with mammos every 6 months (high risk due to combination of LCIS and family history)--in hopes that what one test may miss, the other will pick up, hopefully very early when it's most easily treated.
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O.K. Here is some food for thought...I recently had an MRI that showed an area of question in my left breast,which had been previously treated for DCIS with a lumpectomy & rads.Then had an MRI-guided biopsy,which pathology came back as LCIS & ALH.I decided on having a bi-lateral mastectomy,and the pathology came back with Invasive Lobular Carcinoma in the left breast again,which did NOT show on the MRI.My surgeon said I was very lucky that I decided on the mastecmomy as quickly as I did.Now getting ready to do chemo.
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it shows that none of these tests are 100% accurate. All the more reason to use them in combination,
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My BC did not show on the mammogram I had just 3 weeks before finding a lump. It did show on MRI. I have my first post treatment MRI scheduled for my remaining breast next week. I will be monitered now with yearly MRI's.
Sue -
My radiologist was inexperienced and did not appreciate that my MRI was abnormal. Had my lump biopsied anyway. This technology is new and some radiologists may not be adequately trained...
I will have yearly mammo and MRI too on my remaining breast.
Fists up! -
Does anyone know the sensitivity of CT or PET scan for detecting BC? I've never had an MRI but will insist for the future as I have dense breasts with numerous lumps. It is very difficult for me or a doctor to do physical exam and my BC was only detected via mammogram (too deep). I'm wondering if I will have to put up an arguement to get yearly MRI in addition to mammogram. Joann
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Sue, I have had the same problem....3 lumps, none of which showed on mammograms. Will you still be having mammograms or just the MRIs? TIA!
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i am all for MRI's I had bc twice both times went undetected my mammo the first time was under 1cm but i could feel it and they knew where to look and it didnt show- the 2nd 10yrs later was over 6cms and it did not show up on mammo showed a little on sonogram and showed completely on MRI- i had mammo and sonogram every year since my first dx and if i had mri probably would have been detected long before it became stage 3- i had very dense breasts so MRI's would be appropriately recommended
who cares about false positives when it can save your life -
Post deleted by bco-administrator
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Moderators notified about last post. Title changed back to original.
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Post deleted by bco-administrator
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Moderators notified above. Back to topic.
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Post deleted by bco-administrator
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repeat of above
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I just read the article and found it interesting but you know what? I just had my bilateral mammogram last week and I am freaking scared to ask about having a MRI, "what if they find something?" isnt that insane? Thats the whole reason to have a mammogram isnt it "to find something?" but since I already had good news last week I'm afraid I'll screw up a good thing:)
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