Forewarned Is Forearmed: Can Better Patient Counseling Increase MRI Utilization in High-Risk Women?
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EDITORIAL – BREAST ONCOLOGY
Forewarned Is Forearmed: Can Better Patient Counseling Increase MRI Utilization in High-Risk Women? Amy E. Cyr, MD1, and Ranjna Sharma, MD2 1
Washington University School of Medicine, St. Louis, MO; 2Upstate Specialty Services, Harrison Center, Syracuse, NY
The American Cancer Society, National Comprehensive Cancer Network, American Society of Breast Surgeons, and American College of Radiology (ACR)1–5 recommend supplemental breast cancer screening with magnetic resonance imaging (MRI) for high-risk women, defined as having C 20% lifetime risk of breast cancer.6–8 Although dependent on technical factors, clinical indications, and radiologist experience, the high sensitivity of MRI makes it a useful screening modality:9 Its sensitivity is 70–100% in high-risk populations, notably better than that of mammography alone.6,7, 9, 10 MRI detects cancers earlier, when they are smaller and node negative—and thus lower stage—and it is especially good at identifying aggressive invasive cancers.5,8,11–15 Many MRI-detected cancers are still mammographically occult,8,10 so incorporation of screening MRI may reduce the interval cancer rate to \ 1%.6,7 Despite these advantages, only a minority of eligible women undergo screening MRI. Even among mutation carriers, uptake rates are low.6, 16–18 So why are not more high-risk women pursuing MRI? MRI has well-described drawbacks: first, screening MRI does not clearly improve mortality;6 it is expensive and may be physically uncomfortable; some patients are concerned about cumulative gadolinium exposure and deposition;19 and finally, specificity is lower than that of mammography, and high-risk patients may already be
Ó Society of Surgical Oncology 2020 First Received: 6 July 2020 Accepted: 8 July 2020 A. E. Cyr, MD e-mail: [email protected]
anxious about developing breast cancer, with any false positives and subsequent tests possibly heightening that anxiety. In this issue, Coopey et al. review a cohort of patients from their high-risk breast clinic.20 They identified women with lifetime risk C 20% using the Gail and Tyrer–Cuzick models, excluding those with known germline mutations. Patients in this dedicated clinic had excellent uptake of screening MRI: two-thirds of the 282 patients evaluated during the clinic’s first year pursued the recommended MRI. Like other investigators, however, Coopey et al. note the low specificity of MRI. Almost a quarter of their patients required further evaluation of MRI findings with additional imaging and/or biopsy. As in other studies, most of these MRI findings were benign on core biopsy and not clinically actionable.9,20 Interestingly, Coopey et al. identified only two new breast cancers with MRI, equaling a cancer detection rate of 1%. In literature, cancer detection rates with screening MRI range from 0.8% to 39%,10–12,17 with variability due to study indication and underlying patient risk. Several investigators, for instance, report better cancer yield in women with genetic predisposition, high-risk lesions, or a p
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