Thursday, August 6, 2009

Breast Cancer and MRI

More artillery in JACS from Dr. Morrow's group on the lack of evidence to support routine MRI in the pre-operative evaluation of women with breast cancer.

In summary, here's what MRI buys you: increased treatment delays (by an average of 22 days) and more unnecessary mastectomies (i.e. overreading of MRI leads to a recommendation for more radical surgery when breast conservation would have been more appropriate). Furthermore, MRI doesn't improve negative margin resection rates. So basically we're spending 2-3 grand for a test that does more harm than good. And the number of breast MRI's ordered and performed keeps increasing every year....

A side note: I was seeing a patient recently with recurrent breast cancer. She had had breast conservation surgery for a T2N1 lesion ten years ago. Now she presented with bone, kidney, and lung metastases. A mammogram demonstrated diffuse inflammatory changes of the affected breast. The official radiology reading suggested an MRI to better delineate any occult masses. After consideration of the options, the patient elected to decline further chemotherapy and will pursue palliative care.

All well and good. But for the past week I've been getting "URGENT" faxes from the radiology department in my office reminding me to order the MRI on said patient. I crumple them up and throw them in the trash...

6 comments:

#1 Dinosaur said...

I'd call the radiology dept, let them know you're not going to order it (because it's not clinically indicated), thank them for their concern, and ask them not to send you any more reminders. Less paper; more trees. Just a thought.

DrMidlife said...

Wow, I'm really conflicted on this issue. I was T1N1M0, and I refused the BRCA test and PET scanning as unnecessary. But I had an MRI prior to my surgery, and I was happy about this because it seemed to me that it gave the surgeon a great view on his job.

Is your argument, essentially, that the mammogram sufficiently shows the extent of a tumor, and the MRI really doesn't provide additional value for you?

Buckeye Surgeon said...

Dino-
Trees. Who needs 'em. (My office took care of it). I just find it interesting that the dept is so aggressive in making sure I order the breast MRI. I don't get three faxes in a week reminding to order the 6 month follow up breast ultrasound.....wonder why.

Mdilife-
I'd consider a breast MRI in the following situations: to help resolve discordances betwen conventional imaging and physical exam, to assess response to neoadjuvant chemotherapy, inflammatory breast cancer, patients with positive axillary lymph nodes and occult primary breast cancers, some patients with hereditary breast cancer syndromes. Routine use, however, doesn't do our patients any good.

Frank Drackman said...

T2N1?? Scary... Gotta start doin my own self exams...you never know... And of course its "URGENT" someone's gotta Boat payment...
and #1 Dinosaur, best thing you can do with a tree is make somethin out of it, like a Louisville Slugger...

Frank

radinc said...

The problem is, MR of the breast is a relatively new application for MR. There is a whole lot of really bad breast MR out there right now -- badly performed and badly interpreted. Of course this will result in bad medicine.

When properly done, I think breast MR really can make a big difference in how a patient is managed. I've seen it first hand.

However, I think it's too young a technique to be applied broadly and routinely.

It's like the lap chole. When it first came out, studies were conflicting, is it really better? People who were good at it said hell yes it's clearly better. Others said, well the data is inconclusive, we really don't know yet.

Same with breast MR. In the right hands it's a very good study that can give very important, useful information.

In the wrong hands, it's a total flail.

later,
radinc

skebber said...

thank you for information, I just know when the disease attacked my best friend and pray that all women in the world quickly discovered late
before early breast cancer disease