Lancet article: "MRI of little benefit to Most women with breast cancer

[Lani]

I know many of you had cancers which did not show up on mammogram or ultrasound. Looks like another article insurance companies may use to deny
breast MRIs. As with most things, they probably have not yet identified those patients for whom it is most beneficial (and life-saving). Rather than throwing away the baby with the bathwater, it would be prudent to keep utilizing MRIs until that is determined (analogy with avastin)

Perhaps part of the improvement in the prognosis for those with her2+ breast cancer is not just due to herceptin, but also from earlier diagnosis of the primary cancer itself at an earlier stage due to use of MRIs (including contralateral bcs)?

Will check out the article to see if they even looked at her2+ bc as a subset




MRI of Little Benefit to Most Women With Breast Cancer

November 24, 2011 — For the majority of women with breast cancer, there is no evidence that magnetic resonance imaging (MRI) improves outcome, according to a study published in the November 19 issue of the Lancet.

There is limited evidence that screening women for breast cancer with MRI is beneficial or that its routine use before breast-conserving surgery improves patient selection, reduces surgical procedures, or lowers the risk for local cancer recurrences, say the researchers.

However, MRI screening is of benefit in women at genetically high risk, lead author Monica Morrow, MD, who is chief of the breast service and professor of surgery at the Memorial Sloan-Kettering Cancer Center in New York City, told Medscape Medical News.

It is also better than other methods for assessing response to neoadjuvant chemotherapy and identifying the primary tumor in patients who present with axillary adenopathy, Dr. Morrow said.

"For very high-risk women — that is those who have BRCA mutations or a family history suggestive of such mutations — I think there is good evidence that MRI screening is an advantage, but that's a very small population of women," Dr. Morrow told Medscape Medical News.

Dr. Morrow was approached by the Lancet to take a closer look at the use of MRI for breast cancer screening and for guiding treatment decisions. This use of MRI has been increasing despite any real evidence that it works.

"In patients with breast cancer, the use of MRI has become very common in the United States. When it started a number of years ago, people made the assumption that finding more cancers, which MRI does, is bound to benefit patients," Dr. Morrow said.

"Now we have actual outcome data that look at whether or not that assumption is true, and the amount of outcome data has been increasing over time. It seemed like a good time to put that together and review it, along with the evidence from trials of screening," she said.

In this review, which represents the first paper in the Lancet series on breast cancer, Dr. Morrow and her team conducted an electronic literature search of articles published from May 1, 2001 to May 25, 2011 in PubMed, Embase, and Cochrane.

The strongest evidence of benefit for the use of MRI as a screening tool was found in women with BRCA mutations and in women with a family history of breast cancer. MRI has better sensitivity than mammography for the detection of invasive breast cancer, which results in the detection of smaller cancers and the occurrence of fewer interval cancers.

However, none of the prospective randomized trials of breast cancer screening with MRI — either in women in general or in women at high risk — had survival as an end point. So whether the benefits seen translate into a survival advantage is still unknown, Dr. Morrow explained.

MRI for Surgical Planning

The researchers also found little evidence that MRI improves the short-term or long-term outcomes of breast-conserving surgery.

They cite 2 randomized trials — MONET (Eur J Cancer. 2011;47:879-886) and COMICE (Lancet. 2010;375:563-571) — that showed that screening patients with MRI did not lead to any decrease in surgical procedures.

Radiologist Stamatia Destounis, MD, from the University of Rochester Medical Center in New York, who was approached for comment by Medscape Medical News, said that the surgeons at her hospital find MRI very helpful for surgical planning.

Dr. Destounis explained that MRI has enabled clinicians to find incidental contralateral cancers. She cited a study demonstrating that MRI can detect cancer in the contralateral breast that is missed by mammography at the time of the initial breast cancer diagnosis (N Engl J Med. 2007;356:1295-1303).

"Dr. Morrow said that there have been no studies that found MRI helpful for contralateral breast cancer diagnosis at the time when one side is diagnosed, but we in radiology do have those articles. We are growing our MRI practice because we find that this is a very helpful tool," she said.

Dr. Destounis agrees that long-term outcome results with MRI are lacking.

"This is true. We don't have randomized trials that follow, long-term, what happens to the patient who gets MRI prior to surgery and the patient who does not.... But I think that people are working on the premise — and this is the premise that all radiologists work from — that if we identify something as early as possible, then the outcome will be better because the disease is small enough to be treated with surgery. It's not invasive. It's not metastatic. That is our premise."

Dr. Morrow and Dr. Destounis have disclosed no relevant financial relationships.

Lancet. 2011;378:1804-1811. Abstract