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

['lizbeth]

With my experience the MRI showed 2 additional lesions that were not found on the Mammogram/Ultrasound.

The first surgeon wanted me to decide between a lumpectomy and a mastectomy.

With the second opinion, the breast surgeon quickly realized a lumpectomy was not an option, as I had multiple lesions throughout the breast.

I really got lucky with the great care I received. From my experience, I would highly encourage taking advantage of a second opinion.

I can see perhaps the mindset here is to discover cancer while it is still in an early stage, as opposed to a mammogram. And the industry does have a concern with false positives.

Since I was in my early 40s, in my case, having dense breast tissue, it was used after the biopsy to further determine the extent of the existing cancer.

My understanding at the time was that an MRI was a better tool in younger women due to the density of the breast tissue. Since women are screened at a younger age with a family history of breast cancer, the MRI would provide an advantage.

I am curious, however, at the last mammogram my technician was really excited about her new digital equipment and its ability to detect cancer at earlier stage. How does the new digital compare to the old technology and to MRIs?

[Mtngrl]

From what I've been able to see, when you use overall survival as an endpoint, screening of all kinds doesn't seem to confer any benefit. Finding breast cancer early just seems to result in people knowing earlier that they have it, and that's all it does. This is really, really counterintuitive, but there you have it.

[tricia keegan]

A friend of mine had very dense breasts and finally a 9cm tumour was dx by MRI although the US and Mammo did'nt show this, she's still doing great four years on after tx but if this had not been dx when it had she surely would have progressed to stage iv by now so I'm skeptical about this!!!

[Mtngrl]

Dear Tricia,

With all due respect, you don't know that your friend surely would have progressed to stage iv if she had been diagnosed later. You also don't know that it won't happen anyway.

But I think the article is simply saying no one has been systematically looking for a correlation between MRI screening and overall survival. There might be one; we just don't know.

[tricia keegan]

Good point Amy, but as she had an aggressive type of bc that grew quickly I'm assuming if left untreated it would have progressed which is the usual as far as I'm aware going by own experience!

Persoanally I think MRI is still a valuble tool on early dx, so many women have dense breasts and would possibly miss a bc dx without mri, certainly with stage iv it may not give much more survival time but in early stage I think an MRI is all important to prevent someone possibly getting to this stage by early dx and tx.

[3twins]

Neither a diagnostic mammogram or a sonogram showed my tumors. Thank goodness the doctor insisted on a biopsy given the abnormal calcifications. After a positive biopsy, an MRI finally showed 3 small tumors, all under 1cm. It confirmed a lumpectomy wasn't an option. Every single day I am grateful to my HR director for approving my MRI.

['lizbeth]

Wow, quite the discussion.

I feel that early detection gives an advantage. This is a war, and cancer is the enemy. We don't know the full intention of this enemy, but it is better to know the enemy is there - before they invade and occupy a greater portion of our territory, and consequently making the cancer cells more difficult to eradicate.

But another point has been made that is also valid, early detection is not always successful. The industry has based treatment on a premise that cancer detected earlier has a higher survival rate, and if we look at studies the 5 year overall survival rates are higher with earlier detection.

The articles I've read and my own experience leads me to an understanding that MRI is a better tool for younger women with denser breast tissue. I would expect that younger women would also have more aggressive cancers. While MRI would be of little benefit to most women, they would be of great value to women with denser breasts.

I did notice on my last mammogram I was categorized by the density of my breast tissue. Has anyone else noticed this change on their scans?

[Lani]

Overall survival is not thought to be much improved by finding breast cancer earlier as micrometastasis of disseminated tumor cells appears to be a very early phenomenon in breast cancer. One recent study showed it even happens in a certain number of DCISs.

Nevertheless, very few studies are even looking at serial bone marrows, despite the fact that DTCs have been found to be a much more reliable predictor of eventual metastases than CTCs. They just keep saying that patients won't like it--- well patients don't like chemo, but they keep giving it, even in those who statistically are very much more unlikely to receive any benefit (and much more likely to experience a side effect).

They keep waiting for the technology for detecting CTCs to improve. Even so, it might end up that DTCs are still more reliable for predicting metastatic disease than CTCs.

When I ask why more bone marrow testing is not being carried out, the usual answer I get is that patients might not like it. When prodded, those answering often admit it is that the doctors don't like to do it. Oncologists used to be hematologists as well and used to doing bone marrows and good at doing them. Perhaps it is time for them to "farm out" bone marrow testing to those comfortable with it and good at it and let us find out whether we couldn't improve treatment (make sure treatment is working, test if another treatment would be better) by serial testing of bone marrows, until such time as CTC testing improves and is found to be more reliable (IF it ever turns out that is the case)

There is more that we don't know than that we do know about breast cancer and if articles like this on MRIs are grabbed by insurance companies and government decision makers to allow/disallow testing (or avastin treatment) we may never get to the stage where we find the best ways to detect, treat and prevent bc ie, if treatment, testing without proof of efficacy continues.

We must subdivide (find subgroups of bc) in order to conquer, and that involves testing and treating more people than necessary in the early stages.

It has been estimated that over 70% of breast cancer (all comers, not her2+ patients or triple + patients or ER+ her2- patients with a high Ki67) patients treated with chemotherapy do not benefit from it (and can truly suffer). The downsides to performing a few too many MRIs while we learn where they are most useful seem miniscule in comparison.

Off my soapbox now (sorry about that)!

['lizbeth]

Lani,

I am always happy to hear what you have to say. And in fact, I may need an updated education on cancer. I was a voracious student when I was first diagnosed, but then got discouraged and stopped reading. I was under the impression that for some women early detection leads to an effective treatment and prevention of metasis. But not for all women, even with early breast cancer.

I do agree, that cancer needs to be divided into subsets for effective treatment. This one shoe fits all MRI study is a detriment to breast cancer patients. I needed an MRI to get the proper medical care for my breast cancer. If I had opted for a lumpectomy, not knowing I had 2 additional tumors in my breast, the cancer would still have been there growing. Not showing up on the mammograms, nor the ultrasound.