Women not following through with recommended breast screening MRI
A study of 64,659 women, recently published in the journal Academic Radiology, found that while 1,246 of these women were at high enough breast cancer risk to recommend additional screening with MRI, only 173 of these women returned to the clinic within a year for the additional screening.
“It’s hard to tell where, exactly, is the disconnect,” says Deborah Glueck, PhD, investigator at the University of Colorado Cancer Center and associate professor of biostatistics and informatics at the Colorado School of Public Health, the paper’s senior author.
But no matter the disconnect, the result is clear: women who should be getting breast screening MRI are not.
Along with her PhD student, John Brinton, Glueck got interested in the data of MRI breast screening soon after the 2007 recommendation by the American Cancer Society that women at elevated lifetime risk for developing breast cancer be screened with MRI in addition to yearly mammograms. In fact, despite most major health insurances offering coverage, few clinics put the recommendation into practice.
An exception is Invision Sally Jobe Breast Centers, in the researchers’ Denver, Colo. backyard.
“The Invision Sally Jobe Breast Centers and our collaborators, Dr. Lora Barke, Mary Freivogel and Stacy Jackson have been invaluable partners in our research,” Glueck says.
At Invision Sally Jobe, clinicians were using the National Cancer Institute’s Gail Model to identify a patient’s lifetime risk of developing breast cancer. For women with greater than 20 percent lifetime risk, the clinic included in the mammography results that were sent to women’s primary care physicians a note explaining the elevated risk and suggesting that the physician refer high-risk women for the recommended MRI.
Women and men diagnosed with stage 0 breast cancer have a 100 percent chance of survival after treatment. Those diagnosed with stage II have a 98 percent chance; virtually everyone survives this stage for at least five years. After stage II, survival rates drop quickly. Those diagnosed with stage IIA breast cancer have a 92 percent survival rate, while those with stage IIB face an 81 percent chance. Stage IIIA has a 67 percent survival rate, and with stage IIIB the rate drops to 54 percent. Those with stage IV breast cancer, the most advanced stage, face a mere 20 percent chance that they will live five years after the diagnosis. When diagnosed with stage IV breast cancer, the patient and treating physician have the difficult task of developing an aggressive treatment plan while maintaining a reasonable quality of life for the patient. Treatment plans at this stage are very personal and require much time and consultation between the patient, physicians, and family members. It is important to note that, while stage IV survival rates may be less than optimal, many individuals can and do survive stage IV breast cancer for a good number of years after their diagnosis, adding several quality years to their life.
These breast cancer survival facts underline how vital it is to do monthly self-exams, get a yearly mammogram, and see a doctor as soon as any symptoms arise.
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The Breast Cancer Society
“Did women never hear the recommendation from their physician? Did they choose not to follow through? Did they go elsewhere for an MRI? We don’t know,” Glueck says.
And so major questions remain in the assessment of the value, feasibility and implementation of breast MRI screening.
According to Glueck and Brinton, the most fundamental and overarching of these questions is whether the benefits of MRI screening for women at high risk for breast cancer, in fact, outweigh its high monetary, medical and psychological costs.
How many cases and deaths are estimated to occur in 2009?
• In 2009, an estimated 192,370 new cases of invasive breast cancer will be diagnosed among women, as well as an estimated 62,280 additional cases of in situ breast cancer.
• In 2009, approximately 40,170 women are expected to die from breast cancer. Only lung cancer accounts for more cancer deaths in women.
• In 2009, about 1,910 cases of breast cancer are expected to occur among men, accounting for about 1% of all breast cancers. In addition, approximately 440 men will die from breast cancer.
“For this to be true, first MRI has to catch breast cancer sooner than traditional mammography, it has to catch cancers that would otherwise kill, it has to catch cancers for which early treatment is more effective than later treatment, and the medical and psychological negatives in the process of screening and follow-up care – for example the potential for increased biopsies – have to be lower than the medical positives,” Glueck says.
Follow-up studies will chip away at these questions, including a planned study in which the researchers will see if informing high-risk women directly about the breast screening MRI recommendation will improve screening adherence.
Sex
• Excluding cancers of the skin, breast cancer is the most common cancer among women, accounting for nearly 1 in 4 cancers diagnosed in US women.
• Men are generally at low risk for developing breast cancer; however, they should report any change in their breasts to a physician.
Age
• Breast cancer incidence and death rates generally increase with age. During 2002-2006, 95% of new cases and 97% of breast cancer deaths occurred in women aged 40 and older.
• During 2002-2006, women aged 20-24 had the lowest incidence rate, 1.4 cases per 100,000 women; women aged 75-79 had the highest incidence rate, 441.9 cases per 100,000. The decrease in incidence rates that occurs in women ages 80 and older may reflect lower rates of screening, the detection of cancers by mammography before age 80, and/or incomplete detection.
• During 2002-2006, the median age at the time of breast cancer diagnosis was 61 years. This means that 50% of women who developed breast cancer were age 61 or younger at the time of diagnosis.
But significant hurdles remain between the theory that shows survival benefit for breast screening MRI in high-risk women and its practice.
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Garth Sundem
University of Colorado Cancer Center