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Invited Commentary |

Patterns of Breast Magnetic Resonance Imaging Use:  An Opportunity for Data-Driven Resource Allocation

E. Shelley Hwang, MD, MPH1; Isabelle Bedrosian, MD2
[+] Author Affiliations
1Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
2MD Anderson Cancer Center, Houston, Texas
JAMA Intern Med. 2014;174(1):122-124. doi:10.1001/jamainternmed.2013.10502.
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Both the American Cancer Society1 and the National Comprehensive Cancer Network2 have published guidelines on the recommended use of breast magnetic resonance imaging (MRI). In both sets of guidelines, lifetime breast cancer risk greater than 20% has been established as an acceptable threshold for annual MRI screening when used together with annual mammography screening. Routine breast MRI screening is not recommended for a new cancer diagnosis or for cancer surveillance.

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Screenshot Example of a Real-Time Risk Assessment Tool

Hughes riskApps (http://www.hughesriskapps.com) is a web-based tool that allows calculation of lifetime breast cancer risk at point of care based on BRCAPRO, Tyrer-Cuzick, Myriad, Claus, and Gail models. The tool incorporates 2 screens for patient self-reported data entry: A, family history screen; B, personal risk factor screen. The tool has been implemented as part of breast cancer screening programs, with referring health care providers given an individual patient’s lifetime breast cancer risk assessment, as well as recommendations for breast cancer screening. Published with permission from Hughes riskApps.

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Benefits of screening for breast cancer with MRI
Posted on November 19, 2013
David L. Keller, M.D.
Disabled internist
Conflict of Interest: None Declared
1) The high prices charged by hospitals for MRI exams are not intrinsically necessary. The regular cash price for a non-contrast 3 Tesla brain MRI, including all physician and facility charges, is $350 at a local for-profit imaging center (1). The local non-profit hospitals charge far more for the same examination. 2) Younger women have a higher content of glandular breast tissue, which is sensitive to the ionizing radiation exposure with mammography. They also have more expected years of lifespan during which to develop radiation-induced breast malignancies. 3) Many women are not compliant with screening mammography due to the pain caused by the compression of the breast glandular tissues. Again, younger women are more affected by this pain, and have more quality-adjusted life years to lose by not screening. Breast MRI is not painful.4) The increased sensitivity of breast MRI, even at the expense of reduced specificity, is compatible with the purpose of a screening exam. When screening for cancer, a false-positive can be addressed with further testing, but the harm caused by a false-negative often cannot be mitigated. The harms caused by a false-positive cancer screening test can be controlled if the informed patient chooses watchful waiting rather than an immediate invasive biopsy.Women who refuse screening mammography due to pain or the wish to avoid ionizing radiation to their breasts should be informed of these issues and offered screening with MRI.
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