Q&A: The high value of breast MRI from a specialists perspective
Rebecca G. Stough, MD
Rebecca G.
Stough, MD
Two recent studies in The New England Journal of Medicine have placed MRI in the spotlight due to its benefits in detecting breast cancer. One study indicated that breast MRI is highly beneficial as a screening tool for certain women with an especially high risk of developing breast cancer. At the same time, the American Cancer Society issued a corresponding guideline recommending that such women get an MRI along with their yearly mammogram.

Another study found that for women who were diagnosed with cancer in one breast, MRI scans detected over 90 percent of cancers in the opposite breast. The MRI-detected cancers had been missed by mammography and breast exams done during an office visit.

To get some perspective on the value of breast MRI, Health Imaging News spoke to Rebecca G. Stough, MD, clinical director of Breast MRI of Oklahoma, LLC, and radiologic director of Mercy Women’s Center in Oklahoma City. Stough has been performing breast MRIs since 2002.

The Breast MRI of Oklahoma installed an Aurora Dedicated Breast MRI System in 2003.

How long have you been doing breast MRI exams?

I started doing breast MRI on a body magnet with a breast coil in about 2002. After doing about 300 patients I realized I didn’t have enough time on that magnet to do all of the patients who needed to be done. With the Aurora system we have an MRI that is created to do breast images. We have a significant number of patients that we scan: all new diagnosis breast cancers; patients with an unknown primary; follow-up breast cancers; and high-risk patients who either have a strong family history, personal past history, or a high-risk pathology. It’s a wonderful tool.

In regards to the recent American Cancer Society Breast MRI recommendations, what determines a women who is at high-risk?

High-risk women are those that have been documented as having the BRCA-1 or 2 gene or have a very strong family history in one or more first degree relatives with breast or ovarian cancer, especially if any of those were pre-menopausal (under the age fifty). In addition, women with a history of radiation to the chest wall between ages 10 and 30 are at high risk. A lifetime risk for breast cancer scored at 20-25 percent or greater based on an accepted mathematical tool such as the Gail Model or Claus Model also throws them into that category. Each of these scenarios dictates that these women should get a yearly breast MRI exam starting at age 30, according to these recommendations.

Because of the NEJM publications do you anticipate a rise in exams at your facility?

I do, partly because in the past we’ve had some problems with the insurance carries. One in particular has claimed in some instances that breast MRI is not proven as a technology. These two publications coming out simultaneously document that breast MRI is proven and is not investigational anymore.

Breast MRI is by far the most sensitive test we have for breast cancer, but it’s also very expensive so doing it on every single patient is impossible. But if we can identify those patients who are at a significantly higher risk than the rest of the population, and use the MRIs judiciously, we can identify breast cancer early and surgically remove all ofthe cancer to begin with. Nationwide, about 30 percent of breast cancer patients have to return to the operating room after a breast cancer surgery. This could be because they didn’t get all the breast cancer the first time due to positive margins or they have to go back and do lymph nodes or something else.

However, at our facility since we instituted the pre-operative breast MRI our return rate to the operating room is five percent. That’s a huge difference. The cost to the insurance company for those patients that have to go back for a second, or in some cases a third time, is so high. I could do a lot of MRIs for just the dollars gathered from what the insurance carriers will save. This doesn’t even calculate in the anguish these patients feel when they find out they didn’t get it all and they have to operate again.

Explain the specific benefits of breast MRI’s accuracy.

MRI maps the true extent of the cancer so that you get the correct surgery the first time. This may involve placing brackets with needles so the surgeon will get all of the disease. Or, in some cases the cancer is so spread out they may need a mastectomy to start rather than the surgeon having to go back once or twice.

And as the NEJM also pointed out in new diagnosis breast cancer patients, if you scan their opposite breast you will find a life threatening cancer in 3 percent of the patients – and in our own study 3.8 percent. We also find in a little more than 7 percent of patients that there is another cancer in the same breast that is located far away from the known cancer. I’ve seen cases where a patient would have gotten limited radiation therapy (such as brachytherapy) for one tumor, while there is another unknown cancer in the same breast that’s too far away to get any radiation during the treatment. So, it would go untreated. Then what you would have at a later date is people showing up with metastatic disease because they had untreated breast cancer that got left behind. With MRI those cancers are identified to start with.

Overall, breast MRI significantly changes the operative plan to some degree in about 27 percent of the patients that we see.

Other than insurance, what are biggest hurdles to access breast MRI exams?

There are some places that just don’t have the access to breast MRI, and I think that’s the biggest issue. When I was doing MRIs on a body magnet with a breast coil I was fighting for time to be able to get my cancer patients in. This is because they are busy being used for scanning brains, spines, knees, hips, shoulders, and a growing list of indications on the body magnets now. It wasn’t until we got the dedicated Aurora Breast MRI that we began to have necessary access to the units. You’ve got to have very high quality MRI, you’ve got to have a bi-lateral breast coil, you’ve got to have a radiologist that can interpret the MRIs as well as a mammogram, and you need biopsy capability. If you can’t do all of those things then you don’t have any business doing breast MRI.

What do you recommend for facilities now considering offering breast MRI?

Most facilities will start with a body magnet and a breast coil. That’s a good place to start. But with these new guidelines the demand is going to be so high that I think they will find that if they are going to purchase a magnet for breast they should probably look into investing in one that is designed for breast.