Message from Dr. Brem

DR. RACHEL BREM SHARES HER VIEWS ON THE
LATEST BREAST CANCER DIAGNOSIS NEWS REPORTS

There is no doubt the media has been filled with information about new technologies and new recommendations for breast cancer detection.  Like all things, some of these recommendations should be heralded and some are a significant setback for women.

MRI FOR BREAST CANCER DETECTION:

Let’s start with the American Cancer Society’s recommendation that women at the greatest risk for breast cancer should have annual MRI examinations to improve breast cancer detection. We have had the data to support this for some time now. However, the formal recommendation by the American Cancer Society will certainly result in further awareness and acceptance of the use of MRI for the improved detection of breast cancer. However, we must remember that this recommendation is only for those women at the greatest risk of breast cancer, either by virtue of them having the “breast cancer gene” (BRCA 1 or BRCA 2) or if they have other genetic conditions that make them at great risk.  However, I believe that the American Cancer Society did not go far enough in including other women at increased risk of breast cancer, albeit not as great a risk as those mentioned above. I think it would be wise for women with other conditions that are known to increase the risk of breast cancer to also consider annual MRI for the improved diagnosis of earlier breast cancer. These women include those with a history of Atypical Ductal Hyperplasia (ADH) or Lobular Carcinoma in Situ (LCIS) where there is a significant increased risk of breast cancer or other clinical situations that would warrant more vigilant follow up so that if a cancer develops it can be found early and treated.  You should discuss your risk and benefit of annual MRI examinations with your family physician as well as a breast specialist, whether that be your breast imager (radiologist) who interprets your mammogram or a breast surgeon.  It is important that you are aware that not all physicians share the same opinion regarding an individual women’s need for annual MRI.

With regard to MRI, it is critical that you are an informed patient. There is no doubt that MRI can find more cancers. However, it is an exquisitely sensitive test that also finds many benign, non-cancerous, findings. This can result in additional tests and biopsies. So, it is a double edged sword. Yes, more cancers can be found but you might also open a door which will result in more tests including ultrasound and additional biopsies. Therefore, it is important to understand all the ramifications of this test prior to undergoing it.  Additionally, MRI requires a patient to be in a “Tube” for the test and some patients are claustrophobic. Most patients tolerate the procedure very well although some might require a mild sedative. It is important to note that the “open” MRI’s do not produce images that are adequate for breast MRI, so don’t have them for that purpose.

Also, it is important to know that there are other technologies that are being developed which seem to also improve breast cancer detection similar to MRI such as Breast Specific Gamma Imaging (BSGI). The available scientific data shows that Breast Specific Gamma Imaging seems to be as sensitive as MRI with possibly fewer false positive findings. However, there is more scientific data available with MRI right now, but more and more studies are being done and published to further define Breast Specific Gamma Imaging. Of note, Breast Specific Gamma Imaging is commercially available and FDA approved.  Breast Specific Gamma Imaging could have a similar role to MRI in screening high risk women, however more studies are needed.

Please note: MRI or Breast Specific Gamma Imaging DOES NOT replace mammography. Each study shows different things that help to diagnose breast cancer. There is no one accepted approach to screening with MRI and mammography.  At our center we see high risk patients every six months, once a year for mammography and once for MRI or Breast Specific Gamma Imaging.

Additionally, something very important about MRI and Breast Specific Gamma Imaging not covered in these recent recommendations is the importance of all newly diagnosed breast cancers getting MRI or BSGI. MRI and BSGI are based on metabolic activity. (Mammography and Ultrasound just look at anatomy). After a diagnosis of breast cancer, getting an MRI or Breast Specific Gamma Imaging (and we are moving more towards the use of BSGI) provides the optimal assessment.

COMPUTER AIDED DETECTION:

In the past few days, we have been hearing and reading a great deal about Computer Aided Detection (CAD). This technology uses digital information which is then analyzed by a computer to identify potential areas of abnormality. The radiologist then looks at the areas that are flagged and decides if it is significant or not.

There are dozens, if not hundreds of published studies in the scientific literature that have unequivocally demonstrated that the use of CAD improves breast cancer detection. In fact, studies have investigated whether CAD helps both novice and experienced breast imagers, whether it works as well in dense breast that are at greater risk of cancer as it does in non-dense breasts, if it works for all types of breast cancers (even the earliest and most curable types) and if it can detect even the smallest of breast cancers. THE ANSWER IS A RESOUNDING YES!!!!

Unfortunately, a single study which was not designed to evaluate CAD and which looked at decade old technology was recently published in the New England Journal of Medicine. This study was clearly designed to prove that CAD was ineffective. The study showed that even in this situation there was an improvement in breast cancer diagnosis. In fact, CAD was best at detecting the earliest of breast cancers, the type we want to find to improve the chance of a cure.   The study also showed, and this is what was publicized, that more women were called back for additional mammography and more biopsies were done. The bottom line is, even under non-optimal circumstances with old equipment in a study designed to discredit CAD - MORE CANCERS WERE FOUND!!! That is the purpose of CAD and it did what it was designed to do.  Further, despite a great deal of press coverage, this one study is CONTRADICTED BY DOZENS OF OTHER STUDIES.

It is a shame that if CAD is used less frequently, less cancers will be found and it seems reasonable that fewer cancers will then be curable at the time of diagnosis. I think it unequivocal that the hardship of additional mammography and possibly additional biopsies is a small price to pay for additional diagnosis of earlier cancers.

     It is clear to me that women should CONTINUE TO HAVE THEIR MAMMOGRAMS evaluated with CAD.

In summary, the use of MRI in very high risk women is a significant advance for the improved diagnosis of breast cancer. If women heed the findings of the recently published article describing negative aspects to the use of CAD with mammography, women will lose a critical opportunity to have their earliest cancers diagnosed due to the results of decade old technology published by authors who are not experts in CAD.

If you have questions, please email: rbrem@mfa.gwu.edu