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Breast MRI Cost-Effective in Certain High-Risk Pts

Breast MRI Cost-Effective in Certain High-Risk Pts

ABSTRACT: Acceptance of expensive new technologies often rests on their proven cost-effectiveness within specific clinical scenarios. A recent article (Plevritis et al: Cost-effectiveness of screening BRCA1/2 mutation carriers with breast MRI. JAMA 295:2374-2384, 2006) suggested that adding breast MRI screening may be cost-effective for women of certain ages who carry BRCA1/2 gene mutations. To shed light on this subject, Cancer Care & Economics (CC&E) spoke with noted breast imaging expert Elsie Levin, MD, medical director of the Faulkner-Sagoff Breast Imaging and Diagnostic Centre in Boston.

CC&E: What is the patient flow at Faulkner-Sagoff?

DR. LEVIN: We see about 150 patients a day for screening and diagnostic mammography, breast ultrasound, and interventional procedures. We also perform about 15 breast MRIs per day.

CC&E: A study recently published in JAMA examining cost-effectiveness of MRI in BRCA1/2 mutation carriers concluded that breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. Further, the study found that the cost-effectiveness of adding MRI to mammography is age sensitive. What does this mean in the context of clinical breast screening?

DR. LEVIN: Women who have any predisposing factors such as BRCA1/2 mutations need to be screened and counseled with extra sensitivity. As the study suggested, in BRCA1 carriers, where the lifetime risk of developing breast cancer is so high and the types of cancers tend to be very fast-growing, breast MRI, even with all the additional testing involved, is a cost-effective constituent in the management of these women. However, in the general population where the incidence of breast cancer is so much lower than it is in gene mutation carriers, we really cannot justify the cost of employing breast MRI as a standard screening tool. Screening mammography remains the gold standard in breast health management for the overall population.

CC&E: Are the increased false-positive findings associated with breast MRI a deterrent for its acceptance?

DR. LEVIN: Everybody talks about the false positives associated with breast MRI, but there are false positives with mammography and ultrasound as well. The first breast MRI is just like the baseline mammogram; you need to do additional testing because you don't have an imaging history. The first MRI may detect benign findings, but once you categorize them as benign—either with ultrasound-guided biopsy or follow-up—during the next round of screening, you're not going to work-up the same abnormalities. There's no costly redundancy. For example, in our practice at least 80% of the abnormal findings on MRI can be seen with either ultrasound or mammography. An ultrasound-guided core biopsy is a 5-minute procedure that's relatively low cost. In short, as we learn more about breast MRI, the specificity ratio will improve, reducing the number of false positives and the costs associated with the subsequent follow-up procedures.

CC&E: Is breast density a variable in MRI efficacy as it is in mammography?

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