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.
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 benigneither with ultrasound-guided biopsy or follow-upduring 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?
DR. LEVIN: The density of the breast does not affect the breast MRI reading or my decision as a clinician to order MRI. I did a screening MRI on a gene mutation carrier whose breasts were completely fatty replaced, the ideal candidate for mammography, and she still had a 1 cm invasive ductal cancer that was not seen on mammography. So, I don't care what their breast density is, if they are a gene mutation carrier they need an MRI, even if their breasts are completely fatty replaced.
CC&E: Our growing knowledge of genetic predisposition creates difficult choices for some women. How do you deal with this in your practice?
DR. LEVIN: Each patient needs to be managed according to her physical and psychological disposition. Some women who are gene mutation carriers have seen multiple family members die of breast cancer, and they may opt for a prophylactic mastectomy. However, there are many female gene mutation carriers who are willing and happy to be carefully monitored, once they fully understand that we have an effective management strategy for them.
I manage my high-risk patients with an annual mammogram and an annual MRI, but given 6 months apart. That allows me a chance to evaluate them twice a year. There are findings that we'll detect in mammography that are not as well demonstrated on MRI and vice versa. This tightly drawn screening and evaluation schedule creates a comfort level for the high-risk patient.
CC&E: Are we approaching a point of consensus among the oncology community about the place of breast MRI as a standard screening tool?
DR. LEVIN: MRI mammography is not intended to replace standard mammography and ultrasound. Instead it builds upon the information from those techniques. That said, I think most clinicians are in favor of recommending MRI for gene mutation carriers who are heavily predisposed to developing breast cancer.
As far as reaching a consensus statement, more data are needed on factors such as specificity rates and the parameters for high-risk classification before societies such as the American Society of Breast Surgeons (ASBS) or the American College of Radiology (ACR) endorse specific guidelines. Much of the problem simply centers on defining those patients in whom MRI would be an effective and cost-effective option.
CC&E: Any closing thoughts on the future of imaging and breast cancer screening?
DR. LEVIN: With improved imaging techniques, screening mammograms enable early detection of smaller cancers. As we learn more about breast MRI, it will become an increasingly valuable screening and diagnostic tool.
There are studies being conducted on cutting edge technologies such as breast ultrasound and digital breast tomosynthesis (DBT). In DBT, researchers have developed a 3D mammography technique that makes it possible to explore the interior of the breast without the superimposition of other overlapping tissues that may hide a cancer.
This is an exciting time in radiology. These powerful new tools will help us improve the speed of detection and the accuracy of diagnosis, which, in turn, will translate into better outcomes for our patients.