Where are the Guidelines for Breast MRI?

Today's blog was inspired by a patient of mine who underwent LAT flap and was wondering if she should have a breast MRI and, if so, how often?

So what’s the deal with MRIs and breast cancer? Everyone is talking about this method of imaging from celebrities who had cancer to patients I see in the office.  An MRI stands for magnetic resonance imaging and is used to better view the soft tissues of the body. Breast MRI has become popular in the last decade as a more sensitive method of breast imaging, but the guidelines for this test are lagging behind. Ask any doctor and they can tell you the American Cancer Society’s recommendation for women to get mammograms (although this has been debated lately) is yearly after age 40 with no history or risk factors for breast cancer. Ask that same doctor about MRI guidelines and he will likely shrug his shoulders! There are no hard and fast guidelines for breast MRI whether you are high risk, have had breast cancer or have reconstructed breasts; there are some vaguely stated guidelines, so I will hash these out for you.

The American College of Radiology (ACR) has determined breast MRI indications as A) screening for 1) high-risk patient (>20 percent lifetime risk of developing breast cancer) 2) screening of opposite breast for a newly diagnosed breast cancer patient 3) postoperative reconstruction B) to determine extent of a person's disease and C) as an additional imaging modality available when mammogram or ultrasound or clinical findings warrant further investigation. To read the full document click this link: ACR MRI Guidelines .

Here is the problem with 1)...what defines high risk? There is no approved risk assessment model. Currently, your healthcare provider likely assesses your risk for developing breast cancer based on the Gail model risk assessment or Tyrer-Cuzick risk assessment model. For those of you with a history of breast cancer, the BOADICEA, Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, would be the risk-assessment tool for you.

The National Cancer Institute has a Breast Cancer Risk Assessment Tool if you want to score yourself, but it is meant for use by healthcare providers. The Tyrer-Cuzick model tends to take a lot more into account when assessing risk and some healthcare providers prefer to use this model over the Gail model. Unfortunately, there is no guideline as to which model to use and so a healthcare provider may use either. 

What is known is that having an accurate risk assessment tool is critical in managing a high-risk patient and there are downfalls with both models. Essentially, I am saying we have a long way to go as the risk-assessment tools are not where they need to be, so it is no wonder that we have no guidelines as to how to use a highly sensitive test like MRI for screening high-risk patients.

What you can do to be proactive is to ask your insurance which model they use for determining MRI eligibilty (see link to Aetna's eligibilty criteria below) and keep an accurate family history of breast/ovarian cancer. You may also want to keep your mammogram reports to show you have dense breasts (if you do).

Use of MRI becomes even more fuzzy for women who have breast cancer because now we have a woman who has had a breast cancer that needs closer monitoring after surgery. Many surgeons will order MRIs immediately after diagnosis but prior to surgery and then not again for 18 months after surgery. Some healthcare providers will then order yearly MRIs on any breast cancer patient who has one or both breasts remaining, yet there are others who only order MRIs every three to five years and still some who will not order MRIs at all.

Once again there are no clear-cut guidelines for managing of a patient post breast cancer. The ACR simply lists MRIs may be indicated to evaluate patients with silicone or saline implants when mammography is difficult, but there is no indication of when or how often an MRI is recommended. Furthermore, there are no recommendations for mammography in post-reconstruction patients, so when would mammography be difficult? The ACR only recommends MRI as useful for patients with flap breast reconstruction when recurrence is suspected, so this is more of a retroactive imaging instead of prophylactic imaging.

How can we justify sending women for a test that costs over $2,000 when we have no guidelines? What often happens is some insurance companies will cover an MRI for a woman who does not really need the test (a waste of healthcare dollars) and then a woman who could benefit from an MRI will be denied the coverage. A standard set of guidelines for breast MRI would help insurance companies weed through the muck and approve this test for women in need. Read more: http://www.livestrong.com/article/128188-breast-cancer-risk-assesment-tools/#ixzz1VPOCF2vJ

So, what does this mean for you? If you have had breast cancer, you should speak to your healthcare provider as likely you are a candidate for yearly breast MRIs. Your insurance may or may not cover this benefit at this time. Keep in mind MRI does NOT replace mammogram, so you should have mammograms with ultrasound and an MRI in addition.

The question remains….when will we get guidelines for breast MRI? This will help many breast cancer survivors breathe easier and it will also help with early detection of those at highest risk for developing breast cancer.

Your Breast Cancer Answer:

Ask your healthcare provider if you are a candidate for MRI; likely if you are reading this, you have had breast cancer, so ask if you should be screened yearly. For ladies with reconstructed breasts, the jury is out on MRI surveillance for you; while MRIs can detect chest wall recurrence, they do not always produce a high yield. You cannot use the Gail model or Tyrer Cuzick model if you have had breast cancer in the past; if you have breast cancer history then you are considered high risk and would be an appropriate candidate for MRI screening.

How frequently are you having your breast MRI done? Please share your experience with us.

Resources:

http://www.cancer.gov/bcrisktool/

Aetna's Guidelines for Determining MRI Eligibilty

http://www.posters2view.com/sabcs08/viewp.php?nu=4074

http://cancerres.aacrjournals.org/cgi/content/abstract/69/24_MeetingAbstracts/6063

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=55&abstractID=31693

http://www.mghradrounds.org/index.php?src=gendocs&link=2007_april

http://www.acr.org/secondarymainmenucategories/quality_safety/guidelines/breast/mri_breast.aspx