Preoperative MRI in Breast Cancer Grows Contentious

Abstract

S ince its introduction in breast imaging, the use of magnetic resonance imaging (MRI) technology has become a source of contentiousness between its ardent supporters and its fierce critics. No sooner had consensus been reached that MRI screening for breast can cer should be restricted to high-risk women than a new controversy flared over its preoperative use in early-stage breast cancer patients. Fueling the debate is a recent fl urry of reports suggesting that MRI use increases mastectomy rates, prolongs the time from diagnosis to treatment, and may increase the rate of overdiagnosis (detection of clinically insignifi cant cancers). Staunch advocates of preoperative MRIs, however, argue that in their hands it reduces reexcision surgeries and therefore reduces costs. Most recently, in a review of more than two dozen recent studies, Nehmat Houssami, Ph.D., of Sydney Medical School, University of Sydney, Australia, and Daniel Hayes, M.D. , of the University of Michigan Comprehensive Cancer Center, Ann Arbor, conclude that little evidence exists to support the routine use of MRI in the care of newly diagnosed breast cancer patients. When the investigators pooled data from 12 primary studies on changes in surgical management based on MRI detection, they found that 11.3% of patients had more extensive surgery than initially planned and that 8.1% of women originally thought eligible for breast-conserving surgery converted to mastectomy because of MRI fi ndings of additional suspicious lesions. The review, published in CA: A Cancer Journal for Clinicians , argues that MRI could have a potentially harmful effect. “What really breaks my heart is seeing an increased rate of mastectomies after 40 years of battling over doing breast conservation,” said Hayes. “I lived through the mastectomy versus breast conservation wars . . . but because of randomized trials, and surgeons willing to challenge their [own] dogma, and because we chose appropriate endpoints, we convinced ourselves that breast conservation was every bit as good as a mastectomy. And now we are reversing those great successes.”