Breast MRI: An Imaging Center Opportunity to Raise Bar of Care

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New guidelines from the American Cancer Society [1] recommending annual breast MRI for high-risk women are expected to result in significantly expanded demand for the study. Robert Smith, director for screening at the American Cancer Society, estimated that the new guidelines would add between 1 million and 2 million women a year to the number who should have breast MRI in the United States, according to an article in the New York Times. [2] In order to participate in the delivery of care, imaging centers must institute stringent new technical standards, invest in MR-compatible biopsy equipment, initiate training for radiologists and technologists, and, in some cases, implement more empathic patient interaction protocols.

Even before the new guidelines were released in March, ProScan Imaging (PSI), a Cincinnati-based network of 25 freestanding imaging centers in 11 Eastern states and one of the largest teleradiology providers in the world, reported a threefold increase in the number of breast MRs read via teleradiology in the past year and 10 of its centers had already begun providing the examination. Stephen J. Pomeranz, M.D., CEO and medical director of PSI, has read approximately 7,000 breast MRs during the past five years and was not at all surprised by the announcement of the ACS’s new recommendations. “I have had the opportunity, first-hand, to appreciate the power of breast MR, especially in women who have tougher breasts to evaluate on x-ray,” Pomeranz said.

The Patient Pool
In addition to imaging women with the high-risk characteristics described in the new ACS guidelines, Pomeranz has promoted breast MR as an important tool in:

breast cancer staging,

imaging younger women with dense breasts,

imaging small-breasted women with dense breasts,

imaging women with indeterminate mammograms over a period of time, and

imaging women with breast implants

Breast MR plays a particularly valuable role in staging breast cancer patients, Pomeranz said. “One study, from the University of Pennsylvania’s Abramson Cancer Center three years ago, showed that between 24% and 27% of all women who had MR for staging actually had their treatment management changed by the MR,” he said. “That’s a big number. We’ve known for quite some time that the size of the cancer and the presence of more than one cancer are often underestimated dramatically by mammography. So this could impact a woman’s decision to have a lumpectomy or mastectomy, as well as the various types of supplemental therapy.”

A new study published in the May issue of the Archives of Surgery found that the use of breast MRI resulted in a 9.7% beneficial change in the surgical management of patients, with a 23.2% overall change. Lumpectomy was converted to mastectomy in 10 patients (8 beneficial), wider excision was performed in 21 patients (10 beneficial), and 5 patients (2 beneficial) underwent contralateral surgery.

The March publication of an ACRIN study in the New England Journal of Medicine [4] also helped to build the case for breast MR in women recently diagnosed with breast cancer. Results showed that breast MR detected twice the number of cancers as mammography in the contralateral breast of women with a recent diagnosis of breast cancer. Sponsored by the National Cancer Institute and conducted by the American College of Radiology Imaging Network, the study reinforces the suggestion that breast MR should be performed on all breast cancer patients prior to treatment planning.

Another category of women who may benefit from breast MR is women with indeterminate mammograms over a period of time. “We usually educate their physicians about the role of MR,” explained Pomeranz. “And, most importantly, we educate their physicians about how important MR can be in those situations where cancers can be tough to detect, the kind of in-between cases in which the woman has some moderate risk and a screening study that is just not adequate because the technology cannot overcome the limitation of the breast configuration: the size and the density. That occurs with enough frequency to make MR very important.”

Breast implants provide one of the foremost indications for breast MR, as mammography can be tough to interpret because of the density of the implant, Pomeranz said. The technology is appropriate for the following implant indications: a mass, cancer, implant rupture, pain, implant getting bigger, and implant getting smaller.

“There are some other areas where