High-risk women get breast MRI—but room remains for improvement

National BCSC study led by Group Health in JAMA Internal Medicine

Seattle, WA—A large national study in JAMA Internal Medicine has found that the rate of women receiving breast MRI (magnetic resonance imaging) nearly tripled from 2005 to 2009: from four to 11 exams per 1,000 women. The same issue of the journal includes a report of breast MRI use in the Northeast—and an editorial accompanying the two studies.

“Ours is the first large-scale report of how women are actually using breast MRI in national community practice,” said lead author Karen Wernli, PhD, an assistant investigator at Group Health Research Institute. This community-based reporting is made possible by the Breast Cancer Surveillance Consortium (BCSC), the nation's largest and most comprehensive collection of information on screening for breast cancer, funded by the National Cancer Institute (NCI).

Breast MRI is recommended in addition to X-ray mammography to screen women at high (20-25 percent or more) risk for developing breast cancer during their lifetime. And among women in the study screened with breast MRI, the proportion at high lifetime risk for breast cancer rose from 9 percent in 2005 to 29 percent in 2009.

“We found that use of breast MRI for breast cancer screening—rather than diagnosis—is rising, as is appropriate,” said Dr. Wernli, who is also an affiliate assistant professor of health services at the University of Washington School of Public Health. During the study period, the proportion of breast MRIs used for diagnosis fell, and the proportion used for screening rose. Screening is done routinely in the absence of suspicion, and diagnostic evaluation is the workup after other breast imaging, like mammography or ultrasound. Diagnostic evaluation with breast MRI, in particular to avoid a biopsy, is not recommended before breast cancer is diagnosed. After a diagnosis, some people use breast MRI to evaluate for staging and extent of disease.

Despite their disparate methods and populations, both papers in the same issue of the journal report similar findings: Breast MRI is now being used for screening more often than for diagnosis; and its use for screening is more common in average-risk women than in higher-risk women—but that pattern is improving.

“Our study suggests breast MRI is being used better,” Dr. Wernli said. But it also shows that more improvement is needed to use breast MRI more appropriately for risk-based screening: The vast majority of the women at high lifetime risk for breast cancer—who could most likely benefit from breast MRI—appeared not to be using it yet, instead using only mammography for screening. Meanwhile, many women at average risk for breast cancer were screened using breast MRI, even though mammography is still considered the best screening test for them.

“To prevent the underuse by women at high risk, and overuse by those at average risk,” Dr. Wernli said, “we need to strengthen the network of providers, like genetic counselors, who can provide women with the breast cancer risk counseling that they need.”

Dr. Wernli explained: “We took a snapshot of how doctors are interpreting the guidelines and using this new technology.” The study of more than 6,700 women receiving breast MRI is among the first to measure why women receive this test.

The researchers used a pool of data on women aged 18‑79 years from five community-based BCSC registries—Group Health, North Carolina, New Hampshire, San Francisco, and Vermont—using electronic data systems, billing codes, and radiology reports. Women completed a questionnaire about their age, ethnicity, family history of breast cancer, history of breast procedures, and other information.

This work was supported by the NCI-funded Breast Cancer Surveillance Consortium co-operative agreement (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, and U01CA70040), the NCI-funded grants RC2CA148577 and P01 CA154292, and the Agency for Healthcare Research and Quality (K12 HS019482). Collection of cancer data used in this study was supported in part by several state public health departments and cancer registries throughout the United States. For a full description of these sources, please see: http://breastscreening.cancer.gov/work/acknowledgement.html.

Dr. Wernli’s co-authors were Laura Ichikawa, MS, senior biostatistician, Group Health Research Institute; Wendy DeMartini, MD, professor of radiology, University of Wisconsin School of Medicine and Public Health; Constance Lehman, MD, PhD, professor and vice chair of radiology and section head of breast imaging, University of Washington, also an affiliate investigator, Group Health Research Institute; Tracy Onega, PhD, assistant professor of community and family medicine, Dartmouth Institute; Karla Kerlikowske, MD, MS, professor of medicine, epidemiology, and biostatistics, University of California, San Francisco (UCSF) and director of the Women Veterans Comprehensive Health Center, San Francisco Veterans Affairs Health Center; Mike Hoffman, programmer in epidemiology, UCSF; Berta Geller, EdD, research professor in family medicine, radiology, and health promotion, University of Vermont; and Bonnie Yankaskas, PhD, emeritus professor of radiology, and Louise Henderson, PhD, assistant professor of radiology, University of North Carolina, Chapel Hill.

Breast Cancer Surveillance Consortium

The Breast Cancer Surveillance Consortium (BCSC) is the nation's largest and most comprehensive collection of breast cancer screening information. It's a research resource for studies designed to assess the delivery and quality of breast cancer screening and related patient outcomes in the United States. The BCSC is a National Cancer Institute-funded collaborative network of seven mammography registries with linkages to tumor and/or pathology registries. The network is supported by a central Statistical Coordinating Center. Currently, the Consortium's database contains information on over 9.9 million mammographic examinations, 2.4 million women, and 120,800 breast cancer cases (100,500 invasive cancers and 20,300 ductal carcinoma in situ). For more information, visit http://breastscreening.cancer.gov.

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