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Data Points #13: Use of preoperative MRI among older women with ductal carcinoma in situ and locally invasive breast cancer

Research Report

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This report is from AHRQ's Data Points Publication Series.

Overview

Rates of MRI use prior to surgery increased dramatically from 2002 to 2007 for both women with DCIS (<1% to 12.9%) and with invasive disease (1% to 14.3%).

MRI use varied across geographic areas and demographic characteristics, with higher use in urban areas and for younger women diagnosed with breast cancer.

MRI use was not consistently different between women diagnosed with DCIS and with locally invasive breast cancer. For both groups, preoperative MRI use was higher for women treated with mastectomy than with breast-conserving surgery.

The American Cancer Society estimates that 229,060 new cases of invasive breast cancer were diagnosed and 39,920 people died of the disease in the United States in 2012. In the same year, approximately 63,300 women were diagnosed with ductal carcinoma in situ (DCIS) of the breast. DCIS is noninvasive breast cancer representing a wide variety of cell abnormalities confined to the ducts of the breast. DCIS encompasses a wide spectrum of tumors with varying histologic patterns, grades, and sizes. DCIS has been implicated as a precursor to invasive breast cancer. While we do not know the percentage of cases of DCIS that would progress to invasive breast cancer, studies suggest a very high risk of invasive breast cancer among women diagnosed with DCIS. Therefore, optimal management of DCIS to prevent subsequent invasive breast cancer is of strong clinical interest.

The typical treatment for both DCIS and early invasive breast cancer is surgical removal of the tumor by mastectomy or breast- conserving surgery (BCS) plus radiation therapy, and use of MRI may influence treatment planning.6 For some patients, mammography can underestimate the extent of DCIS and invasive cancer. Magnetic resonance imaging (MRI) findings may lead to changes in treatment plans such as wider excisions, unilateral mastectomy, and/or early detection and treatment of contralateral breast cancer. Nevertheless, preoperative breast MRI has not been significantly associated with improvement in oncologic outcomes, such as lower recurrence rates or mortality. Some argue that the occult disease detected by MRI is eradicated by radiation therapy, chemotherapy, and/or endocrine therapy following BCS or mastectomy regardless of MRI use, making the benefit of MRI minimal. Moreover, breast MRI has several potential disadvantages, including costs, unnecessary biopsies, increased anxiety, and higher mastectomy rates.

Our study describes the use of preoperative MRI among older women with DCIS and early invasive breast cancer. We discuss changes in use over time and provide a cross-sectional view of use in 2007.

Conclusion

Rates of preoperative MRI use have increased over time, despite limited evidence of improved outcomes. The increase was observed for both women with DCIS and early invasive disease. Rates varied strongly by location (residence in big metropolitan areas and certain registries), race, and receipt of State assistance. This suggests greater use where the technology is available. Consistent with this finding, variation by registry fluctuated over time. This likely reflected differences in availability or adoption of this technology.

Rates also varied by clinical characteristics. In general, women with higher risk DCIS (larger tumor size, higher grade disease, or ER-negative tumors) received more MRIs prior to surgery than those with lower risk disease. However, for women with early invasive disease, MRI use did not vary by risk of recurrence.