Screening Breast MRI Under-Utilized for High-Risk Women

Primary care providers are less likely to recommend breast MRI for screening high-risk women.

Primary care providers are less likely to routinely order supplemental breast MRI screening for women at high risk for breast cancer, meaning many of these women could go unrecognized.

Even though the American Cancer Society (ACS) recommends dynamic contrast enhanced MRI (DCE-MRI) for high-risk women – those with a 20 percent-to-25 percent or greater lifetime risk of the disease – many of these women are still only screened with mammography.

In a study published the July/August issue of Current Problems in Diagnostic Radiology, a team of researchers from the University of Massachusetts Medical School revealed survey results from their institution that showed the reasons behind the lack of utilization can be multi-factorial.

“Our study demonstrated that primary care providers at our academic institution under-recognized and under-utilized MRI as a supplemental screening tool for high-risk women,” said the team led by Nita Amornsiripanitch, M.D., a radiologist associated with Brigham & Women’s Hospital. “[It] highlighted some missed opportunities in current breast cancer risk management.”

According to a 2011 study of 10,518 women, less than half of women included who had a high-risk genetic mutations received supplemental MRI screening. So, identifying strategies to improve screening for this group is paramount, the team said. To accomplish this goal, they evaluated not only the risk assessment methods providers use, but their familiarity with what puts a woman in a high-risk category, and what recommendations they make for this patient group.

Study Results

For their study, the team created a 17-question survey and distributed it to the 524 practitioners (family medicine, internal medicine, and ob/gyns) within their institution who ordered between 10 and 1,000 mammograms annually. At 75 respondents, they had a 17 percent reply rate.

Based on their evaluation, the team determined that most providers – 97 percent – reported estimating breast cancer risk qualitatively, relying on a patient’s family and clinical history, as well as breast density. A much smaller proportion – 29 percent – relied to quantitative risk calculators.

In addition, most providers were unable to correctly define “high risk.” Only 31 percent correctly identified the ACS definition – and more providers who used quantitative assessments than those who used qualitative measures knew the correct answer, 45 percent and 25 percent, respectively.

The survey results also revealed that, even though providers were not ordering breast MRI for high-risk women, they were ordering it for other reasons. Most commonly, they recommended it for the evaluation of inconclusive clinical or imaging findings (67 percent of orders), followed by screening MRI for women with dense breasts (31 percent).

So, if they knew breast MRI was an option for women, why not recommend it? Only 18 practitioners offered reasons, and they mainly said they either felt mammography was sufficient or they preferred to defer to breast specialists to make the decision. Others said ordering the exam was too difficult and time consuming or it could lead to unnecessary follow-up or biopsy. A lack of experience was a concern for only a few providers, the team said.

“Our findings suggest that practitioners are not necessarily opposed to recommending MRI as a modality, and the low utilization of MRI for high-risk screening may instead be due to current perception or level of familiarity,” the team said. “Unfortunately, this perception was found to be pervasive at our institution regardless of practitioner’s age, sex, or length of practice.”

Screening Improvement Strategies

Based on their results, the team said some tactics for improving the use of screening breast MRI emerged.

Education: Primary care providers receive less targeted women’s health training than do ob/gyns, so additional educational efforts would be beneficial, the team said. Implementing methods to increase awareness of the ACS guidelines and recommendations, such as grand rounds and small group sessions between breast sub-specialists and primary care providers, could produce positive results.

Technology: Using technology to assess risk can also increase the number of women identified who could benefit from screening breast MRI. According to existing literature, women who use a computerized risk intake system to assess their breast cancer risk are more likely to discuss chemo-prevention and genetic counseling with their providers, and assessment at the time of mammography has been shown to increase breast MRI use, as well.

Ensuring a strong relationship between radiologist and referring provider can help with the management of these patients. In addition, the team said, conducting risk assessment at mammography also opens the door for radiologists to select risk models that are appropriate for MRI recommendations, as well as to develop new models that incorporate radiomics.

“In today’s setting of demanding primary care workflow, risk assessment and communication at the time of screening mammography may be one way to improve screening MRI utility, as well as represent an opportunity for radiologists to directly participate in patient-centered breast case,” the team concluded.

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