Diagnostic Breast MRI & Surgical
Treatment for Breast Cancer
Melony E.
E Sorbero,
Sorbero PhD,
PhD MS,
MS MPH
June 27
27, 2009
Background
• Breast MRI increasingly used in pre-operative
assessment of women with newly diagnosed
breast cancer
– Performed on both breasts
– More sensitive than mammography,
particularly in dense breasts
– No guidelines for its use in this manner
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Background
• Ipsilateral breast (i
(i.e.
e one with identified breast cancer)
– Clarify ambiguous findings
– Identify
y additional disease
• Wider excisions in up to 13.5%
• Change treatment plan to mastectomy in up to
25%
• Contralateral breast
– Detect clinically and mammographically occult
disease
• Up to 20% have additional biopsies
• Occult contralateral cancer identified in 3-5% of
women having MRI
• Rate of contralateral prophylactic mastectomy (CPM)
more than doubled 1998
1998-2003
2003
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Research Objective
• To examine whether increased use of diagnostic
breastt MRI is
b
i associated
i t d with
ith increase
i
in
i CPM
• Explored two pathways:
Diagnostic
Breast
MRI
Therapeutic
Mastectomy
Contralateral
Prophylactic
Mastectomy
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Sample
• Women identified through Magee-Womens Hospital
of UMPC tumor registry
– Primary unilateral DCIS or Stage I, II or III
invasive breast cancer
– Excluded
E l d d women with
ith bilateral
bil t l disease
di
• Linked to radiology database
• Two time periods
– 1998 – 2000 (early period)
– 2003 – 2005 ((late p
period))
• Data included year of dx, age at dx, family history,
surgical treatments, use of pre-operative MRI
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Analysis
• Logistic regressions
– CPM=ƒ(MRI, MRI*Stage, Stage, Age at Dx, Year
of Dx,
Dx Family History)
– Mastectomy=ƒ(MRI,
y ƒ(
, MRI*Stage,
g , Stage,
g , Age
g at
Dx, Year of Dx, Family History)
– CPM|Mastectomy=ƒ(MRI, MRI*Stage, Stage, Age
at Dx, Year of Dx, Family History)
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Sample Characteristics
Early Period
N
N
Age
<40
40-49
50-64
65+
Stage
DCIS
I
II
III
First Degree Relative
Yes
Unknown
Late Period
%
1863
N
%
p-value
1743
0.017
140
510
738
475
7.5
27.4
39.6
25.5
87
481
727
448
5.0
27.6
41.7
25.7
<0.001
0.001
365
776
663
89
19.6
41.7
34.0
4.8
418
729
455
141
24.0
41.8
26.1
8.1
<0.001
380
559
20.4
20
4
30.0
392
396
22.5
22
5
22.7
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Sample Characteristics
%
40
30
20
10
0
p<0.001
p=0 18
p=0.18
p=0.002
I
R
M
to
c
e
st
a
M
my
Early Period
Late Period
M
P
C
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Use of MRI
• More common:
– Family history of breast cancer
– Under age 50
– Stage II or III
• Less common:
– Unknown whether first degree relative with
breast cancer
– Age over 65
– DCIS
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MRI and Surgical Treatment
p<0.001
40
35
30
25
% 20
15
10
5
0
MRI
No MRI
p<0.001
Mastectomy
CPM
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Multivariate Results: Overall Relationship Between
MRI and CPM
MRI &
Stage III
MRI &
Stage I/II
MRI &
DCIS
0
1
2
3
4
Odds Ratio
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Multivariate Results: Decomposed Relationship
Between MRI and CPM
MRI & Mastectomy
MRI & CPM | Mastectomy
MRI &
Stage III
MRI &
Stage
g I/II
MRI &
DCIS
0
0.5
1
1.5
Odds Ratio
2
2.5
3
0
1
2
3
4
Odds Ratio
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Limitations
• Retrospective study
• Single institution
• Limited ability to control for potential confounders
– BRCA status
stat s
– Histology
• Lack information
– MRI results
– Subsequent
q
biopsies
p
– Long-term outcomes
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Conclusions & Implications
• Results suggest pre-operative MRI changes
surgical
i l treatment
t t
t among subset
b t off women with
ith
breast cancer
• Reasons warrant additional exploration
– Increased emotional distress
– Physician recommendation
• Unproven benefits at what cost?
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Study Team
• Andrew W. Dick, PhD, RAND Corporation
• Ellen Burke Beckjord, PhD, MPH, RAND
Corporation
• Gretchen
G t h Ahrendt,
Ah
dt MD,
MD FACS,
FACS Magee-Womens
M
W
Hospital of UMPC
For More Information
Melony Sorbero
msorbero@rand org
msorbero@rand.org
Sorbero ME
ME, Dick AW
AW, Beckjord E
E, Ahrendt G
G. “Diagnostic
Diagnostic
Breast MRI and Contralateral Prophylactic Mastectomy.”
Annals of Surgical Oncology 2009; 16(6):1597-1605.
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