M.R.I. Screening for Breast Cancer

A Dutch study published this week in The New England Journal of Medicine produced the strongest evidence yet that magnetic resonance imaging can detect breast cancer in women at high risk of the disease far better than standard mammography. The finding is bound to accelerate the use of M.R.I. in this high-risk group, but women facing only a normal risk of breast cancer have no good reason to request costly M.R.I. scans, which yield many false alarms.

The Dutch study - the largest ever conducted on the subject - searched for cancer in some 1,900 women with a high or moderately elevated risk of the disease because of a genetic mutation or a family history of breast cancer. Doctors screened the women every six months by physically examining their breasts and once a year by using M.R.I. scans and mammograms. Among 45 cancers that were detected and evaluated, M.R.I. found 32 of the tumors and missed 13, whereas mammography found only 18 of the tumors and missed 27.

The main reason for this disparity appears to be that radiologists reading mammograms have difficulty identifying tumors in the dense breast tissue of many younger high-risk women, and M.R.I. scans provide more sensitive discrimination. Even so, no one is recommending that high-risk women abandon mammograms in favor of M.R.I. scans. Each technology missed cancers that the other found, so they are in a sense complementary.

The main drawback of M.R.I. scans is a high rate of false positives. The study found that magnetic resonance imaging yielded twice as many false alarms and three times as many needless biopsies as did mammography, subjecting patients to unnecessary anxiety and hassle and the added cost of follow-up exams and procedures. Biopsies, though a relatively simple surgical procedure, carry some risk of infection.

Many women will be happy to take a chance on anxiety and hassle in exchange for a higher detection rate. But they should be aware that there is still some controversy about whether the early detection of small tumors, whether by M.R.I. or mammography, will save many lives. Some of the tiny tumors detected may not be destined to be lethal. An editorial in The New England Journal suggests that only a randomized, controlled clinical trial can definitively prove that screening improves survival rates.

Although the Dutch findings may lead women with only an average risk of breast cancer to seek M.R.I. screening, there is no good reason for them to do so. For one thing, while M.R.I. has an advantage in screening dense breast tissue, it may not have a comparable advantage in women with less dense tissues. For another, M.R.I. scans can cost more than $1,000 apiece, about 10 times the cost of a mammogram, and insurance coverage is limited. With the medical system struggling desperately to control costs, this is not a propitious time to add a costly screening technique of unproven value for most women.

WONDERFUL.

Actually, we have one woman at our clinic who needs MRI's because of a strong family history. But wait til the yuppies find out this works better and insist on a yearly MRI (Price $2000) instead of a mammogram ($200). Talk about soaring health care costs.

And yesterday I reviewed a dozen mammograms that needed "close up views". Only two were suspicious of cancer, and in the old days would have been sent for biopsies. But now the radiologists insist on close up views and ultrasouns on everyone with any lump, to improve "efficiency".

well, I guess it's better than dying of cancer...

My only "revenge" is that now men, with the PSA test, have to undergo all those test too when they get a "suspicious" PSA test, where 80 percent will be normal but 20 percent will be cancer.

And in the future: COLONOSCOPIES for all...my joke to patients is that when I was in private practice, if I disliked a patient, I sent them for a Barium enema.

On the other hand, we are cutting down the deaths from colon cancer.

REmember all that the next time they complain about high medical costs.

re: But wait til the yuppies find out this works better and insist on a yearly MRI (Price $2000) instead of a mammogram ($200). Talk about soaring health care costs.)))

Isn't it terrible that getting newer, better costs more? People who upgrade their houses, install a new bathtub, understand this. But upgrade medical care and get called a greedy gus.

The real problem will be when docs and hospitals cannot use their judgement in deciding who gets mam/ultras and who gets the MRIs. The, just to make the "good faith" paper trail, all non-risk patients will have to have the more expensive treatment (standard of care inflation). This one thing--not allowing docs and hospitals some safe harbor in these decisions--is IMO the single biggest driver of otherwise controllable medical costs. It is a side effect of the litigation drug.

The medical scene will not change until the medical community is no longer being paid to treat symptoms, and the longer the treatment the more profitable, and instead is paid to cure disease and improve both health and lifespan.

Lifetime maintenance medicines will always be more profitable than cures.

Most people that cure cancers like Rife and others outside of the FDA/drug companies/AMA cartel in the last century have not lived long.

I realize that the first number is better than the second, but both are abysmal. I have my regular mammograms and check ups, but it still seems more like a crap shoot than anything. :(

Finding cancer on a mammogram is not just like finding a needle in a haystack, it's like finding a specific stalk of hay that is shaped slightly differently from all the rest.

I guess you could call it a crap shoot for any one individual, but across the population that should get screening mammograms (ages 40 through 80) the odds are favorable for earlier detection and a higher likelihood of cure.

This is a difficult thing to explain to juries in medical malpractice lawsuits. It's quite easy for a plaintiff's lawyer to take almost any mammogram showing cancer this year, pull the mammogram for the same breast last year, and blow them up in a 10 foot diameter slide show for the jury. Then he claims that some little nubbin that lay nearby but wasn't noted on the older study was OBVIOUS cancer. It may be the size of a pinhead or rice grain on the original study but it will be a foot high when the trial lawyer is done magnifying it.

The facts are that even the very best radiologists with the very latest equipment will only find 90% or 95% of cancers. Yet people seem to think that anything less than 100% constitutes malpractice. This means that jury awards for failure to diagnose cancer climb ever higher, some exceeding 20 million dollars, and that doctors who diagnose and treat breast cancer are now at even more risk of a lawsuit than obstetricians or neurosurgeons.

Is it any surprise that this year, out of 100 or so slots available for specialty training for doctors who want to read mammograms, only 10 were filled nationwide? The wait for a mammogram is more than 6 months and climbing in some areas.

I blame the filthy pirates of the plaintiff's bar. They are pure evil scum. Tar and feathers are too good for them; horse whips are more like it.

-ccm

So where does screening mammography or MR fit in your crackpot conspiracy theories? Are you saying it would be best for women to put their trust in vitamins and coffee enemas and crystal vibrations, and forget about trying to detect or treat cancer?

-ccm

But now the radiologists insist on close up views and ultrasouns on everyone with any lump, to improve "efficiency".

Actually, they do that because they don't want to lose their homes and careers to the depredations of filthy greedy trial lawyers and juries made up of Jerry Springer Show rejects.

It would be far more 'efficient' not to go to such extreme lengths to diagnose breast cancer, wouldn't it?

-ccm

I realize it's not even close to 95%, but I didn't think it was this bad.

That's because it is much easier to find cancer in old ladies whose breasts are almost entirely low-density fat. Sensitivity does come closer to 100% in these women, although even in these cases, cancers can be missed if the technologist does not position the breast properly for the mammogram.

The high-risk women in this particular study were much younger and had much denser breasts. It's not a fair comparison to standard screening.

This is also the reason why routine screening mammography is not recommended for normal women younger than 40 (or until recently, age 50.) It's too insensitive in young women with dense breasts, and its usefulness could even be outweighed by the risk of causing cancers due to radiation exposure.

Cancer is vastly more rare in young women anyway, so any spots that do show up in these women are far more likely to be false alarms and lead to unneccessary surgery.

Moreover, the few young women who DO get cancer tend to have very aggressive fast-growing tumors-- these are typically detected by the patient or doctor before the yearly mammogram rolls around, and they grow so fast that early detection does not really affect the outcome.

-ccm

Yup. I agree.

I have a very high risk woman who goes 100 miles to the center in Oklahoma that does MRI's...but yuppies (Yup, we have a few in Oklahoma) want everything done all the time. So it will cost money. Oh, not THEIR money--they complain "I have to spend $500 a month for health insurance"-- while their car payments are more than that for their brand new SUV.

When the patient comes in wearing more jewels than I own, when her (it's usually women) house costs four times as much as my house, and when her car is new (mine is 11 years old) and then complains of how high medicine is because she wants the new stuff, not the old stuff (and usually wants Retin A for her acne (Actually for the wrinkles-- the acne is a single pimple now and then), Celexa for her "mood swings", and insists on Celbrex when she could take motrin but she watches commercials, gets mad at me for not writing a letter to her insurance company so she can get diet pills (she is 15 pounds overweight) and wants her knees seen by a specialist for minor pain, then complains of the high cost of medical care, I laugh...

re: doctors who diagnose and treat breast cancer are now at even more risk of a lawsuit than obstetricians or neurosurgeons.)))

I've learned this week that Elizabeth Edwards enjoyed the best medical care in bringing about her late-life pregnancies to healthy babies. Considering how many women are having trouble finding OBs thanks to the predation of Eliz's husband...it is a bitter irony. She can afford to access the best that US science can offer because junk science was sold to a jury by her husband. He works hard to keep those abortuaries churning away... very cruel to think about.

From the research I have heard of, the statistics for actual lifespan comparison between those who pursue mammograms and aggressive medical treatment are not that much different from those who simply live their lives and do the best they can with various alternative medicine approaches after finding a tumor.

There is a distinct possibility that the radiation from the mammograms and the physical stress and tissue damage from the high pressure compression to get a clearer picture actually cause more cancer than it cures, but the research is not totally clear at this point.

Even if the mammogram and chemo path did cure a few more than would survive without it, I think there is a distinct possibility that the mammogram and chemo path results in rather poorer life quality overall.

To me the bottom line is that the medical community pushes a path that definitely results in additional harm to some of those in the path, while helping others. The Hippocratic oath states that we are to first do no harm, and the standard medical treatments for almost everything pose a distinct danger for up to 2/3 of all who accept any treatment. Standard procedures for drug testing guarantee some deaths, and most major drugs are effective only on certain genotypes and not others, which the pharmaceutical companies admit to, and they refuse to test for the known genotypes before treating anyone.

Besides, just because I may be a crackpot, it does not mean that I am wrong, at least not on everything. Paranoia is a disease only if "they" are not actually after you. You speak as if there are no conspiracies in the world today, as if no one would endanger others for their own gain or goals. This is false on the face of it.

You seem to be stating that the "alternative medicine" community is selling worthless things to get dying cancer sufferers' money, obviously a widespread conspiracy to discredit the AMA and associated groups, and yet at the same time you are saying there are no widespread conspiracies among the AMA and associated groups to extract money from dying cancer patients because only a crackpot would see a large conspiracy in today's world.

So I guess the conspiracy can only include "the other guys", not the government sponsored and government mandated monopoly on health care. It seems you do believe in conspiracies, just not among the group you have chosen to put your trust and faith in.

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