Women with a much-higher-than-average risk of breast cancer usually follow an aggressive breast cancer screening plan. Women at very high risk could have an abnormal breast cancer gene (BRCA1 or BRCA2), a very strong family history of breast cancer, or a personal history of breast cancer.
Breast MRI (magnetic resonance imaging), along with mammogram and breast ultrasound, often are recommended as part of an aggressive screening plan. Other research has shown the value of screening with breast MRI for high-risk women. This is especially true for young women with dense breasts because screening mammograms may be less effective at identifying early-stage cancer in dense breasts.
The study reviewed here found many women at high-risk for breast cancer for whom MRI screening was recommended refused to have breast MRI. The researchers were surprised that so many women refused and wanted to know why. These results were presented at the 2009 San Antonio Breast Cancer Symposium.
In another study looking at breast cancer screening in high-risk women (which included breast MRI), more than 42% of the women (512 out of 1,215) refused to have breast MRI. The 512 women gave the following reasons for refusing breast MRI:
Still, breast MRI is expensive. Even with insurance, out-of-pocket costs can be high. People without insurance coverage for breast MRI may view the cost of breast MRI as out of their reach.
Other reasons for refusing breast MRI were:
The reasons the women gave for not getting an MRI are understandable. Still, other research has clearly shown that frequent breast cancer screening using multiple techniques -- mammograms, ultrasounds, and MRIs -- is the best approach for high-risk women to ensure that if breast cancer develops, the cancer is found at an early, more treatable stage.
If an aggressive breast cancer screening plan is recommended to you, you may have concerns similar to the women in this study. Still, your screening plan is about keeping you healthy, so you may want to consider these points:
Many women at elevated breast cancer risk may refuse MRI as part of their screening program, largely because of fear and inconvenience, researchers found.
Among eligible women with dense breasts who were at intermediate to high risk for breast cancer, 42.1% refused additional MRI screening as part of a clinical trial of mammography and ultrasound screening.
Claustrophobia was by far the top reason given for turning down MRI screening, cited by 25.4% of women approached, according Wendie A. Berg, MD, PhD, of Johns Hopkins, and colleagues.
Travel and time required accounted for another 20% of rejections, they wrote in the January 2010 issue of Radiology.
These results suggested that patient acceptance has been overestimated for breast MRI screening, Berg's group said.
The reasons cited weren't unexpected, but the number who elected not to participate in MRI screening was "much higher than I would have thought," commented Edith Perez, MD, of the Mayo Clinic in Jacksonville, Fla., who wasn't involved in the trial.
Gary Lyman, MD, MPH, of Duke University, agreed that the number who refused was somewhat higher than expected from his clinical experience.
But understanding the hurdles to acceptance may help physicians tailor how they counsel elevated-risk women, he said.
"The bottom line is if women are not getting a succinct, strong recommendation from their primary care physician or surgeon -- depending on who is recommending it -- there's a multitude of possible excuses," Lyman said in an interview.
"They might be willing to overcome these if they felt it absolutely necessary, but if they don't get that message from physicians, they could easily find reasons not to do it."
High-risk women, such as those with risk-associated BRCA mutations, often enter screening programs at age 25 to 30, when breast tissue is more dense and thus less effectively screened by mammography, the researchers noted.
The American Cancer Society recommends annual MRI in addition to mammography for the high-risk group, although whether the supplemental screening is warranted is still debated for intermediate-risk women.
For average-risk women, the controversial U.S Preventive Services Task Force recommendations that recently suggested no routine screening before age 50 also said there's not enough evidence upon which to use MRI for this population at any age.
Berg's study -- ACRIN 6666 -- had previously shown improved diagnostic yield from adding MRI to mammography and ultrasound, with an absolute 56% increase in cancer detection over the two together.
All participants had at least heterogeneously dense breasts and at least intermediate risk of breast cancer.
But the researchers said they were surprised to find that only 703 of the 1,215 eligible women (57.9%) accepted when offered MRI in this substudy within the larger trial.
So Berg's group delved into the reasons for the poor acceptance rate.
As might have been expected, women with the highest lifetime risk -- 25% or greater risk by the Gail or Claus model -- were more likely to accept MRI screening (OR 1.55, 95% CI 1.12 to 2.15).
At most centers, women were told that their insurance would be billed and that the study would cover any costs related to MRI that insurance didn't cover. At other sites where insurance couldn't be billed, the study covered all MRI screening costs.
So, although cost shouldn't have been a factor, "financial concerns" was the third most common reason cited by women (12.1%) to turned down the screening.
Other reasons given for declining MRI screening were:
One reason some physicians may have been unwilling to accept or suggest MRI for their patients may have been that only 20% of the study population fell within the American Cancer Society criteria for high risk, and thus under recommendations for MRI screening, the researchers noted.
For women who are claustrophobic or otherwise unwilling to have MRI screening, Berg's group recommended supplementing mammography with ultrasound instead.
But these women should be "informed of the high risk of false-positive results with ultrasound screening and the reduced sensitivity for cancer detection compared with the risks of false-positive results and the sensitivity of MR imaging," they wrote.
The study was supported by a grant from the Avon Foundation and grants from the National Cancer Institute.
Berg reported being a consultant to Naviscan and receiving equipment support from Siemens and MediPattern.
Coauthors reported conflicts of interest with GE Medical Systems, Siemens, Philips Ultrasound, Sectra, Konica Minolta, Hologic, Johnson & Johnson, SenoRx, MediPattern, Toshiba Ultrasound, and SuperSonic Imagine.
Lyman reported no relevant disclosures.
Perez has reported serving on the steering committee for sorafenib (Nexavar) and for a Genetech trial and serving on an independent monitoring committe for Novartis, all without direct funding from the companies.
Primary source: Radiology Source reference: Berg WA, et al "Reasons Women at Elevated Risk of Breast Cancer Refuse Breast MR Imaging Screening: ACRIN 6666" Radiology 2010; 254: 79-87.
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