Costs of diagnostic and preoperative workup with and without breast MRI in older women with a breast cancer diagnosis

The Canadian Breast Cancer Symposium 2023 Meeting Report

On 15-16 June 2023, healthcare professionals and breast cancer patients and advocates from across Canada met in Toronto, Ontario, for the 2023 Canadian Breast Cancer Symposium (CBSC.). The CBSC. is a national, multidisciplinary event that occurs every 2 years with the goal of developing a personalized approach to the management of breast cancer in Canada. Experts provided state-of-the-art information to help optimally manage breast cancer patients, including etiology, prevention, diagnosis, experimental biology, and therapy of breast cancer and premalignant breast disease. The symposium also had the objectives of increasing communication and collaboration among breast cancer healthcare providers nationwide and providing a comprehensive and real-life review of the many facets of breast cancer. The sessions covered the patient voice, the top breast cancer papers from different disciplines in 2022, artificial intelligence in breast cancer, systemic therapy updates, the management of central nervous system metastases, multidisciplinary management of ductal carcinoma in situ, special populations, optimization-based individual prognostic factors, toxicity management of novel therapeutics, survivorship, and updates in surgical oncology. The key takeaways of these sessions have been summarized in this conference report.

Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial

BACKGROUND

The aim of this study was to compare the clinical outcomes between breast cancer patients who underwent axillary lymph node dissection with postoperative management using a polyethylene glycol-coated patch versus axillary drainage. The direct costs associated with both postoperative management strategies were also evaluated.

METHODS

This was a multicentre RCT in women with breast cancer who underwent axillary lymph node dissection (ClinicalTrials.gov identifier: NCT04487561). Patients were randomly assigned (1 : 1) to receive either drainage or a polyethylene glycol-coated patch as postoperative management. The primary endpoints were the need for an emergency department visit for any event related to the surgery and the rate of seroma development.

RESULTS

A total of 227 patients were included , 115 in the patch group (50.7 per cent) and 112 (29.4 per cent ) in the drainage group. The incidence of emergency department visits was significantly greater for patients with drainage versus a polyethylene glycol-coated patch (incidence rate difference 26.1 per cent, 95 per cent c.i. 14.5 to 37.7 per cent; P < 0.001). Conversely, the seroma rate was significantly higher in the polyethylene glycol-coated patch group (incidence rate difference 22.8 per cent, 95 per cent c.i. 6.7 to 38.9 per cent; P < 0.0055). Compared with drainage, using a polyethylene glycol-coated patch resulted in cost savings of €100.41 per patient. An incremental cost-effectiveness ratio analysis found that drainage was associated with an incremental cost-effectiveness ratio of €7594.4 for no need for hospital admission and €491.7 for no need for an emergency department visit.

CONCLUSION

Compared with patients who received drainage after axillary lymph node dissection, the use of a polyethylene glycol-coated patch resulted in a higher rate of seroma, but a lower number of postoperative outpatient or emergency department visits and thus a reduction in overall costs.

Predicting the response to neoadjuvant chemotherapy. Can the addition of tomosynthesis improve the accuracy of contrast-enhanced spectral mammography? A comparison with breast MRI

OBJECTIVES

Image monitoring is essential to monitor response to neoadjuvant chemotherapy (NACT). Whilst breast MRI is the gold-standard technique, evidence suggests contrast-enhanced spectral mammography (CESM) is comparable. We investigate whether the addition of digital breast tomosynthesis (DBT) to CESM increases the accuracy of response prediction.

METHODS

Women receiving NACT for breast cancer were included. Imaging with CESM+DBT and MRI was performed post-NACT. Imaging appearance was compared with pathological specimens. Accuracy for predicting pathological complete response (pCR) and concordance with size of residual disease was calculated.

RESULTS

Sixteen cancers in 14 patients were included, 10 demonstrated pCR. Greatest accuracy for predicting pCR was with CESM enhancement (accuracy: 81.3%, sensitivity: 100%, specificity: 57.1%), followed by MRI (accuracy: 62.5%, sensitivity: 44.4%, specificity: 85.7%). Concordance with invasive tumour size was greater for CESM enhancement than MRI, concordance-coefficients 0.70 vs 0.66 respectively. MRI demonstrated greatest concordance with whole tumour size followed by CESM+microcalcification, concordance coefficients 0.86 vs 0.69. DBT did not improve accuracy for prediction of pCR or residual disease size. CESM+DBT underestimated size of residual disease, MRI overestimated but no significant differences were seen (p>0.05).

CONCLUSIONS

CESM is similar to MRI for predicting residual disease post-NACT. Size of enhancement alone demonstrates best concordance with invasive disease. Inclusion of residual microcalcification improves concordance with ductal carcinoma in situ. The addition of DBT to CESM does not improve accuracy.

ADVANCES IN KNOWLEDGE

The addition ofDBT to CESM does not improve NACT response prediction.CESM enhancement has greatest accuracy for residual invasive disease, CESM+calcification has greater accuracy for residual in situ disease.

Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density

PURPOSE

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer.

METHODS

We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density.

RESULTS

Survey participation rate was 27.9% (957/3430). Study population was primarily > 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome.

CONCLUSIONS AND RELEVANCE

Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03029286.

Contrast-enhanced digital breast tomosythesis and breast MRI to monitor response to neoadjuvant chemotherapy: patient tolerance and preference

OBJECTIVE

Contrast-enhanced digital breast tomosynthesis (CE-DBT) is a novel imaging technique, combining contrast-enhanced spectral mammography and tomosynthesis. This may offer an alternative imaging technique to breast MRI for monitoring of response to neoadjuvant chemotherapy. This paper addresses patient experience and preference regarding the two techniques.

METHODS

Conducted as part of a prospective pilot study; patients were asked to complete questionnaires pertaining to their experience of CE-DBT and MRI following pre-treatment and end-of-treatment imaging. Questionnaires consisted of eight questions answered on a categorical scale, two using a visual analogue scale (VAS), and a question to indicate preference of imaging technique. Statistical analysis was performed with Wilcoxon signed rank test and McNemar test for related samples using SPSS v. 25.

RESULTS

18 patients were enrolled in the pilot study. Matched CE-DBT and MRI questionnaires were completed after 22 patient episodes. Patient preference was indicated after 31 patient episodes. Overall, on 77% of occasions patients preferred CE-DBT with no difference between pre-treatment and end-of-treatment imaging. Overall experience (p = 0.008), non-breast pain (p = 0.046), anxiety measured using VAS (p = 0.003), and feeling of being put at ease by staff (p = 0.023) was better for CE-DBT. However, more breast pain was experienced during CE-DBT when measured on both VAS (p = 0.011) and categorical scale (p = 0.021).

CONCLUSION

Our paper suggests that patients prefer CE-DBT to MRI, adding further evidence in favour of contrast-enhanced mammographic techniques.

ADVANCES IN KNOWLEDGE

Contrast mammographic techniques offer an alternative, more accessible imaging technique to breast MRI. Whilst other studies have addressed patient experience of contrast-enhanced spectral mammography, this is the first study to directly explore patient preference for CE-DBT over MRI in the setting of neoadjuvant chemotherapy, finding that overall, patients preferred CE-DBT despite the relatively long breast compression.

An Online Calculator for Estimating Breast Implant Volume from Imaging

Breast implant surgery remains one of the most common surgical procedures performed in the United States. Implant exchange can be complicated by unavailability of medical records or implant identification cards. Using chest imaging of 154 breast implants, an algorithm for estimating breast implant volume was generated. Based on four simple measurements and patient body mass index, a free, online calculator was created with a mean error of volume estimate of less than 1 cm3 and a SD of 44 cm3. In instances where a surgeon does not have implant records available but has chest imaging, this online tool can be used to obtain a relatively accurate estimate of implant volume.

Preoperative breast magnetic resonance imaging in patients with ductal carcinoma in situ: a systematic review for the European Commission Initiative on Breast Cancer (ECIBC)

Objective

To evaluate the impact of preoperative MRI in the management of Ductal carcinoma in situ (DCIS).

Methods

We searched the PubMed, EMBASE and Cochrane Library databases to identify randomised clinical trials (RCTs) or cohort studies assessing the impact of preoperative breast MRI in surgical outcomes, treatment change or loco-regional recurrence. We provided pooled estimates for odds ratios (OR), relative risks (RR) and proportions and assessed the certainty of the evidence using the GRADE approach.

Results

We included 3 RCTs and 23 observational cohorts, corresponding to 20,415 patients. For initial breast-conserving surgery (BCS), the RCTs showed that MRI may result in little to no difference (RR 0.95, 95% CI 0.90 to 1.00) (low certainty); observational studies showed that MRI may have no difference in the odds of re-operation after BCS (OR 0.96; 95% CI 0.36 to 2.61) (low certainty); and uncertain evidence from RCTs suggests little to no difference with respect to total mastectomy rate (RR 0.91; 95% CI 0.65 to 1.27) (very low certainty). We also found that MRI may change the initial treatment plans in 17% (95% CI 12 to 24%) of cases, but with little to no effect on locoregional recurrence (aHR = 1.18; 95% CI 0.79 to 1.76) (very low certainty).

Conclusion

We found evidence of low to very low certainty which may suggest there is no improvement of surgical outcomes with pre-operative MRI assessment of women with DCIS lesions. There is a need for large rigorously conducted RCTs to evaluate the role of preoperative MRI in this population.

Key Points

• Evidence of low to very low certainty may suggest there is no improvement in surgical outcomes with pre-operative MRI.

• There is a need for large rigorously conducted RCTs evaluating the role of preoperative MRI to improve treatment planning for DCIS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07873-2.

The role of breast MRI in newly diagnosed breast cancer: An evidence-based review

The utility of pre-operative MRI in patients with newly diagnosed invasive breast cancer remains a topic of debate. Those who advocate for pre-treatment imaging contend that MRI may detect additional disease not otherwise appreciated on conventional imaging and may provide more accurate staging information to guide treatment. Additionally, it has been proposed that MRI can be utilized to assess extent of residual disease in patients undergoing neoadjuvant chemotherapy. Conversely, those in opposition maintain that routine pre-operative MRI subjects patients to unnecessary ipsilateral mastectomies and prophylactic contralateral mastectomies with no difference in oncologic outcome. When stratified based on tumor biology and patient characteristics, the data suggests that pre-treatment MRI may be advantageous in certain subsets when compared to the general cohort of breast cancer patients. This review recapitulates the current literature on the impact of breast MRI on the surgical management and outcomes of newly diagnosed breast cancer.

Fully Automated Support System for Diagnosis of Breast Cancer in Contrast-Enhanced Spectral Mammography Images

Contrast-Enhanced Spectral Mammography (CESM) is a novelty instrumentation for diagnosing of breast cancer, but it can still be considered operator dependent. In this paper, we proposed a fully automatic system as a diagnostic support tool for the clinicians. For each Region Of Interest (ROI), a features set was extracted from low-energy and recombined images by using different techniques. A Random Forest classifier was trained on a selected subset of significant features by a sequential feature selection algorithm. The proposed Computer-Automated Diagnosis system is tested on 48 ROIs extracted from 53 patients referred to Istituto Tumori “Giovanni Paolo II” of Bari (Italy) from the breast cancer screening phase between March 2017 and June 2018. The present method resulted highly performing in the prediction of benign/malignant ROIs with median values of sensitivity and specificity of 87.5% and 91.7%, respectively. The performance was high compared to the state-of-the-art, even with a moderate/marked level of parenchymal background. Our classification model outperformed the human reader, by increasing the specificity over 8%. Therefore, our system could represent a valid support tool for radiologists for interpreting CESM images, both reducing the false positive rate and limiting biopsies and surgeries.

Magnetic resonance imaging for invasive lobular carcinoma: is it worth it?

Background

Invasive lobular cancer (ILC) of the breast can provide diagnostic and therapeutic challenges due to its often mammographically occult and multifocal nature. UK guidelines recommend magnetic resonance imaging (MRI) when considering breast conserving surgery (BCS) in women with a diagnosis of ILC. A small number of studies have shown that due to its low specificity, MRI can lead to additional invasive investigations whilst rarely identifying additional tumour foci that affect management. We carried out a retrospective study of patients diagnosed with ILC to assess the impact of MRI on management and to evaluate if breast density on mammography could indicate likelihood of additional disease being found on MRI.

Methods

A retrospective analysis of the electronic patient records for all cases of ILC diagnosed between January 2013 and December 2016 was carried out.

Results

A total of 110 cases of ILC were identified of which 69 women were considered for BCS and 58 (84.1%) women underwent MRI. A further abnormality was seen in 22 (37.9%) patients of whom 13 (59.1%) had a further core biopsy with 4 cases being positive for malignancy. Overall MRI changed the surgical plan from BCS to mastectomy in 7 (10.1%). Breast density did not predict the presence of additional findings on MRI.

Conclusions

MRI assessment of ILC rarely affects the management when BCS is considered. Having radiologically denser breasts did not correlate with increased reoperation rate. Larger prospective studies may provide further guidance on MRI specificity and breast density.

Can we predict lesion detection rates in second-look ultrasound of MRI-detected breast lesions? A systematic analysis

PURPOSE

To predict detection rates (DR) in second-look ultrasound of MRI-detected breast lesions by systematically combining clinical and anthropomorphic features.

METHODS

A total of 104 suspicious breast-lesions, that were initially detected on breast MRI and underwent subsequent SLU from January 2013 through December 2013, were evaluated in this retrospective analysis. All images were reviewed by an experienced radiologist for this study. Both anthropomorphic, spatial and BI-RADS lesion features were recorded. Uni- and multivariate Classification and Regression Trees (CRT) statistics were used to predict SLU DR by these features.

RESULTS

Among 104 MRI-detected lesions, 58 (55.8%) showed a correlate on SLU. In univariate analysis, homogeneous fatty or dense fibro-glandular-tissue-composition (FGT) as assessed by ultrasound, segmental non-mass-distribution pattern and small breast size as assessed by MRI were significantly associated with higher DR on SLU. The remaining BI-RADS features did not significantly affect SLU DR according to our data. The predictive model could stratify the likelihood of SLU correlates as high, intermediate and low according to FGT, lesion type, size and position.

CONCLUSIONS

By systematically combining the features FGT, lesion type, size and position, we could predict SLU DR of MRI-detected breast lesions. This may help to decide the preferable method for lesion biopsy or follow-up in clinical practice.

Surgeon peer network characteristics and adoption of new imaging techniques in breast cancer: A study of perioperative MRI

Background

Perioperative MRI has disseminated into breast cancer practice despite equivocal evidence. We used a novel social network approach to assess the relationship between the characteristics of surgeons’ patient‐sharing networks and subsequent use of MRI.

Methods

We identified a cohort of female patients with stage 0‐III breast cancer from the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database. We used claims data from these patients and non‐cancer patients from the 5% Medicare sample to identify peer groups of physicians who shared patients during 2004‐2006 (T1). We used a multivariable hierarchical model to identify peer group characteristics associated with uptake of MRI in T2 (2007‐2009) by surgeons who had not used MRI in T1.

Results

Our T1 sample included 15 149 patients with breast cancer, treated by 2439 surgeons in 390 physician groups. During T1, 9.1% of patients received an MRI; the use of MRI varied from 0% to 100% (IQR 0%, 8.5%) across peer groups. After adjusting for clinical characteristics, patients treated by surgeons in groups with a higher proportion of primary care physicians (PCPs) in T1 were less likely to receive MRI in T2 (OR = 0.81 for 10% increase in PCPs, 95% CI = 0.71, 0.93). Surgeon transitivity (ie, clustering of surgeons) was significantly associated with MRI receipt (P = 0.013); patients whose surgeons were in groups with higher transitivity in T1 were more likely to receive MRI in T2 (OR = 1.29 for 10% increase in clustering, 95% CI = 1.06, 1.58).

Conclusion

The characteristics of a surgeon's peer network are associated with their patients’ subsequent receipt of perioperative MRI.

Preoperative breast MRI and mortality in older women with breast cancer

PURPOSE

The survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial.

METHODS

We followed a cohort of 4454 women diagnosed with non-metastatic breast cancer (stage I-III) from 2/2005-6/2010 in five registries of the breast cancer surveillance consortium (BCSC). BCSC clinical and registry data were linked to Medicare claims and enrollment data. We estimated the cumulative probability of breast cancer-specific and all-cause mortality. We tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model.

RESULTS

917 (20.6%) women underwent preoperative MRI. No significant difference in the cumulative probability of breast cancer-specific mortality was found. We observed no significant difference in the hazard of all-cause mortality during the follow-up period after adjusting for sociodemographic and clinical factors among women with MRI (HR 0.90; 95% CI 0.72-1.12) compared to those without MRI.

CONCLUSION

Our findings of no breast cancer-specific or all-cause mortality benefit supplement prior results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the results of this analysis highlight the importance of exploring the benefit of preoperative MRI in patient-reported outcomes such as women's decision quality and confidence levels with decisions involving treatment choices.

Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer

BACKGROUND

Although there is no consensus on whether pre-operative MRI in women with breast cancer (BC) benefits surgical treatment, MRI continues to be used pre-operatively in practice. This meta-analysis examines the association between pre-operative MRI and surgical outcomes in BC.

METHODS

A systematic review was performed to identify studies reporting quantitative data on pre-operative MRI and surgical outcomes (without restriction by type of surgery received or type of BC) and using a controlled design. Random-effects logistic regression calculated the pooled odds ratio (OR) for each surgical outcome (MRI vs. no-MRI groups), and estimated ORs stratified by study-level age. Subgroup analysis was performed for invasive lobular cancer (ILC).

RESULTS

Nineteen studies met eligibility criteria: 3 RCTs and 16 comparative studies that included newly diagnosed BC of any type except for three studies restricted to ILC. Primary analysis (85,975 subjects) showed that pre-operative MRI was associated with increased odds of receiving mastectomy [OR 1.39 (1.23, 1.57); p < 0.001]; similar findings were shown in analyses stratified by study-level median age. Secondary analyses did not find statistical evidence of an effect of MRI on the rates of re-excision, re-operation, or positive margins; however, MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy [OR 1.91 (1.25, 2.91); p = 0.003]. Subgroup analysis for ILC did not find any association between MRI and the odds of receiving mastectomy [OR 1.00 (0.75, 1.33); p = 0.988] or the odds of re-excision [OR 0.65 (0.35, 1.24); p = 0.192].

CONCLUSIONS

Pre-operative MRI is associated with increased odds of receiving ipsilateral mastectomy and contralateral prophylactic mastectomy as surgical treatment in newly diagnosed BC patients.

Surgeon Attitudes and Use of MRI in Patients Newly Diagnosed with Breast Cancer

BACKGROUND

Usage of magnetic resonance imaging (MRI) in newly diagnosed breast cancer patients is increasing, despite scant evidence that it improves outcomes. Little is known about the knowledge, perspectives, and clinical characteristics of surgeons associated with MRI use.

METHODS

Women with early-stage breast cancer undergoing definitive surgery between July 2013 and August 2015 were identified from the Los Angeles and Georgia Surveillance, Epidemiology and End Results (SEER) registries and were asked to name their attending surgeons. The 489 surgeons were sent a questionnaire; 77% (n = 377) responded. Questions that addressed the likelihood of ordering an MRI in different scenarios were used to create a scale to measure surgeon propensity for MRI use. Knowledge and practice characteristics also were assessed.

RESULTS

Mean surgeon age was 54 years, 25% were female, and median number of years in practice was 21. Wide MRI use variation was observed, with 26% obtaining MRI for a clinical stage I screen-detected breast cancer and 72% for infiltrating lobular cancer. High users of MRI were significantly more likely to be higher-volume surgeons (p < 0.001) and to have misconceptions about MRI benefits (p < 0.001). Of surgeons who felt they used MRI more often, 60% were high MRI users; only 6% were low MRI users.

CONCLUSIONS

Our findings suggest relatively frequent use of MRI, even in uncomplicated clinical scenarios, in the absence of evidence of benefit, and use was more common among high-volume surgeons. A substantial number of surgeons who are high MRI users harbor misconceptions about MRI benefit, suggesting an opportunity for education and consensus building regarding appropriate use.

G9A performs important roles in the progression of breast cancer through upregulating its targets

Breast cancer (BC) is the most common type of malignancy in females worldwide, however, its underlying mechanisms remain poorly understood. The present study aimed to investigate the mechanisms behind the development and progression of BC and identify potential biomarkers for it. The chromatin immunoprecipitation-DNA sequencing (ChIP-Seq) dataset GSM1642516 and gene expression dataset GSE34925 were downloaded from the Gene Expression Omnibus database. Affy and oligo packages were used for the background correction and normalization of the gene expression dataset. Based on Limma package and the criteria of a fold change >1.41 or <0.71, and a false discovery rate adjusted P-value <0.05, differentially-expressed genes (DEGs) in euchromatic histone lysine methyltransferase 2 (G9A) -knockout (KO) breast samples compared with control samples were identified. The Database for Annotation, Visualization and Integrated Analysis was used for the functional enrichment analysis of the DEGs. Bowtie 2 and model-based analysis of ChIP-Seq version 14 (macs14) were used for the mapping of raw reads and the identification of G9A binding sites (peaks), respectively. In addition, overlapping genes between the DEGs and genes in the peaks located in −3000 to 3000 bp centered in the transcription start sites (conpeaks) were screened out and microRNAs (miRNAs) believed to regulate those overlaps were identified through the TargetScan database. A total of 217 DEGs were identified in G9A-KO samples, which were mainly involved in the biological processes and pathways associated with the inflammatory response and cancer progression. A total of 10,422 peaks, containing 1,210 conpeaks involving 1,138 genes, were identified. Among the 1,138 genes, 15 were overlapped with the DEGs, and 35 miRNAs were identified to regulate those overlaps. Insulin-induced gene 1 was regulated by 9 genes in the miRNA-gene regulation network, which may indicate its importance in the progression of BC. The present study identified potential biomarkers of BC that may be useful in the diagnosis and treatment of patients with the disease.