11/19/2013
Aaron CarrollWe’ve discussed the potential overuse of mammograms before. We’ve discussed how diagnosis has increased without comparable reductions in mortality. Now we get to talk about mammograms MRIs and breast cancer:
Importance Breast magnetic resonance imaging (MRI) is highly sensitive for detecting breast cancer. Low specificity, cost, and little evidence regarding mortality benefits, however, limit recommendations for its use to high-risk women. How breast MRI is actually used in community settings is unknown.
Objective To describe breast MRI trends and indications in a community setting.
Design, Setting, and Participants Retrospective cohort study at a not-for-profit health plan and multispecialty group medical practice in New England of 10 518 women aged 20 years and older enrolled in the health plan for at least 1 year who had at least 1 breast MRI between January 1, 2000, and December 31, 2011.
Main Outcomes and Measures Breast MRI counts were obtained from claims data. Clinical indication (screening, diagnostic evaluation, staging or treatment, or surveillance) was determined using a prediction model developed from electronic medical records on a subset of participants. Breast cancer risk status was assessed using claims data and, for the subset, also through electronic medical record review.
Results Breast MRI use increased more than 20-fold from 6.5 per 10 000 women in 2000 to 130.7 per 10 000 in 2009. Use then declined and stabilized to 104.8 per 10 000 by 2011. Screening and surveillance, rare indications in 2000, together accounted for 57.6% of MRI use by 2011; 30.1% had a claims-documented personal history and 51.7% a family history of breast cancer, whereas 3.5% of women had a documented genetic mutation. In the subset of women with electronic medical records who received screening or surveillance MRIs, only 21.0% had evidence of meeting American Cancer Society (ACS) criteria for breast MRI. Conversely, only 48.4% of women with documented deleterious genetic mutations received breast MRI screening.
No one is disputing that MRI is a sensitive test for breast cancer. What many dispute is its cost-effectiveness. That hasn’t stopped its use from increasing by more than 2000% percent from 2000-2011.
Here’s the bottom line: most of the women who were screened for breast cancer by MRI didn’t have documentation warranting it. Many more women who did have a genetic mutation who might have benefitted from MRI screening didn’t get it.
Best in the world?
UPDATE: Edited cause I was tired last night.
by Zach the MRI Tech on November 19th, 2013 at 07:58
Sure, only a fifth of women in this study met ACS criteria for breast MR. However that narrow focus neglects criteria from other professional societies like the American College of Radiology who has its own, albeit similar, criteria for breast MR use. Moreover, I think you are too quick to judge our healthcare delivery system on this one. More research needs done as to why those with mutations didn’t receive appropriate MRI screening. There are myriad scenarios as to why this number is low, beyond system failure (e.g. MRI is not an inclusive test and the amount of devices and implants that contraindicate MRI examination is staggering). And not just that, but why did MRI use increase so drastically (I’m looking at you, Dr. Oz, and your idiotic mammos cause thyroid cancer episode)? Or more likely, improved access as a result of higher availability of MRI coupled with growing consumerism and patient ‘education’ (thanks, internet) lead the push.
by robert aylward on November 19th, 2013 at 08:25
Left unstated is the reason for the disconnect between ACS criteria and MRI testing, which I would assume is attributable to the availability of reimbursement (or patient willingness to self-pay) but I don’t know. Colonoscopy is another cancer test that has increased exponentially in the past ten years, which I attribute to two factors: (1) it’s availability and acceptance and (2) insurers’ increased willingness to reimburse. I have worked on the development of many endoscopy centers over the past 15 years, and factor (2) is highly relevant. Ten plus years ago, insurers resisted reimbursement except in extraordinary cases, such as history of colon cancer in the family; indeed, the GI’s staff had to be proactive in seeking approval from the insurer. In the intervening years, insurers have relaxed the requirements to include history of most any cancer in the family as long as the patient is at least age 50. Of course, unlike MRI, colonoscopy is invasive and has significant risks. My point isn’t to defend or criticize the increased use of colonoscopy, or MRI screening for that matter, but to emphasize the importance of third party reimbursement in deciding whether to screen. Should reimbursement be such an important factor, maybe the most important factor?
by dbh on November 19th, 2013 at 09:17
Well, to use this to interpret “best in the world” one would have to compare the rates and indications for breast MR in the US to those elsewhere. For something like this, you would also need to pick criteria. You imply that the criterion should be “utilization that best matches ACS guidelines for breast MRI”. I can imagine patients might say the criterion should be “best health outcomes”.
Of course, for an international comparison of the US to the world, one would need data beyond one region of New England from one plan.
More seriously, is “best conforms to the ACS guidelines” a good criterion? As we have seen from the AHA and ACC, guidelines take a long time to develop, they of necessity use old data even when the drugs (statins) or technology (MRI) progress rapidly. There are always questions about applicability outside of the populations that generated the data, and the goals of the treatment or diagnostic test.
For something like this, where it seems no one knows the “correct” indications for breast MRI, it would be exceedingly difficult to know whether any of the utilization rates noted in the study were correct. The optimal rate may have changed during the course of the study as the availability and capabilities of breast MR and digital tomosynthesis evolved.
I suggest a patient would want a breast MRI if having one would lead to a longer healthier life. Since no one knows what rate of breast MRI utilization would produce that outcome, no one knows whether breast MRI was used too much, too little or just right in those subjects during the time of this study.
If one were to do the study again based on 2012 and 2013 data, the rates might very well have changed again. Unless we know the right answer, we cannot grade performance with this utilization metric.
From an economic perspective, one might hope that a study whose best rate of utilization is unknown might not increase as rapidly as breast MRI has. However, remember that “we don’t know the correct rate” is not the same thing as “the correct rate is zero”. It means precisely that we don’t know. It is possible the physicians collectively were using breast MRI appropriately, but it may take years to find out.
by Steve on November 19th, 2013 at 09:35
You draw wrong conclusions with the screening conclusion statement. Breast MRI in breast cancer pts. change treatment plans 20% of e time increasing survival and decreasing morbidity. Divide cancer positive patients from non cancer patients. HUGE difference. I am a community based radiologist, we do very few screening breast mRi’s. I see many more pts who would benefit but insurance denies.
by Floccina on November 19th, 2013 at 12:49
Best in the world?
If care in the USA is not the best, maybe much more skin in the game would lead to more of this:
About 90 percent said they felt the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent. A few more rated the care excellent in the United States than in Mexico care, but, in addition, more people rated the care poor in the United States than in Mexico. ‘Disgrace at the Border’
I wonder if the states on the border allow insurance companies to force their enrolled to go south of the border?
Dean Baker also has some interesting ideas on this:
This gap suggests one obvious way to deal with this projected explosion of healthcare costs. If our political system is too corrupt to allow for meaningful healthcare reform in the United States, why not just let people get their healthcare from systems that work?
This actually would not be as hard to implement as it may first appear. The major government healthcare program is Medicare, which primarily serves a population of retirees. (Medicaid expenditures also disproportionately go the elderly.) Suppose that Medicare beneficiaries were given a voucher that allowed them to buy into the healthcare systems of other countries. (A simple quality control mechanism would be a requirement that the country must have a longer life expectancy than the United States.)