Preop MRI in Breast Ca Patients Not Helpful


SAN ANTONIO — Preoperative evaluation by breast MRI did not reduce reoperation or mastectomy rates following planned wide local excision for breast cancer in the randomized U.K. COMICE trial.

COMICE (the Comparative Effectiveness of Magnetic Resonance Imaging in Breast Cancer) was a large multicenter technology assessment study undertaken at the request of the U.K. National Health Service, which sought to determine whether preoperative MRI in patients diagnosed with breast cancer is cost effective.

“This was a simple study that asked a very simple question, and here is the answer: There was no reduction in reoperation rates. End of story,” Dr. Phil Drew declared at the San Antonio Breast Cancer Symposium.

COMICE involved 1,623 breast cancer patients who were scheduled at 45 medical centers for wide local excision based upon standard triple assessment by physical exam, mammography, and ultrasound. On a randomized basis, half of them underwent preoperative contrast-enhanced MRI. Unlike prior retrospective studies of the utility of breast MRI for preoperative cancer staging, COMICE was an inclusive study not limited to specialized centers.

The reoperation rate within 6 months was 18.75% in the MRI group and closely similar at 19.33% in controls.

Preoperative MRI led to a change in management from the planned wide local excision to more extensive surgery in 6.1% of patients; however, 28% of these revised operations were found after the fact based upon pathology not to have been necessary, said Dr. Drew of at the University of Hull (England).

Disease-free survival at a median 3.1 years of follow-up was 93.9% in the MRI group and statistically similar at 96.5% in women who did not undergo MRI.

MRI had no net effect upon quality of life as reflected in formal assessment of patient distress. Thirty-four percent of patients found the experience of undergoing MRI to be anxiety provoking, but paradoxically an identical percentage of patients in the control group were anxious that they had not had an MRI.

Dr. Drew opined that the problem with MRI is not the technology itself, but rather the inability of surgeons to effectively translate the imaging information into the operating environment, where the goal is to take out just enough but not too much breast tissue the first time around rather than in two operations.

“I think we're missing something here. We don't really want to look at how we find the tumor, we want to look at how we remove it. We haven't changed how we take tumors out in 50 years,” Dr. Drew said.

In her plenary lecture, Dr. Monica Morrow cited the COMICE findings in a multipronged argument that preoperative MRI is vastly overutilized in breast cancer patients.

“The routine use of MRI in cancer patients requires some evidence of clinical benefit. To date, this does not exist,” said Dr. Morrow, chief of the breast service in the department of surgery at Memorial Sloan-Kettering Cancer Center, New York.

COMICE was funded by the U.K. National Institute of Health Research. Dr. Drew reported having no financial conflicts of interest.

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