IRA FLATOW, host:
You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.
For the rest of the hour we'll take a look at some new guidelines for breast cancer screening, guidelines announced this week. The American Cancer Society is recommending now that some women at high-risk for the disease get regular breast MRIs. Breast MRIs in addition, not in place of, in addition to routine mammograms.
Who falls into that high-risk category, and who shouldn't get the test? And what exactly do MRIs detect that mammograms don't and vice versa?
Joining us now to talk about the new guidelines and to answer some of these questions is a member of the committee that made those recommendations to the American Cancer Society. Dr. Elizabeth Morris is director of the breast MRI at Memorial Sloan-Kettering Cancer Center in New York. She joins today by phone from her office. Welcome to the program, Dr. Morris.
Dr. ELIZABETH MORRIS (Memorial Sloan-Kettering Cancer Center): Thank you, Ira. It's good to be here.
FLATOW: There must be a lot of interest in this this week, I imagine.
Dr. MORRIS: There is huge amount of interest. And I've been personally just very happy with the degree of coverage that this has received because we've known for many years that MRI can really add something to mammography for especially high-risk women.
FLATOW: Give us a little bit - let's go right into the guidelines. Who are high-risk? Who should get the MRIs with the mammograms and who shouldn't?
Dr. MORRIS: Well, I think the most high-risk of all are those women who carry the BRCA gene. And that's actually very few of the women, it's really only one to two percent of women overall. And it only represents a small percent of our breast cancer that we diagnose. But they are very high-risk. They have approximately a 50 to 75 percent chance of developing breast cancer. So for those women, they should be having routine yearly MRI examinations in addition to mammography.
FLATOW: Now what's the danger of not - why not just get the routine MRIs?
Dr. MORRIS: Well, there's a downside, as with any screening tests. You can have false positive findings that are basically findings that are benign but you have to do a biopsy to figure that out. So many women who have the test may undergo unnecessary biopsies.
FLATOW: 1-800-989-8255 if you'd like to talk about these screenings and these tests. And as always when we talk about issues in medicine, I can't ask our guest, I can't ask Dr. Morris to personally prescribe for you what you can do because it's not ethical for her. She doesn't - you're not her patient. She can't talk to you, so we'll try to talk about it in generalities. 1-800-989-8255.
Who else is high-risk besides those women with the genes?
Dr. MORRIS: Well, women who have a strong family history of breast cancer or ovarian cancer. That is, patients who have maybe one or two relatives who have had breast cancer or ovarian cancers, say, an aunt, a sister, a mother, that sort of relative.
Also patients who have been treated for Hodgkin's disease and had radiation to their mediastinum, which is the center of their chest. They are at high-risk as well. So they would be recommended to have screening annual MRI in addition to mammography.
FLATOW: 1-800-989-8255. Barbara in San Francisco welcome to SCIENCE FRIDAY.
BARBARA (Caller): Thank you. And I actually have a comment and a question. My question is, Dr. Morris, you just said if somebody has one or two relatives, first-degree relatives you might be at high-risk. Did you really mean to say that? If a person has a mother who had breast cancer at 75, that doesn't necessarily put her at high-risk for these guidelines, does it?
Dr. MORRIS: No. It's usually - and that's why it's really important for women to talk to their referring physician in order to figure out how high-risk they really are. Because it's usually - actually you need two or more first-degree relatives in order to be considered high-risk.
And it's usually for those women who have had a relative who have had premenopausal breast cancer or breast cancer in the perimenopausal years.
BARBARA: Thanks. My comment is: the American Cancer Society's guidelines seem to be way ahead of our ability as a society to deal with them. As the guidelines themselves point out and as some of the news articles about it have pointed out, there are not enough radiologists in the world who know how to read a breast MRI. There are not enough places where women can actually get them.
Mostly urban centers, they might be able to get a breast MRI. But if you live in the middle of nowhere it's going to be very hard to do. So I'm wondering why the American Cancer Society is recommending something that is not really as a social matter available yet.
Dr. MORRIS: I think you're making an absolutely excellent point. And that has been of concern, I think, to the American Cancer Society and especially when we are drafting up these guidelines. But the evidence has really come to the fore, and we really felt that we have to share this with women and give them the information.
Things are really rapidly progressing in the radiology community. Breast MRI examinations have tremendously improved just over the last three to five years, and all bets are that they will keep improving in the future. So there is definitely an issue about access. I agree with you completely. But these guidelines need to get out there first, and then the ACS is sort of pulling along the radiology community, the insurers, to say, hey, we need to do this test.
FLATOW: So thank you very much, Barbara, for calling.
BARBARA (Caller): Thanks, Ira.
FLATOW: So these tests are, what, $1,000, $2,000 each, the MRI tests?
Dr. MORRIS: Yeah, they are.
FLATOW: And so the - and insurance is not covering them then?
Dr. MORRIS: Actually, most insurers are covering them for high-risk patients.
FLATOW: And they decide what a high-risk patient is?
Dr. MORRIS: You usually have to get pre-certification, and most - and at least - depends on the area of the country, but at least on the coasts, most of these examinations are being covered.
FLATOW: So fly to the coasts.
Dr. MORRIS: I guess, yeah.
FLATOW: Because it'll be a lot cheaper. Get JetBlue and go somewhere, and get a…
Dr. MORRIS: Right, right.
(Soundbite of laughter)
FLATOW: Do we have to do medicine like this? Is this how medicine is going to be done?
Dr. MORRIS: No, I don't think so. I mean, I think that there are many quality centers, obviously, in the Midwest, and there's a huge amount of interest, I can tell you, amongst radiologists in learning this technology and learning how to interpret this exam. It's probably one of the most growth areas in radiology at the time.
FLATOW: Elizabeth in Sacramento, staying in California. Hi, welcome to SCIENCE FRIDAY.
ELIZABETH (Caller): Hi, thanks.
FLATOW: Hi there, go ahead.
ELIZABETH: Hi, great show. I just have a quick question. What about those of us who don't know what our family history is? For instance, those that are adopted and have their records hidden. Does that put us at a higher risk group, or does that just not make a difference?
Dr. MORRIS: Well, there are other things that you can ask, and there are other things that you can be assessed for other than just family history, and there are risk models, actually, that can be used to assess how high risk you are. But your doctor is probably the best one to discuss this with, to figure out whether or not you would benefit from the test or not.
Now, things that you don't need to know, whether your mother or sister, particularly if you're adopted, whether they had breast cancer, if you know your breast density, for example, or if you know that you've already had benign biopsies, all that sort of thing can factor into assessing your risk.
FLATOW: Thanks for calling. Lots of phone calls. Marty in St. Louis. Hi, Marty.
MARTY (Caller): Hey, how are you doing? Thanks for taking my call.
FLATOW: Go ahead.
MARTY: I have a specific question. It has to do with patients who are high risks, patients who are positive, bracket one, bracket two. Currently, recommendations have to do with mastectomy, prophylactic mastectomy. How is the MRI, breast MRI, going to change those recommendations? In other words, is the screening tool good enough to change a recommendation of a prophylactic mastectomy towards just continued screening with MRI?
FLATOW: Good question.
Dr. MORRIS: Yeah, Marty, that's a great point, because I think that's part of the reason why we wanted to get these recommendations out there, because there's been a frustration, especially with women who know that they're gene-positive, and yet they know that mammography is not particularly good at picking up their cancers, mostly because they have very dense breasts.
So many women in the past have felt frustrated and have resorted to actually having a bilateral prophylactic mastectomy. So the thought is, is that with this test - it's a much less invasive procedure, obviously, than having both breasts removed - that with this test we can offer women a way to be screened and they can feel comfortable, and they can feel comfortable that their cancer will be detected early.
FLATOW: And plus, you don't have the radiation, so possibly you could have it more often.
Dr. MORRIS: Absolutely. That's another point, too, is that many of these women are very young, and you don't want to be radiating women in their 20s with X-rays from mammography.
MARTY: Right, okay. Thank you very much.
FLATOW: Thank you.
Dr. MORRIS: Thank you.
FLATOW: 1-800-989-8255 - especially for these women who are very high risk who could start this out earlier and keep watching them.
Dr. MORRIS: Right, absolutely.
FLATOW: You just have to bring the cost down or find a way of having the cost being picked up.
Dr. MORRIS: Yeah. Well, the cost - you know, the cost has to do with how long the exam takes, and it used to be that the exam used to take an hour, but it's now down to a half an hour, and so - and it does involve an injection of contrast because what we're looking at is abnormal blood flow. So those are things that do add to the cost.
FLATOW: There's a study out in the New England Journal of Medicine this week. I'm sure you're familiar with it.
Dr. MORRIS: Yeah.
FLATOW: It's recommending that women diagnosed with cancer in one breast should have an MRI done on the other breast.
Dr. MORRIS: Correct.
FLATOW: Why is that?
Dr. MORRIS: Well, I think, you know, women who are recently diagnosed with breast cancer are the ultimate high-risk women, and looking at the other breast with MR, we know that we can find cancer in up to five percent of women that's not detected on mammography.
So what that means is, is that we go ahead traditionally and just treat one breast, but we're ignoring the other breast. So MR can give us an amazing amount of information and actually have the woman go through treatment all at once, up front, instead of waiting and having another cancer develop in her opposite breast.
FLATOW: Jean in Boston. Hi, Jean.
JEAN (Caller): Hi. I'm very interested in this show, but one of things that confuses me is I had cancer, and I'm way outside of treatment, thank God, six years. You know, it was stage one. I don't consider myself high-risk anymore, except that I did have cancer. So one of the things we don't hear talked about a lot is - how do you judge your high-riskness if you have had cancer? Where do you fit in? How do you make those decisions in terms of getting the MRI, particularly in the other breast?
Dr. MORRIS: That is a fantastic point, and I think that it is something that we are strongly considering. The problem is, is before the society can make any kind of recommendations, it needs data. It needs to have studies, it needs to have numbers, that sort of thing.
Unfortunately, no one has numbers. No one really has enough numbers that strongly show that patients who have had breast cancer benefit from screening MR after their diagnosis.
The feeling is, is probably they do, and it's sort of - it's put in this list with the recommendations that there's insufficient data at this time for people who have had breast cancer to make a recommendation. But the American Cancer Society doesn't want these patients not to get an MR or to be dissuaded by the fact that they're not put in the high-risk group.
FLATOW: Well, if there's no risk because there's no radiation for the exam, why not just get it done?
Dr. MORRIS: Well, the feeling is, is that before - for example, in our practice we screen many patients who have had a personal history of breast cancer, but the problem is, is that the society obviously can't come out and say we think that these patients have to have an MR without the data.
FLATOW: So they can ask for it themselves.
Dr. MORRIS: Yeah, they can.
FLATOW: You think it's a good idea for them to ask for it.
Dr. MORRIS: Well, I think…
FLATOW: Off the record, so to speak.
Dr. MORRIS: Off the record. I mean, frankly, we don't have the numbers, and so you can't come out and say a blanket recommendation for everyone, but I think that if you're young and you've had a breast cancer that was diagnosed around menopause or pre-menopausal, it might behoove you to get a breast MR.
FLATOW: Okay, Jean, there's off the record for you.
JEAN: Thank you.
FLATOW: 1-800-989-8255. Let's go to Evie in Burlington. Hi, Evie.
EVIE (Caller): How are you doing? Great show.
FLATOW: Thank you.
EVIE: I wanted to know about fibrocystic breasts. I think that's the concept. If you need to get an MRI, or you should get an MRI if you have fibrocystic breasts.
Dr. MORRIS: Evie, that's a great question because I think a lot of times fibrocystic breasts are sort of those - you know, you have breasts that are very difficult to examine, and so you don't know - you know, this new lump, is it something, or what's going on? And you sort of - and also it means usually that you may have a mammogram that's difficult to interpret as well.
So there is a feeling that, hey, let's just get an MR and make sure that there's nothing there, but unfortunately that's probably the worst reason for getting an MR, because if you have fibrocystic breasts, you probably have very proliferative breasts. There's a lot of stuff going on, and you are probably one of the people who is going to have a false positive finding. So unless you have something else that puts you at high risk, I wouldn't get an MR.
FLATOW: All right, thanks for calling. How much better is an MRI - as you call it, an MR - better at detecting or worse at detecting lumps or any kinds of breast cancer over mammography?
Dr. MORRIS: Well, it has definitely improved sensitivity with detecting invasive cancers.
FLATOW: You mean size of the cancer itself?
Dr. MORRIS: Yeah, well, there's two types of cancer. One's, you know, the ductile type, where it hasn't invaded yet, and the other is where it's invaded into the breast. and MRI is actually better at picking that up than mammography overall.
Dr. MORRIS: Sensitivity is much higher. Sensitivity is in the high 90s, whereas sensitivity from mammography in probably dense breasts that are in young women is about 50 percent.
FLATOW: Wow, that drops way down.
Dr. MORRIS: Yeah.
FLATOW: Because of the false positives?
Dr. MORRIS: No, it's just that it's harder to detect cancers in dense breasts on mammography.
FLATOW: Quick question, one last quick question from Judy in San Antonio.
JUDY (Caller): Hello.
FLATOW: Hi there, go ahead.
JUDY: Hi, thank you. Do you consider having a first-degree - I'm sorry, first cousin on maternal side and paternal side, both with pre-menopausal breast cancer - do you consider that to be a risk factor?
Dr. MORRIS: You know, in general it's first-degree relatives that really put you at increased risk, and that would not be a first-degree, but you may have other things going on that I don't know about, and so I would just recommend that you run that by your primary care physician or your internist and try to figure out whether you are at high risk or not.
FLATOW: Dr. Morris, do you think these guidelines are going to be revised as time goes on?
Dr. MORRIS: Absolutely. I think we can look forward to revisions.
FLATOW: In which direction?
Dr. MORRIS: Probably in increased use.
FLATOW: Increased use. In other words, the Cancer Society will come out with the things you say it hasn't come out with yet.
Dr. MORRIS: Right, exactly, like personal history of breast cancer or benign biopsies where atypia is shown or LTIS. We don't know does MR help in that situation as well.
FLATOW: I want to thank you very much, Dr. Morris.
Dr. MORRIS: You are more than welcome, Ira, this is great.
FLATOW: You're welcome. Thank you. Elizabeth Morris is director of breast MRI at Memorial Sloan-Kettering Cancer Center here in New York.