Magnetic Resonance Imaging - Health - Lecture Slides, Slides of Public Health

Download Magnetic Resonance Imaging - Health - Lecture Slides and more Slides Public Health in PDF only on Docsity! Magnetic Resonance Imaging (MRI) Screening for High Risk Patients docsity.com Each year in the U.S. alone: • 5.3 million affected • 40,000 deaths docsity.com Definition of ‘High Risk’ • Known BRCA mutation carrier or • Close relative of mutation carrier or • Family history suggestive of inherited predisposition docsity.com Cumulative Risk of Breast Cancer 0% 10% 20% 30% 40% 50% 60% 70% 30 40 50 60 70 Age 1. Antoniou et al. Am J Hum Genet, 2003 2. SEER Cancer Stats Review, 2004. BRCA1 BRCA1 + oophorectomy general population no family mutation docsity.com High Risk Screening Guidelines U.S. (NCCN, 2004) U.K. (NICE, 2004) France (Eisinger, 2004) Mammography (annual) 25+ 30+ 30+ CBE (q 6months) 25+ - 20-25+ BSE (monthly) 18+ - - Ultrasound (annual) - - 30+ (dense breasts) docsity.com eens aes docsity.com Mammographic Visibility of Palpable Breast Cancers 0% 20% 40% 60% 80% 100% BRCA1 sporadic Chang Lancet, ‘99 Goffin JNCI ‘01 Tilanus -Linthorst Int J Cancer ‘02 P=.03 P=.01 P=.01 docsity.com Limitations of Mammography for HBC Surveillance • young age = dense breasts • tumour pathology (BRCA1) – less DCIS – fleshy, ‘pushing’ borders docsity.com Breast MRI Screening Studies for High Risk Women Kriege et al. The Netherlands Kuhl, et al. Bonn, Germany Leach et al. U.K. Podo et al. Italy Schnall, Lehman et al. U.S. Warner, Plewes, et al. Toronto, Canada docsity.com Breast MRI Screening Studies for High Risk Women Similarities • prospective, non-randomized • not restricted to mutation carriers • annual mammography + MRI Differences • single / multiple centers • patient population • additional modalities • MRI technique docsity.com Dutch National Study Kriege et al. NEJM 351: 427, 2004. • 6 centers • unaffected women • ages 25-70 •  15% lifetime risk • MRI + mammography + CBE docsity.com Sensitivity: Invasive vs. In-Situ Dutch Study: Results 17% 80% 33% 83% 0% 20% 40% 60% 80% 100% Invasive In-Situ MRI Mammography n=39 n=6 docsity.com False Positives Recalls Biopsies MRI 10% 5.8% Mammography 5% 1.7% Dutch Study: Results docsity.com Invasive Tumor Stage 40% 48% 43% 14% 12% 32% 37% 49% 25% 0% 20% 40% 60% 80% 100% Study Control 1 Control 2 > 2 cm 1.1 - 2 cm < 1 cm Dutch Study: Results n=45 n=1500 n=45 21% node + 52% node + 56% node + docsity.com Toronto Study: Results • 437 women – 318 BRCA mutation carriers – mean age 43 – mean # screens = 3 Only 1 interval cancer! • 37 cancers – 32 in carriers – mean age 48 (34-64) – 28 invasive (2 lobular), 9 DCIS docsity.com Sensitivity of Individual Modalities Toronto Study: Results 84% 30% 8% 33% 0% 20% 40% 60% 80% 100% MRI Mam CBE US docsity.com Sensitivity of Combined Modalities Toronto Study: Results 97% 92% 92% 57% 38% 0% 20% 40% 60% 80% 100% All but CBE All but Mam All but US All but MRI Mam+ CBE docsity.com docsity.com docsity.com Sensitivity by Age Toronto Study: Results 80% 88% 24% 35% 29% 45% 0% 20% 40% 60% 80% 100% <50 (n=20) 50+ (n=17) MRI MMG US docsity.com False Positives: Biopsies Toronto Study: Results 11% 5%6% 6% 3% 16% 10% 4% 3% 1% 1% 0 0% 5% 10% 15% 20% Year 1 Year 2 Years 3-5 Any MRI M US docsity.com 74% 43% 22% 32% 3% 25% 0% 20% 40% 60% 80% 100% Toronto the Netherlands > 2 cm 1.1 - 2 cm < 1 cm Invasive Tumour Size docsity.com Toronto Study: Results Yr. # cancers DCIS Mean Invasive Size Node + 1 18 22% 1.1 (0.4 - 3.0) cm 3 2 9 11% 1.2 (0.4 - 2.0) cm 1 3-5 9 44% 0.8 (0.7 - 1.0) cm 0 Tumor Stage by Year No recurrences to date. Median f/u 3yrs. (range 1 to 7) docsity.com Cost-Benefit Estimate $$$ • 62 million women ages 30-60 in U.S. • 1% high risk (620,000) • $1200 per screen ____________________ $744 million/year • 620,000 high risk • 1% (6,200) have cancer • mortality 30%  10% • 1240 more cured • mean years saved = 25 ________________________ 31,000 life years saved $24,000 / year of life saved docsity.com Summary Breast MRI for high risk women: • most sensitive screening modality • finds cancers at an earlier stage • has acceptable specificity • saves lives? docsity.com Other Research Questions • Optimal MRI screening schedule for subgroups? – age – mutation status – breast density • Role of other screening modalities? • Role of MRI for other high risk women? – Atypical hyperplasia, LCIS – Chest irradiation < age 30 – Very dense breasts docsity.com