Intermountain Health radiologist, Dr. Brett Parkinson talks about a new way to detect breast cancers with an abbreviated breast MRI.
Interview conducted by Ivanhoe Broadcast News in 2023
Tell me what is an abbreviated MRI?
PARKINSON: An abbreviated breast MRI is actually a shortened version of a standard breast MRI. Whereas standard MRI takes about 30 to 40 minutes, an abbreviated breast MRI takes about 10 minutes, but the information it gives us is equivalent to that which we see on the standard examination. Its sensitivity is roughly the same.
Why would you use that instead of a mammogram?
PARKINSON: We don’t use MRI instead of mammography, we use it as an adjunct to mammography. A screening mammography is still very important. Over the last 30 years, the death rate from breast cancer has decreased by 50 percent. Because of screening mammography, the death rate from breast cancer has decreased by 30 percent. That has been borne out by multiple randomized control clinical trials. Mammography has been the workhorse and over the years, it has improved significantly. We’ve gone from analog mammography to digital mammography, and now we have 3D mammography or tomosynthesis. With each iteration, we’ve gotten better. MRI is the most sensitive tool that we have for the detection of breast cancer. However, it has traditionally been very expensive. This is why abbreviated MRI will revolutionize what we do.
Is it the same technology? Why is it less expensive?
PARKINSON: It’s the same technology, but it’s less expensive for a few reasons. The first reason being, there is less scanner time. What we used to do in a half an hour or more can now be done in about 10 minutes. There are fewer sequences. Abbreviated breast MRI is cheaper because it doesn’t take as long and we use fewer resources when we don’t use as much time. In addition, there are fewer sequences, so the radiologist doesn’t have to spend as much time going through all the sequences, but sensitivity is not sacrificed by this new technology.
But you can’t replace a mammogram with this?
PARKINSON: No, it’s important that women still have a yearly screening mammogram and for those who qualify by virtue of their risk, an MRI. Not all women need breast MRI. If a woman has fatty breast tissue, meaning the breast has been replaced by fat, which typically occurs in middle age and older women, you don’t necessarily need an MRI because mammography has a great sensitivity for fatty breast tissue. It approaches 95 to 100 percent. But in very dense breast tissue, mammography sensitivity goes down to less than 50 percent in some patients. That’s where MRI comes in strong. In MRI we don’t have to worry about breast density like we do with mammography. MRI looks at function rather than just structure because structure can be obscured by dense breast tissue or complex breast tissue, and MRI basically allows us to see through that because we use contrast. The contrast goes to the tumor and shows us what the blood supply is doing. Basically tumors recruit more blood vessels and we can see that on MRI by virtue of the contrast that is injected. It’s like when you have a CT scan, you can see many things better once you’ve injected the contrast. This is not iodinated contrast, so we don’t have the reactions that we do with iodinated contrast material.
Can mammograms tell you something that abbreviated MRI can’t?
PARKINSON: Yes, mammograms can sometimes pick up very early breast cancer in the duct. We call that ductal carcinoma in situ. Mammography is very good at picking that up. The cure rate for ductal carcinoma in situ approaches 100 percent. We can see that very well with mammography. Sometimes MRI doesn’t show us the less aggressive forms of DCIS, but MRIs specialty, but MRI is very good at detecting aggressive tumors. We don’t want to abandon mammography though for most women, mammography is all they need. However, there’s a subset of women with very dense breast tissue or who are high risk that benefit from mammography.
Is the abbreviated MRI more expensive than a mammogram?
PARKINSON: An abbreviated breast MRI is not more expensive than the digital mammogram. What we have here at Intermountain is we have coverage through SelectHealth, which is our insurance company for women who meet the criteria for high risk. It’s covered by insurance, so the cost of the patient is negligible. However, for patients who don’t qualify, by virtue of their risk, they can pay cash. It’s 375 dollars, which of course is less than many copays for patients. This really is going to be a game changer around the country. We’re not the first to offer abbreviated breast MRI, but Intermountain is the first to cover it by its insurance company, and we have led the way and I’m really proud of this organization for putting women’s lives first. The problem with mammography as the sole imaging modality for the detection of early breast cancer is that it will miss breast cancers in women who are at high risk or who have very dense breast tissue. MRI will show us the cancers in those patients before mammography will in many instances. Mammography picks up about four cancers per 1,000 women in the general population. MRI on the other hand, can pick up anywhere from 12 to 16 early breast cancer. You can see that the sensitivity is far greater.
So the whole machine is why women don’t get MRIs?
PARKINSON: We’ve asked women why they don’t get mammograms. Now, some women say it’s the fear of knowing that they don’t want to know if they have breast cancer. Other women say a mammogram is so uncomfortable, I do not want my breast compressed by that machine. They will avoid coming in because of the discomfort. However, MRI doesn’t compress the breast in that way. The breast is compressed during an MRI exam, but the women don’t seem to complain about it as much as with mammography. With abbreviated breast MRI, the time in compression is less than with a standard breast MRI.
Do you ever see this becoming the future? Will things improve and it will be the future of mammograms?
PARKINSON: I think that we’re seeing the future unfold right before our eyes here at Intermountain Healthcare and other forward-thinking healthcare systems in the country. I think breast MRI is here to stay and I think it will not necessarily replace mammography, but it will be an adjunct to mammography and it will become much more common as the price comes down with this abbreviated version.
Could this replace biopsies? Can you see more that you’re going to know that’s just a calcification and not?
PARKINSON: No, I don’t think it’s going to replace biopsies because as we have discussed before, except they don’t know that you and I had a discussion. I don’t think that MRI is going to decrease the number of biopsies because there is a continuum of what looks benign and what looks malignant. That’s true in mammography, and in ultrasound, and in MRI. We’ll continue to have to biopsy. In a good program, about 20 to 40 percent of the things we biopsy will end up being malignant. If you are not biopsying at least 15 to 20 percent, you are doing great. If 80 percent of the things you biopsy are malignant, you are not sampling enough. If only 10 percent of the things that you biopsy are malignant, you are sampling too many things. We want to be in that sweet spot of 20 to 40 percent. Now, will that change as we develop our program with abbreviated breast MRI? Yes, it might change. In the short term, it may actually increase the number of biopsies, but more importantly, it’s going to increase the number of cancers that we can find. Our goal is to detect cancers when they are small at their earliest most treatable stage. We can do that with a combination of mammography and breast MRI. Another goal is we don’t want women who are screened every year to come with a cancer five months after they’ve been screened. That does happen with mammography. Our hope and what we have seen born out of multiple studies is that number of what we call interval cancers between screens goes way down with breast MRI. Sometimes those are the more aggressive cancers, the cancers that kill people, especially younger women. We don’t want anybody to die from breast cancer. Right now we lose anywhere from 45 to 50 thousand women a year to breast cancer. That is too many. We don’t want to lose any women to breast cancer. We want to be like colon cancer because with the advent of colonoscopy, the death rate from colon cancer has dropped. Ours has dropped with mammography and breast MRI, but until we are screening appropriately and we’re finding the high risk women, we’re still going to have too many women die from breast cancer. That leads me into another question that you’re asking with your eyes.
How do we find out who the high risk women are that should start screening early with either mammography or breast MRI?
PARKINSON: Yes. How do we find out who the high-risk women are that should start screening early with either mammography or breast MRI? Well, the important thing is for women to know their risk. And what is unique to Intermountain, and some other systems do it as well, is that when women come into one of our facilities, they fill out a risk assessment questionnaire. It’s the Tyrer-Cuzick questionnaire which is well regarded across multiple specialties in this country or rather subspecialties in breast cancer in this country. And it asked very specific questions about the woman’s history. When did she have her first period? When did she go through menopause? What about her family history? Does she have a mother, a sister, a grandmother, a cousin? Because all of those things will increase her risk if she answers affirmatively. Moreover, it includes breast density. So if a woman has very dense breast tissue, that will be reflected in her risks. So every woman that comes into our facilities for breast imaging procedure, fills out the Tyrer-Cuzick questionnaire. And before she walks out, she has a risk assessment assigned to her. If that risk assessment is greater than 20%, then she is a candidate for screening breast MRI. And in our system that would be abbreviated breast MRI. And as I said before, that is covered by SelectHealth, our insurance company. And for those women who don’t reach that threshold, but who have dense breast and who are worried, they can actually pay cash and it’s only 375 dollars.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Erin Goff
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
