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• W2024705026 abstract "All correspondents raise the issue of costs. Breast MRI is indeed expensive; however, costs are currently “only” about four times higher than those of digital mammography—and will come down with increased use. Additionally, early diagnosis of breast cancer will also help save money—money that is currently spent on treatment of late stages of breast cancer. Mangesh Thorat quotes “for every 2000 women invited for screening throughout 10 years, [only] one will have her life prolonged”. Such contemplations make sense when assessing the economic implications of screening, but on medical grounds, it makes no sense to reference the benefit of screening to the entire screening cohort. If a woman participates in screening and does not develop breast cancer, she will not profit and will go through unnecessary diagnostic procedures. If, however, she participates and does develop breast cancer, then she will reduce her risk of dying by 30%, and will receive less toxic treatments. This is the conditional benefit of screening—a concept women seem to understand rather better than many epidemiologists. It is true that early detection (“secondary prevention”) does not necessarily translate into improved survival. The diagnosis of ductal carcinoma in situ (DCIS), however, can be regarded as primary, rather than secondary, prevention, because it helps avoid the development of invasive cancer. An improved diagnosis of DCIS will therefore reduce breast cancer mortality. What has to be investigated by prospective clinical trials is the extent to which morbidity and mortality will be reduced, and what we would have to pay for the additional life-years saved. Once we know the results, it will be a societal rather than a medical question to decide whether or not we want to make this investment. The correspondents are concerned about overdiagnosis and overtreatment of DCIS. One should keep in mind that most breast cancers develop through an intraductal stage. However, even in women who undergo annual mammographic screening, most cancers are not diagnosed until the invasive stage; in other words, most DCIS still progress to invasive cancers because we fail to identify them. If we use a tool that doubles the sensitivity with which we are able to diagnose DCIS, this will improve our ability to identify these precursors of breast cancer. Overdiagnosis of DCIS will happen, but it will be a rare event compared with the number of patients who will undergo appropriate treatment for biologically relevant preinvasive cancer. Breast cancer continues to represent the most important cause of cancer death in women. As long as this is the case, we should not prematurely reject a new diagnostic tool for an added (negative) effect on a small problem, as long as it has a substantial (positive) effect on a big problem. Lastly, there is concern about unnecessary surgical procedures. We do indeed mention the number of false-positive diagnoses made in our cohort. Arjan Shouten van der Velden and Theo Wobbes mention that, in their article (a retrospective comparison of MRI and mammography in 22 patients), MRI overestimated the size of DCIS, leading to unnecessarily radical surgery. We would like to underscore that oncological surgery should never be done without histological proof of the extent of a presumed breast cancer. This holds as true for MRI as for mammographic diagnoses. Luckily, this proof is easy to obtain by mammography or MRI-guided vacuum biopsy. We declare that we have no conflict of interest. Should we undertake an MRI breast screening trial?Christiane Kuhl and colleagues (Aug 11, p 485)1 report that MRI has significantly higher sensitivity than mammography in detecting ductal carcinoma in situ (DCIS), especially high-grade DCIS. On the basis of these findings, Carla Boetes and Ritse Mann conclude their accompanying Comment2 by saying that a multicentre breast screening trial with MRI for the general population is now essential. We must pause for a moment to ponder over the expected outcomes and consequences of such a trial before committing to this kind of large-scale effort. Full-Text PDF Should we undertake an MRI breast screening trial?Christiane Kuhl and colleagues' finding that MRI could help improve the ability to diagnose ductal carcinoma in situ (DCIS) of high nuclear grade1 should lead to careful consideration of its implications rather than to a conclusive statement that MRI should be used “as a distinct method to detect breast cancer” and to a call for a large multicentre breast-screening trial in the general population.2 Full-Text PDF Should we undertake an MRI breast screening trial?The paper by Christiane Kuhl and colleagues1 is interesting because it makes clear that ductal carcinoma in-situ (DCIS) is not just a mammographically detectable disease. Kuhl and colleagues nuance their findings by mentioning their high level of experience in breast imaging and that a standard for breast MRI is still to be defined. Full-Text PDF" @default.
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• W2024705026 title "Should we undertake an MRI breast screening trial? – Authors' reply" @default.
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