An article published in this week’s edition of The Lancet reports that addition of magnetic resonance imaging (MRI) scans to conventional triple assessment techniques for diagnosis of breast cancer has no effect on the re-operation rate.
Triple assessment is the combination of three modes of assessment: clinical examination, imaging of the breast (by X-ray mammography and/or ultrasound), and pathological assessment of the “lump” (by either fine needle aspiration cytology or core biopsy).
About 20 percent of women will return to surgery for “re-operation” because their tumor has not been completely removed. The hope of the COMICE study was that by better delineating the extent of tumor, the “re-operation” rate would be minimized. However, although MRI did delineate the tumor better than other imaging techniques this was not translated into better surgery. The article is the work of Professor Lindsay Turnbull, University of Hull and Hull Royal Infirmary, UK, and colleagues.
Forty five UK centres were included in this randomized controlled study. A total of 1,623 women aged 18 years or older were recruited. They all had biopsy-proven primary breast cancer and were scheduled for surgery to remove their tumours after triple assessment. At random, a total of 816 patients were assigned to receive MRI and 807 to no further imaging. The primary endpoint was the proportion of patients undergoing a repeat operation or further mastectomy within six months of randomisation, or a pathologically avoidable mastectomy at initial operation.
The findings indicate that addition of MRI to conventional triple assessment was not significantly associated with a reduced re-operation rate:
• Nineteen percent (153) needed re-operation in the MRI group.
• Nineteen percent (156) need re-operation in the no MRI group.
The researchers explain: “In the analysis, we identified no difference in health-related quality of life between groups 12 months after initial surgery. However, in terms of total costs, results suggested a difference between the two trial groups, with the MRI group costing more than the no MRI group, although the difference was not statistically significant. In view of the similar clinical and health related quality-of-life outcomes of patients in both groups, we conclude that the addition of MRI to the conventional triple assessment might result in extra use of resources at the initial surgery period, with few or no benefits to saving resources or health outcomes, and the additional burden on patients to attend extra hospital visits.”
They write in conclusion: “Our results have important implications in routine clinical practice for the appropriate use of health-service resources and patient burden on health services. MRI is an expensive procedure. Because surgical use of MRI data to direct wide local excision is similar worldwide, we believe that our findings are generalisable to all healthcare providers, and show that MRI might not be necessary in this population of patients in terms of reduction of reoperation rates.”
In an associated note, Dr Elizabeth A Morris, Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, USA, comment: “It is too early to completely dispense with preoperative breast MRI. Importantly, COMICE has shown that preoperative breast MRI might not be for all women and that routine breast MRI in the evaluation of early breast cancer, as managed by those participating in this study, does not decrease reoperation rates.”
“Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial”
Lindsay Turnbull, Sarah Brown, Ian Harvey, Catherine Olivier, Phil Drew, Vicky Napp, Andrew Hanby, Julia Brown
Lancet 2010; 375: 563-71
The Lancet
Written by Stephanie Brunner (B.A.)