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Comment & Response
August 2014

In Defense of Screening for Breast Cancer With Magnetic Resonance Imaging—Reply

Author Affiliations
  • 1Duke University Health Systems, Duke Cancer Institute, Durham, North Carolina
JAMA Intern Med. 2014;174(8):1417-1418. doi:10.1001/jamainternmed.2014.803

In Reply We thank Dr Keller for drawing attention to several additional points regarding the use of breast magnetic resonance imaging (MRI) for breast cancer screening. With respect to the first comment, we concur that the attributes of a screening test include that it must be both noninvasive and inexpensive. While the $350 reported charges for an MRI by a for-profit screening center is not exorbitant, it still remains much higher than the cost of a routine screening mammogram, is a significant out-of-pocket cost for most patients, and begs the question of whether patients should cover the cost of their own cancer screening, given that MRI has not been shown to offer benefit over mammography for the general population.

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    1 Comment for this article
    Dr. Hwang has misquoted me and I request she reply to this
    David L. Keller, MD | none
    Dr. Hwang has written a long statement which does not reply to my actual recommendation, which I shall repeat here: I wrote: “Women who refuse screening mammography because of pain or the wish to avoid ionizing radiation to their breasts should be informed of these issues and offered screening with MRI.” The above sentence is the only actual recommendation I made in my letter. Dr. Hwang did not address this scenario. What do you do when a patient refuses mammography, Dr. Hwang? I offer her breast MRI. Dr. Hwang wrote: "Most breast cancer screening guidelines recommend against mammographic screening in women younger than 40 years owing to the low breast cancer incidence in this population;” I never suggested mammograms or any radiological screening for breast cancer in women younger than 40 years of age, nor have I ever read of any guideline making that recommendation. Let me state for the record that I agree with the American Cancer Society, that routine annual screening mammography should begin at age 40 (1). I only suggested breast cancer screening with MRI for women who refuse mammography due to pain or worries about radiation exposure. By “younger women”, I meant premenopausal women under the age of 50, for whom the glandular component of breast tissue is substantial, increasing the risk of pain and malignancy due to ionizing radiation exposure. Dr. Hwang then wrote: “Furthermore, it has been clearly demonstrated that premenopausal women experience MRI changes with the menstrual cycle, which can often lead to false-positive MRI findings." I agree, and menstrual cycle variations in breast imaging characteristics (both MRI and mammographic) can and should be mitigated by the proper timing of the examination within the menstrual cycle.She then goes to great lengths to prove that mammography is a better screening test for breast cancer than MRI, which I never disputed. Again, my suggestion was to offer breast MRI to screen women who refuse mammography. I would like very much to know what Dr. Hwang recommends for such women. The available choices I am aware of are breast MRI versus ultrasound versus neglect. Which of those 3 choices do you advocate, Dr. Hwang, bearing in mind that the patient refused mammography?(1) American Cancer Society website, accessed on 8/4/2014 at the following URL: http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs