1. McGraw, Mark

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New research finds that female patients with high breast cancer risk who are recommended to undergo supplemental MRI screening may not be getting these scans done. Presented at the RSNA 2021 Annual Meeting, the study also found that the lack of follow-through on supplemental breast MRI exams seems to be especially prevalent among racial and ethnic minorities and patients in lower income brackets.

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Dayna Levin, MD, Associate Program Director of the Diagnostic Radiology Residency Program at the University of Pennsylvania (UPenn), and colleagues noted in their presentation that early breast cancer detection improves outcomes for female patients, and breast MRI is more adept at detecting breast cancer than mammography or ultrasound.


As Levin and her co-authors pointed out, the American College of Radiology recommends that women at higher risk of breast cancer undergo breast MRI on an annual basis, but it's not clear as to whether patients in this group are undergoing these additional scans.


Levin, who is also Associate Professor of Clinical Radiology at UPenn, and her colleagues conducted a study including data gleaned from electronic health records at three breast imaging centers, identifying 2,431 women with elevated Gail risk scores (above 20%) who presented for either screening or diagnostic mammography. These patients had undergone a breast MRI within the following 2-year period.


The researchers analyzed the patient data for socioeconomic and demographic factors such as income, race, and age, finding that less than 20 percent of these high-risk patients received supplemental breast MRI screening.


In addition, Asian women were 88 percent less likely to undergo a supplemental breast MRI than White women, while Black women were 70 percent less likely to receive a supplemental breast MRI exam than White women, and women with median incomes of more than $150,000 per year were 27 percent more likely to undergo breast MRI screening. Conversely, female patients with median incomes of less than $50,000 annually were 54 percent less likely to have the same exam done. With regard to age, women over the age of 50 were 36 percent less likely to take part in supplemental screening breast MRI than women under 50 years old.


The study authors also found several barriers preventing high-risk patients from undergoing breast MRI screening, such as time constraints with primary care providers, lack of familiarity with risk-assessment tools, patients' lack of insurance and the subsequent out-of-pocket costs, and anxiety about MRI screening, according to Levin. In her presentation, she also offered recommendations designed to help remove these barriers, such as educating primary care physicians as to determining and counseling high-risk patients, using artificial intelligence and behavioral economics to identify high-risk patients, for example.


There are indeed many factors contributing to the lack of women at greater breast cancer risk who are recommended for supplemental MRI screening actually getting the scan done, Levin noted.


"There is a lack of public awareness and messaging around high-risk screening. Many patients may not be aware that they are at high risk for breast cancer, and even those who know that they are at risk often do not know supplemental screening is recommended," she said. "Primary care providers are working harder than ever, and time constraints often do not allow for a focus on supplemental breast cancer screening. Additionally, primary care providers may be unfamiliar with current recommendations."


And, while there may be no clear answer as to the number of racial and ethnic minorities and lower-income patients not following through with supplemental breast MRI, "it is certainly a challenge we need to fix," Levin added. "There is a large gap in breast cancer outcomes among Black women and supplemental screening in high-risk Black women can make big differences. Insurance coverage and out-of-pocket costs of supplemental screening likely factor into the decreased utilization."


Additionally, low-income and minority patients may have inadequate access to health care facilities and providers, Levin stated, noting that "increasing community education and outreach aimed at improving understanding of breast cancer risk in racial and ethnic minority patients is paramount. Social media can also be leveraged to get the message out.


Levin also urged care providers, including radiology teams, to take steps to help remove the obstacles to undergoing needed supplemental MRI and improving the number of high-risk female patients getting these scans.


"I strongly believe that, if we are going to move the needle on supplemental screening for high-risk patients, radiologists need to lead the charge. [A given] patient's lifetime risk of breast cancer can be provided at the time of her screening mammogram," she stated. "Breast radiology providers can play a large role in informing and educating patients at high risk. Our electronic health record has the capacity to alert providers to a patient's high-risk status and nudge them to order indicated studies. We also need political advocacy to ensure these studies are covered by insurance."


Mark McGraw is a contributing writer.