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Unfortunately, the most common mathematical model
(Gail model - a.k.a NCI model) used to determine risk is considered
least desirable in the new guidelines. This is a peculiar stance since
the Gail model is the most validated and most utilized of all the
available mathematical methods. However, the reasoning of the ACS is
that the published studies on MRI screening did not use the Gail model,
but instead, focused on strong family histories. Thus, the mathematical
models used in published studies are favored. Whether or not insurers
will base their policies on specific mathematical model is unknown at
this point in time. The Gail model can be accessed online and used by
anyone. However, the other models (Claus, Tyrer-Cusick, BRCAPRO) are
preferred by the American Cancer Society, while at the same time are
more complicated and generally require a formal risk assessment. At our
facility, we are able to perform calculations with any or all of these
models to see if you qualify for MRI screening. In addition, we assist
patients in obtaining insurance coverage at writing letters to insurers
explaining the ACS guidelines and how the lifetime risk determinations
were made.
If you qualify, there are three other major points
to be made about the new ACS guidelines. First, the screening interval
is recommended to be every year, the same as mammography, Second,
mammograms are to be performed along with the MRI (MRI does not dismiss
the need for X-rays, the letter being better at detecting calcium).
Third, the starting age for screening these high-risk women is 30, ten
years prior to the usual starting age of 40.
As for women with lifetime risks of 15-20%, the ACS
has stated research is needed." Women with prior biopsies showing
atypical hyperplasia or LCIS, or a past history of breast cancer, or
dense mammograms are also in this "more research" group, Oddly enough,
though, depending on your age, these risk factors are sometimes enough to
bring calculated risks above 20% even with the "approved"
mathematical
models. So, we have to remember that the ACS has only provided
guidelines, and the real issue is whether or not your insurer is going
to cover the expense.
Because most women who consider themselves high-risk
are in this 15-20% controversial zone, we believe it is important to
consider the density of mammograms since this is the primary
determinant as to whether or not eventual cancer will be detected on
routine screening. In fact, we developed an in-house protocol from Day
One that included both risk level and mammographic density in providing
patient guidance. In most cases, we advise MRI screening be done every
two years in this group of patients, while reserving annual screening
for the extremely high-risk patients.
Because the issues here are so complex, we submit
claims for MRI screening in our high-risk patients, but if the claim is
denied, we make arrangements for payments at a discounted rate.
For patients who are below 15% lifetime risk, the
ACS has advised against MRI screening. This does not mean MRI doesn't
work in this group. Such a statement is made for economic and practical
reasons. The breast MRI capacity in the U.S. is unable to handle even
high-risk screening. much less screening the general population. Sadly,
though, at least half of all breast cancers that eventually develop will
come from this group, speaking for the need for alternative ways to
select patients for MRI screening.
In April 2006, Dr. Hollinsworth addressed the general assembly of the
American Society of Breast Disease on "MRI Screening in High- Risk
Patients" becoming the first non-radiologist to speak on the subject in
a national forum. This has led to requests for other speaking
engagements and publications on the subject. And, it is the proven
superiority of MRI screening for breast cancer that is the justification
of his research agenda to develop a screening blood test that would
render obsolete the idea of using risk status as the criterion for MRI
screening. |
