Pre-operative breast MRI in women with recently diagnosed breast cancer--where to next?

The appropriate application of breast MRI in the pre-operative evaluation of women with a new diagnosis of breast cancer is currently one of themost debated and controversial issues in breast cancer management. While it initially seemed clear tomany that MRI’s superior detection capability relative to conventional breast imaging1,3,4,6 for both the affected breast, and the contralateral breast, would result in improved patient outcomes, an increasing body of evidence based on clinical experience suggests that this may not be the case. This issue of the journal presents some of the varying perspectives on this topic in three commentaries reflecting the views of physicians specializing in breast imaging and the local therapy of breast cancer, and decision-making experts. Sardanelli provides an overview on pre-operative MRI and makes recommendations to help guide the use of MRI in this setting. A counter-view from Solin presents an evidence-driven discussion on pre-operative MRI, emphasizing that existing evidence has not shown any clinical benefit. McCaffery & Jansen provide insights into the complex process of decision-making for both clinicians and patients, and outline methods to potentially improve decision-making around pre-operative MRI in breast cancer. All three commentaries raise the need for prospective clinical trials. For clinicians working in breast diagnosis, it is difficult to ignore the detection capability of MRI, and equally difficult to comprehend (or even accept) that finding additional disease (that would have remained occult on conventional imaging) in either the affected or contralateral breast6,8 does not necessarily translate into improved clinical outcomes. There is no question about the ability of MRI to detect additional occult cancer in women newly affected by breast cancer: this has been shown in numerous studies and confirmed in pooled analyses.1,8 Yet the one consistent finding in studies of pre-operative MRI is that its detection capability results in more extensive surgery (frequently a change to mastectomy) than what would have been done based on routine care – without associated evidence that this leads to improved short-term outcomes such as a decreased need for re-excision for involved margins or a decrease in the number of unplanned mastectomies. It is also not clear that long-term clinical endpoints such as the incidence of local recurrence in the conserved breast are improved when MRI is used for patient selection.1,2,7 While more extensive surgery due to false positive MRI results should be avoidable with the use of MRI-guided biopsy to confirm malignancy prior to changes in the surgical plan, the real debate is