L. S. Sparber1, A. B. Warman2, W. Doscher1,3,4 1Northwell Health System North Shore LIJ,Division Of Vascular Surgery, Department Of Surgery,New Hyde Park, NY, USA 2Columbia University,School Of Professional Studies Dept Of Bioethics,New York, NY, USA 3Northwell Health System North Shore LIJ,Department Of Medicine, Division Of Ethics,New Hyde Park, NY, USA 4Hofstra University,School Of Medicine,Hempstead, NY, USA
Introduction: Breast magnetic resonance imaging (MRI) has emerged as a potentially more sensitive imaging modality than traditional mammography, for detecting in situ breast tumors. The question that remains is whether this modality should be universally utilized as all interventions have decisions related to their results? Quality of life implications and functional outcomes should be considered. It is unclear whether breast MRI has resulted in overtreatment and therefore unnecessary mastectomies in patients with Ductal Carcinoma in situ (DCIS).
Methods: A comprehensive search for all published clinical studies on the use of MRI and its impact on DCIS management (2010-2017) was conducted using Pub Med and Google Scholar. The search focused on the value of MRI to guide treatment strategies, including mastectomy rates, the overall benefit of this added imaging modality as well as ethical dilemmas associated with its use. Keywords searched included: “breast MRI”, “mastectomy”, “DCIS”, “surgical planning” and ethics in all possible combinations.
Results: Eleven studies involving 3,655 patients have been published. Lallemand et al, reported that routine use of MRI often leads to multiple procedures which have limited benefit. The largest study was reported by Pilewskie et al (2014) involving 2,321 DCIS patients examining loco-regional recurrence. Itakura et al reported increased mastectomy rates in patients undergoing preoperative MRI (p < .001). In contrast, three studies analyzed the impact of MRI on DCIS mastectomy rates, with Allen et al reporting no significant difference in mastectomy rates if an MRI was performed (p = .62). Pilewskie et al, demonstrated that breast conserving surgery was more successful in the non-MRI group (p = .06), whereas Allen et al and Kropcho et al found the results to not be statistically significant (p = .41 and p = .414, respectively). Doyle et al, reported that use of MRI accurately predicted the extent of DCIS requiring further surgery (p=0.01). All but one study demonstrated that preoperative MRI was not routinely beneficial in DCIS patients.
Conclusion: Decision making is complex and value-laden in interventions that could lead to body altering procedures. Breast MRI is associated with an increased sensitivity compared to other breast imaging technologies, which may contribute to an increase in unnecessary mastectomies in patients diagnosed with DCIS. Proportionality, which is the assessment of benefits versus risks, must be considered. Shared decision making between the clinician and the patient is essential in this process. The clinician’s virtue is the source of the principles of non-maleficence and beneficence- both of which aim to honor the patient’s moral status: wanting to help a patient live optimally, while avoiding inflicting harm. Therefore, the issue becomes who decides what is the best medical care for a patient?