Breast Magnetic Resonance Imaging: Are Those Who Need It Getting It?

Abstract

Background:
Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for breast investigation, remain controversial, and accessibility is limited. The purposes of our study were to determine the proportion of breast mri exams performed for various clinical indications, to assess the wait times for breast mri, and to create a list of evidence-based indications for breast mri.

Methods:
The indications for breast mri exams performed in September 2013 at our academic centre were audited. A multidisciplinary meeting held in May 2014 established a list of evidence-based indications for breast mri, after which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests were calculated.

Results:
In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of breast mri exams (24 of 113), with preoperative staging representing 18% of exams (20 of 113) and high-risk screening representing 12% (13 of 113). Of pending mri requests, 230 were within the recommended delay period, and 457 exceeded the recommended delay. After elaboration of evidence-based guidelines, repeat audits in September 2014 and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23% (33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and 11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams. Overall, wait times were improved for all breast mri indications.

Conclusions:
Through multidisciplinary discussion, we actualized a list of breast mri indications, prioritized requests more adequately, and improved wait times.

Full text

IS THE NEED FOR BREAST MRI BEING MET? Tan et al.
e205Current Oncology, Vol. 24, No. 3, June 2017
© 2017 Multimed Inc.
ORIGINAL ARTICLE
Breast magnetic resonance imaging:
are those who need it getting it?
S. Tan md,* J. David md,* L. Lalonde md,* M. El Khoury md,* M. Labelle md,* R. Younan md,†
E. Patocskai md,† J. Richard md,‡ and I. Trop md mph*
ABSTRACT
Background Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for
breast invest igation, remai n controversia l, and accessibilit y is limited. The pu rposes of our st udy were to determine
the propor tion of breast mri exams p erformed for va rious clinica l indicat ions, to assess t he wait ti mes for breast mri,
and to create a list of evidence-based indications for breast mri.
Methods The indic ations for breast mr i exam s performed i n September 2013 at our academ ic centre were audit ed.
A multidisciplinar y meeting held in May 2014 established a list of evidence-based indications for breast mri, after
which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests
were calculated.
Results In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of
breast mri exams (24 of 113), w ith preoperat ive stagi ng representi ng 18% of ex ams (20 of 113) and h igh-risk scre ening
representing 12% (13 of 113). Of pending mri requests, 230 were wit hin the recommended delay period, and 457
exceeded the recommended delay. Af ter elaboration of evidence-based guidelines, repeat audits in September 2014
and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23%
(33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and
11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams.
Overa ll, wait times were improved for all breast mri indications.
Conclusions Through multidisciplinary discussion, we actualized a list of breast mr i indications, prioritized
requests more adequately, and improved wait times.
Key Words Breast cancer, imaging, mri
Curr Oncol. 2017 June;24(3):e205-e213 www.current-oncology.com
BACKGROUND
The Canada Hea lth Act governs every health system in
Canada and ensures universal access to health care for all
Canadian residents. However, accessibilit y, another prin-
ciple of the C anada Healt h Act, can b ecome compromise d.
Lately, the federa l government and the Wait T ime All iance
have been particu larly concerned about accessibility to
cancer care and diagnostic imaging1, 2. In t he 2015 Wait
Time Alliance report3, wa it times for magnetic resonance
imaging (mri) were on the r ise in Onta rio and Ma nitoba and
excee ded recommended b enchmark s for more than 50 % of
the popu lation in A lberta and P rince Edw ard Island . (Data
for the other 6 provinces are unknown because sufficient
data for the assessment were not provided.)
Despite the limited availability of mri, indications for
mri exa ms are incre asing ex ponential ly. In brea st imagi ng,
mri is ind icated for the dete ction and ma nagement of brea st
cancer, offering a sensitivity for cancer detection superior
to that w ith other imaging modalities—ranging between
71% and 100%4 –11. Bet ween 2000 and 2009, demand for
breast mri soared, increa sing by a factor of more t han 2012.
However, breas t mri must be u sed with d iscernment given
its limited specificity: ver y low in the earliest reports, but
now generally accepted to be in the 60%–80% range4 –11.
Moreover, evidence is increasing t hat preoperative stag-
ing mri might be detrimental to patients, unnecessarily
lengt hening thei r investigation time bec ause of the detec-
tion of additional nonspecific findings13 ,14 and increasing
the mastectomy rate with little reduction in re-excision
Correspondence to: Stephanie Tan, 5000 Belanger Street, Montreal, Quebec H1T 1C8.
E-mail: steph_tan@hotmail.com n DOI: https://doi.org/10.3747/co.24.3441

IS THE NEED FOR BREAST MRI BEING MET? Tan et al.
e206 Current Oncology, Vol. 24, No. 3, June 2017
© 2017 Multimed Inc.
and negative margins rates15. In that context, there has
been a call for moderation with respect to routine orders
for staging breast mri because no randomized controlled
trial has yet demonstrated improved surv ival for women
who undergo breast mri16.
Although severa l publications have analyzed breast
mri and its use, application of t he resulting knowledge
does not necessarily translate in day-to-day practice. In
2014, the Br east Cancer Sur veilla nce Consort ium reported
that only 25% of screening mr i exams were performed
for appropriate indications as defined by the American
Cancer Society guidelines17. Conversely, fewer t han 5% of
patient s at high ris k of breast canc er received brea st mri17.
In this era in which wait lists for mri exams and health
costs a re constant ly growing, improved pat ient selection
is urgently needed18.
In the fall of 2013, given the increasing controversy
about the use of breast mri, particularly as a preoperative
staging tool, and given the lengt hy wait lists for breast mri
at our institution, we audited our breast mri use. Using a
problem-solv ing model to br idge the gap bet ween academ ic
knowledge and clinical practice, we strove to improve
quality of care by a method that could be applied at other
institutions as well. The objectives of our project were to
ndetermine how breast mri was being used at our aca-
demic cent re, and par ticul arly the prop ortions of brea st
mri exams performed for various clinical indications;
nassess the wait times for breast mr i;
nrevie w the literat ure about breas t mri indications w ith
our multidisciplinary panel of breast specialists; and
ncreate a l ist of evid ence-based i ndication s for breast mri.
METHODS
The study used a clinica l audit strategy model.
Identify the Problem
The study was performed at the Centre hospitalier de
l’Univers ité de Montréal, a n academic tert iary-c are hospi-
tal where the medical team includes 5 fellowship-trained
breast i magers and 5 onco-surge ons special izing i n breast
surgery. Our breast clinic is an investigation site (Centre
de référence pour investigation désigné) for the Quebec
Breast C ancer Scree ning Prog ram, and it re ceives referr als
from other institutions in the province of Quebec, mostly
in the wider Montreal area. Annually, about 1600 breast
mri exams are performed.
To evaluate t he situation at our inst itution and to de-
term ine the improv ements required, a ll breast mri ex ams
perfor med in September 2013 were ret rospectively audit-
ed. All breast mri exams completed during that 1-month
period were retrieved and collected from our picture
arch iving a nd communica tion system, a nd the indication
for each ex am was rec orded. We then cla ssified ind ications
into these categories: preoperative staging; screening of
high-risk women; follow-up of mri-identified anomalies;
investigat ions for women wit h a personal h istory of breas t
cancer; surveillance of women with a history of lobula r
carcinoma in situ, at ypical ducta l hyperpla sia, or aty pical
lobular hyperplasia; troubleshooting (after a ny one or a
combin ation of inconclusive m ammogr aphy, ult rasonog-
raphy, or biopsy); investigation of nipple discharge; and
“other,” including e valuation of bre ast impla nts, search for
a primary cancer in the presence of malignant adenopa-
thy, and positive margins after breast surgery.
Evaluate Outcomes
In September 2013, 16 hours were dedicated every week
for breast mri exams, allowing for the evaluation of ap-
proximately 26 patients having a standard 30-minute
diagnostic exam and 2 patients having mri-guided
breast biopsies (90 minutes allotted per procedure). At
the end of September 2013, we ana lyzed pending breast
mri requests as tracked by our administrative system.
We classified ever y request as being within wait times
recommended by the Canadia n Association of Radio-
logists19 and set out in Quebec governmental guidelines
(provincial recommendations are for imaging within 90
days after reception of a first request a nd within 30 days
for follow-up ex aminat ions); exceeding wait t imes by less
tha n 6 months; exc eeding wa it times by 6 –12 months; a nd
exceeding wait t imes by more than 12 months. We also
projected the number of days before the next non-urgent
breast mri would be available.
Adapt Knowledge to Local Context
To verify that our use of breast mri complied with the
latest published recommendations and to improve our
serv ice to patients, we organized a multidiscipl inary half-
day scientific session for the breast team, which was held
in May 2014. Of 28 possible participants, 21 attended the
meeting, representing all invited fields: 5 radiologists, 4
surgical oncologists, 2 medical oncologists, 2 radiat ion
oncologists, 2 geneticists, 3 breast physicians, and 3 radi-
ology residents. An informal review of the literature about
mri use for brea st cancer sta ging, hig h-risk screening, and
other indicat ions was presented. There was t hen a discus-
sion until multidisciplina ry consensus was reached for a
scientifically acceptable compromise between published
evidence and mr i availability at our institution.
The order ing radiolog y form for breast mri wa s subse-
quentl y modified to refle ct the actu aliz ed accepted ind ica-
tions for mri, and steps were taken to make the document
easi ly accessible to a ll cli nician s in their da ily cli nical wor k.
Monitor Knowledge Use
In September 2014 and September 2015, we re-audited all
breast mri exams performed during the 1-month period
and collected data for each exa m’s indication. We calcu-
lated t he number of pendi ng breast mri reques ts at the end
of both mont hs and categor ized them i n the same ma nner
as before the consensus.
RESULTS
Pre-consensus Evaluation
Our initial institutional review from September 2013
showed that 27% of breast mri exa ms (30 of 113) were per-
formed for follow-up of an mr i-identified lesion. Women
with a personal histor y of breast cancer or needing preop-
erative stag ing constit uted the 2nd and 3rd most common

IS THE NEED FOR BREAST MRI BEING MET? Tan et al.
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indications for women to undergo breast mri (21%, 24 of
113, and 18%, 20 of 113, respe ctively). Sc reening of h igh-risk
women came in 4th place and represented only 12% of all
breast mri studies (13 of 113, Table i).
Review of 687 pending breast mri requests at the
end of September 2013 revealed that 67% exceeded
recom mended wait times, with 294 (43%) exceeding rec-
ommended wait times by less than 6 months, 93 (14%)
exceeding them by 6 –12 months, and 70 (10%) exceeding
them by more t han 12 months (Table i). Actuaria l calcula-
tions e stimated t hat the next e lective brea st mri slot would
be available in 320 days.
Consensus
Review of the September 2013 breakdown of breast mri
examinations according to indications and compilation
of the overall wait times for such exams confirmed t hat
improvement was in order.
Discussion by t he 21 member s of the br east team who
participated in the May 2014 multidisciplinar y meeting
achieved a consensus regarding the use of breast mri.
Evidence-based accepted indications for breast mri fell
into t wo major categorie s: preoperat ive stagi ng in specific
clinical situations and high-risk screening (Table ii). For
the lat ter category, given that severa l requests for women
wit h a strong fam ily hist ory of breast ca ncer were awa iting
forma l genetic eva luation, screening mri was a lso accept-
ed for women fulfilling the high-risk criteria for familial
breast cancer based on the (Australian) National Breast
and Ov arian Cancer Centre classi fication62. Discussions
als o covered when to sta rt and stop mri sc reening. Table ii
presents t he full list of evidence-based indications for
breast mri applied at the C entre hospital ier de l’Université
de Montréa l.
Alt hough evidenc e from the lit erature for med the base
of our in stitution al guidel ines, the re ality of ou r partic ular
pract ice was ta ken into considera tion durin g the multid is-
cipli nary me eting. Ou r genetics ex perts sug gested referr ing
women for a genetic evaluation when they fulfilled any of
these criteria: less than 50 years of age with breast cancer;
havi ng a first-degr ee relative d iagnosed w ith breast c ancer
before t he age of 50; hav ing multice ntr ic cancer; a nd being
diag nosed wit h triple-negat ive cance r at a young age. How-
ever, because the wait time for a genetic consultation can
be relat ively long, potent ially del aying brea st mri screening
for patients who might be at high risk, the consensus of
the breast tea m was to allow patients considered hig h risk
according to clinical criteria who were awaiting genet ics
evaluation to immediately benefit from annual breast mri
evaluation. The high-risk clinical criteria were based on
the Austra lian classification because that classification is
easily applicable62.
The dec ision to use mri to eva luate patients w ith tr iple-
negative breast cancer was another point of discussion
during the meeting. Although results from the alliance
A011104/ac rin 6694 study on the subject are st ill pending,
radiology ex perts determined they had the capacity to
honour reque sts for thi s indicat ion given that p atients wit h
tr iple-negative ca ncer represent on ly a small p roportion of
our patient population.
TABLE I Volume of, and wait times for, breast magnetic resonance imaging (MRI) exams before and after consensus implementation
Variable Month of September in ...
2013 2014 2015
Breast MRI exams performed (n) 113 141 143
Exams performed (%) for ...
Preoperative staging 18 9 11
(n=20) (n=13) (n=16)
High-risk screening 12 36 46
(n=13) (n=51) (n=66)
Women with a personal history of breast cancer 21 23 7
(n=24) (n=33) (n=10)
Follow-up of a MRI-identified lesion 27 13 18
(n=30) (n=18) (n=26)
Total pending breast MRI requests [n (%)] 687 612 301
Requests within recommended wait timea230 (33) 168 (27) 129 (43)
Requests exceeding wait time
By <6 months 294 (43) 182 (30) 82 (27)
By 6–12 months 93 (14) 192* (31) 74 (25)
By >12 months 70 (10) 70* (11) 16 (5)
Actuarial estimate of next non-urgent breast MRI availability (days) 320 250 176
a Quebec provincial guidelines are for imaging within 90 days of reception of a first request; follow-up examinations should be performed within
30 days.

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It was determined that all requests for breast mri that
deviated from the consensus would no longer be routinely
accepte d at our institut ion, inc luding speci fic situation s in
which , althoug h the literat ure mig ht show some evidenc e of
benefit, the benefit is not sufficient to warrant routine use
of mri (Tab le iii). For ex ample, women whos e famil y history
suggests a moderate risk for breast cancer are not candi-
dates for mri screening before formal genetic evaluation,
nor are women w ith no risk factor other than a personal
histor y of breast cancer. Similarly, our literature review
did not support continued mri screening for high-risk
women who had u ndergone bilatera l mastect omy whether
prophylactic or therapeutic, nor did it support continued
mri surveillance of high-risk women after 69 years of age.
The conclusions from our exchanges were summa-
rized in a w ritten document that was circulated to a ll 28
TABLE II Institutional consensus of evidence-supported, accepted breast magnetic resonance imaging (MRI) indications
1. Preoperative staging15,20–39
Recommend or consider MRI in these situations:
nSearch for primary breast cancer in woman with metastatic axillary lymph nodes
nPaget’s disease of the nipple
nInfiltrating lobular carcinoma (unless mammography and ultrasonography evaluations were felt to be radiologically satisfactory)
nBreast cancer in a woman younger than 35 years of age
nHER2-positive or triple-negative cancers (as part of research protocols)
nBefore neoadjuvant chemotherapy (unless MRI would not affect surgical planning)
nLocally advanced breast cancer with suspected pectoralis muscle or skin invasion
nAfter surgery with positive margins
2. High-risk screening36,37,38,40–61
Recommend annual MRI screening for these women:
nHaving BRCA mutation or being a first-degree relative of a family member with BRCA mutation
nSyndromes44
nHaving Li-Fraumeni (TP53), Cowden (PTEN), or Bannayan–Riley–Ruvalcaba, and their first-degree relatives
nLifetime risk exceeding 20% as calculated by breast cancer risk-assessment tool
nHaving had radiation to the chest between the ages of 10 and 30 years
Recommended MRI screening for women with a strong family history who have not yet been evaluated in genetics when they fulfil these high-
risk criteria:
nMutation identified in the family
nHaving 3 or more first- or second-degree relatives with breast or ovarian cancer (same side of the family)
n Having 2 or more first- or second-degree relatives with breast or ovarian cancer (same side of the family) and at least 1 of the following
risk factors: bilateral cancer, diagnosis at less than 40 years of age, male breast cancer, or breast and ovarian cancer in the same person
When screening MRI should begin
nStart at 25–30 years of age for those with a BRCA1/2 mutation (or who are a first-degree relative)
nStart at 20 years of age for those with Li-Fraumeni (TP53) (or who are a first-degree relative)
nStart at 30 years of age for high-risk patients without formal genetic evaluation
nStart at 8 years after the end of treatment for patients with history of mediastinal radiation therapy
When screening MRI should stop
nAnnual screening MRI can cease at 69 years of age for all high-risk patients, regardless of breast density
nFor women with prophylactic mastectomy (including removal of the nipple–areola complex)
nClinical surveillance if no reconstruction
nIn the presence of an autologous graft, mammography every 18–24 months
n In presence of breast implants: first postoperative evaluation includes mammography; if no residual breast tissue, perform subsequently
physical exam only, no imaging follow-up
nFor women with therapeutic mastectomy (including removal of the nipple–areola complex)
nClinical surveillance if no reconstruction
nIf reconstruction with an autologous graft: annual mammography
n If reconstruction with breast implants: postoperative mammography to verify presence of residual tissue and yearly mammography
thereafter if tissue is present
nFor women with preserved nipple–areola: annual mammography

IS THE NEED FOR BREAST MRI BEING MET? Tan et al.
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members of the breast tea m for final approval (the 21 who
had attended the meeting and t he few who had not been
able to atte nd). The fina l document was t hen sent by e-mai l
to all physicians involved in breast care at our institution,
and a pr intout of the consen sus was made ea sily acce ssible
to clinicians and radiologists at their clinics and worksta-
tions. It was decided that all breast mri requests received
before t he consensus me eting would b e honoured, wit hout
questioning the indication. However, for every new mri
request received after May 2014 that did not meet the new
consensus, a letter informing the referring physician of
the rejected request was sent together with the summa-
rized recommendations from the consensus meeting. It
was clearly stated t hat the consensus g uidelines aimed to
standardize our institution’s use of breast mri, but did not
replace t he physician’s clin ical judg ment. They were t here-
fore inv ited to contact t he radiologi st direc tly to disc uss the
case in further detail, if desired.
The ordering radiolog y form for breast mri wa s
modified to reflect the consensus guidelines (Table iv).
Although our initia l prescription form included subcat-
egories of preoperative imaging (re-excision for posi-
tive margins and search for primary breast cancer), all
subcategories were merged under the single category of
preoperat ive stagi ng. To improve access to screen ing mri
for women with a genet ic susceptibilit y, the ordering form
was a lso modified to subdivide a ll screen ing mri requests
into t wo groups: wome n with a proven gen etic suscept ibil-
ity to breast ca ncer, such as carriers of a BRCA mutation
and their first-degree relatives; a nd all other women wit h
suf ficiently str ong risk factor s to justif y mri screeni ng, but
with no formal genetic evaluation. Specific reference to
our consensus document was added to the new ordering
form to reaffirm our determination to respect the insti-
tutional consensus.
In addit ion to detailing the indications for breast mri,
our new ordering form also provided guidelines for exam
priorit y: preopera tive stag ing and eva luation of chemot her-
apy response are first-priority evaluations (P1); follow-up
for probably b enign lesions ( Breast Imag ing Report ing and
Data Sys tem class 3), proble m-solving a fter mam mography
and u ltrasonog raphy, and invest igation of nipple d ischarg e
are moderate-priority evaluations (P2); and screening of
high-risk women with a genetic susceptibility receive the
next priority rating (P3). All other screening requests and
implant evaluations are last-priority examinations (P4).
Post-consensus Evaluation
After implementation of the consensus guidelines, the
proport ion of breast mri ex ams perfor med for each ind ica-
tion changed markedly (Table i, Figure 1). One year after
apply ing the new g uidelines , at the first re-au dit, screen ing
mri rose fr om the 4th most com mon indication to t he most
common indicat ion. That trend continued in t he subse-
quent year, with t he proportion of screening mri exams
reaching 46% of all breast mri exams in September 2015,
compared with 36% 1 year earlier and only 12% in 2013.
Conversely, the proportion of breast mri exams per-
formed for preoperat ive stagi ng was cut in half 1 year a fter
the consensus, dropping to 9% (2014) from 18% (2013). In
September 2015, the proport ion of preoperative br east mri
exams remained relatively stable at 11%.
TABLE III Institutional consensus about breast magnetic resonance
imaging (MRI) indications no longer accepted at our institution
There is not enough evidence to recommend annual surveillance
with MRI for women with these risk factors:
nPrior history of breast cancer
n Personal history of lobular neoplasia or atypia (lobular
carcinoma in situ, atypical lobular hyperplasia, atypical ductal
hyperplasia)
nWomen with dense breasts
Screening MRI will not be offered to women at moderate risk based
on family history, before a formal calculation of their lifetime risk
nThese criteria serve as reference to define moderate risk:
n 1 or 2 first-degree relatives with breast cancer before 50
years of age (same side of the family) and without high-risk
factors
n 2 first- or second-degree relatives with breast or ovarian
cancer (same side of the family) without high-risk factors
TABLE IV Changes made to the initial prescription form after the
consensus
Initial prescription form
Indications
nBreast cancer
n Breast Imaging Reporting and Data System (BI-RADS)
5 lesion (awaiting confirmation)
nRecent diagnosis—evaluate extension
nPrevious diagnosis
nScreening: high-risk for breast cancer
nEvaluation of chemotherapy response
nSearch for primary cancer
nPositive margins post-tumourectomy
nShort-term magnetic resonance imaging follow-up (BI-RADS 3)
nProblem-solving: mammography or ultrasound anomaly
nNipple discharge
nBreast implants
nPost-biopsy follow-up
nOther
Post-consensus form
Indications
nPreoperative staging (per the May 2014 consensus)
nEvaluation of chemotherapy response
n Short-term follow-up (BI-RADS 3 and post–magnetic resonance
imaging biopsy)
nProblem-solving after mammography and ultrasonography
nNipple discharge
n Screening high-risk women (for example, BRCA
and first-degree relatives)
nScreening other women at increased risk
nBreast implant evaluation

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The 2nd most c ommon indic ation for breast mri i n 201 3
was surveillance of women prev iously treated for breast
cancer, but consensus guidelines established t hat breast
mri would no longer be performed solely for that risk fac-
tor. Because of an important back log of women awaiting
mri for that indication, the effect of the recommendation
was noticed only 2 years after implementation, when the
proport ion of breast mri ex ams for th at indicati on dropped
to 7% from the 21% observed in September 2013.
The number of scheduling slots available for breast
mri increa sed slight ly during t he study period, to 19 hours
from 16 hours weekly, thus allowing 143 breast mri exams
to be performed i n September 2015 compared w ith the 113
performed in September 2013. That measure, combined
with an improved selection of women undergoing breast
mri because of clear institutional consensus guidelines
having been established, resulted in globally improved
wait times for all breast mri exams (Table i): the 320-day
delay for the next av ailable mri slot in September 2013 was
reduced t o 176 day s in September 2015. Breast mr i requests
awaiting scheduling and requests exceeding recommended
wait t imes by less t han 6 months a lso improved i n the year
af ter the consen sus guidel ines were est ablished. B ecause of
the accumulated backlog, the effect of the new guidelines
on requests exceeding recommended wait times by more
than 6 months was observed only during the 2nd year of
follow-up.
DISCUSSION
With the introduction of mri into the detection and man-
agement of brea st cancer, mult iple associat ions, includ ing
the Canadian Association of Radiolog ists, the American
Cancer Societ y, and the American College of Radiology,
have publ ished guide lines for the a ppropriate use of brea st
mri38,63,65. Taking into account more recently published
data, those recommendations can be incomplete, contra-
dictor y, or outdated for some situations. Moreover, given
that policies and distribution of medical resources can
be quite different from country to count ry, recommenda-
tions by foreign medica l associations should be caref ully
considere d before they a re adopted into loca l practice. T he
Choosi ng Wisely Ca nada camp aign— based on the conc ept
that good care for patients is achieved by prescribing the
right tests to the right pat ients64,65—is crucial consider ing
the high cost and limited availability of breast mri. With
its excellent sensitivity but lower specificity, mri leads to
additional tests and investigations, increased costs, and
incre ased wait t imes for pat ients, which m ight lead to more
harm tha n good.
Acknowledging t he challenges associated w ith breast
mri, the objectives of our clinical audit were successfully
reached. We improved breast mri use at our institution by
accept ing only ev idence-base d indication s, and as a resu lt,
avai lability for this imaging moda lity for all women need-
ing it was improved. By better defining high-risk patients
in need of screening, clearly listing situations in which
preoperat ive imag ing could be bene ficial, and el iminat ing
mri use where scientific ev idence of benefit was not estab-
lished, increased priority was given to high-risk screening
stud ies, with i mproved schedu ling of speci fic preoperativ e
mri evaluations.
Our ex pert consensus on breast mri indications had a
positive effect on wait times within the initial year of ap-
plicat ion. However, because of t he high volu me of pending
mri request s, with dela ys for non-urgent mri exa ms of close
to a year (320 days) at the project’s onset, the effect of t he
new guidelines was not fu lly evident until the 2-year post-
implementation cycle.
As soon a s the consensu s guidelines were i ntroduced,
complia nce was high, reflecting the elevated participa-
tion rate in our multidisciplinary meeting, with at least
FIGURE 1 The distribution of clinical indications for which breast magnetic resonance imaging (MRI) was performed in the months of September
2013, September 2014, and September 2015. LCIS = lobular carcinoma in situ; ADH = atypical ductal hyperplasia; ALH = atypical lobular hyperplasia.

IS THE NEED FOR BREAST MRI BEING MET? Tan et al.
e211Current Oncology, Vol. 24, No. 3, June 2017
© 2017 Multimed Inc.
1 representative of each subspecia lty being present. By
significantly contributing to the project, all members of
the breast team felt motivated to adhere to t he group’s
consensus and to take pride in its success. Enough t ime
was prov ided in the multidisciplinary consensus meeting
to allow for all concerns about possible sequelae of the
upcoming changes to be voiced, thus ensuring that, as
soon as the consensus g uidelines were introduced, they
would be readily applicable for our breast centre and our
patient population. Reminding the breast team and refer-
ring physicians of t he consensus guidelines and making
them easily available for quick reference during the daily
workflow were also critical to the project’s success.
Beyond our hospita l, our instit utional work was made
available to all professionals interested in breast mr i and
striving to improve their use of this technology. It also
formed the basis for a first draft of prov incial Quebec
guidelines, mandated by t he Ministère de la Santé et des
Serv ices sociaux and proposed by the Direction générale
de cancérologie, with publication in May 201666.
CONCLUSIONS
Through collaboration by a ll members of the breast
team, we actualized a list of breast mri indications at
our institution. Application of the resulting guidelines
improved the service to women awaiting breast mri,
particularly those with a genetic predisposition, for
whom annual screening is recommended. We expect to
regu larly update our ex pert consensus as new guidelines
and studies are published.
Because access to technology is a constant challenge
and a preoccupation in our health system and elsewhere
in the world, the method we used to tackle the volume of
breast mri requests in the presence of limited technol-
ogy availability could be applicable in other settings. The
process of a clinica l audit is relatively simple, based on
multidisciplinar y work a nd a desire to improve access for
all patients.
Addendum
Since the writing of this manuscript, the results of our
project have been used as the foundation of a prov incial
eva luation of breast mri i ndications u nder the super vision
of the In stitut national d’excellence en sa nté et en services
sociaux of Quebec.
CONFLICT OF INTEREST DISCLOSURES
We have read a nd understood Current Oncology’s policy on dis-
closing confl icts of interest, and we declare that we have none.
AUTHOR AFFILIATIONS
*Depa rtment of Rad iology, †Depa rtment of Su rgery, and ‡Depart-
ment of Gener al Medic ine, l’Unive rsité de Montré al, Montre al, QC.
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