7 ms·

Breast MRI in cancer survivors results in more unneeded biopsies

29 points by howard941 7y ago

jedberg 7y ago
It's the same results for starting mammograms at 40 vs 50. They're now recommending to start at 50, unless you have a family history, because they found a lot of false positives in women who started getting mammograms at 40 who didn't have high risk.
- makmanalp 7y ago
  I have two questions: 1) From the POV of the patient, how bad / invasive is getting a biopsy? Wouldn't you always want the low-risk biopsy over having discovered a problem too late? From a public health / insurance perspective, I get that you're trying to lower costs and time wasted, which are sadly conflicting goals :-( 2) It's always been so shocking to me that the reaction to "we get false positives" is not "we need to pour money for research into much better diagnostic techniques yesterday" and instead it's "well I guess we'll just not look then".
  - deleted 7y ago
    [deleted]
  - momokoko 7y ago
    Considering that this was funded by the Patient-Centered Outcomes Research Institute[1], which was started as part of the Affordable Care Act, my guess is that this was indeed done to help reduce overall health care costs from unneeded procedures. [1] https://www.pcori.org https://www.pcori.org
  - joshgel 7y ago
    These are interesting questions. If biopsy was totally benign you'd be right. But there are complications and rarely serious complications of breast biopsy. "How bad / invasive is getting a biopsy?" perhaps you are willing to accept those risks, but you have to also accept the risk that you are getting treated for cancer you don't have. Pathology isn't perfect [0]. Should we invest more in getting better results? Yes, and we are. But, we also have to come up with a risk/benefits strategy for the technology we have now for the patients we have now. Everything in medicine is risk/benefit because our data and our interpretation of that data isn't perfect. 0: https://jamanetwork.com/journals/jama/fullarticle/2203798 https://jamanetwork.com/journals/jama/fullarticle/2203798
  - bregma 7y ago
    > how bad / invasive is getting a biopsy? About the same as getting a prostate biopsy, except you can lie on your back instead of on your side while they shove several large hollow needles into your flesh to cut out pieces of a very sensitive gland.
    - lotu 7y ago
      I don't think comparing it to prostate biopsy helps most people. I assume they anesthetize you so you don't actually feel pain just really weird, possibly upsetting tugging right? Afterwards you take some regular pain killers for a few days. This doesn't feel like a big deal to me but I'm likely wrong. Maybe it is only a big deal for some people like how how people who are claustrophobic freak out in the MRI.
      - bregma 7y ago
        Prostate biopsies are usually done without any anaethesia, just a bug gun up the bung that fires multiple needles and retracts. Breast biopsies maybe use sedation and maybe a local bit of lidocaine, maybe not, depending. It doesn't make a lot of sense to stick a needle in so you don't feel a needle sticking in, but they're different gauge needles.
    - walshemj 7y ago
      Depends on where, I have had kidney biopsys its painless but does take a team of 3 and you spend most of a day flat on your back (taking up a hospital bed) being monitored every 15 mins
  - jedberg 7y ago
    > It's always been so shocking to me that the reaction to "we get false positives" is not "we need to pour money for research into much better diagnostic techniques yesterday" and instead it's "well I guess we'll just not look then". I think it is both. I think we tell people not to get bad diagnostics while also putting a lot of research into making the diagnostics better so we can tell them to get the diagnostics again.
arkades 7y ago
Countdown to “but more data is always better.”
- deleted 7y ago
  [deleted]
- jdashg 7y ago
  Is it not the saddest thing that our outcomes are so poor that deliberately starving ourselves of data is the safest course of action? Sure, people will die of cancer we could have caught, but at least we wouldn't kill a yet-larger group of false positives through mistreatment?? A system with this-perverse of an outcome is broken.
  - EdwardDiego 7y ago
    I suspect your comment is not super related to the article, as very very few people die from biopsies.
  - arkades 7y ago
    It’s not a broken system. It’s a limitation of the current state of human knowledge. Perfect information about X without the state of knowledge to interpret that information prompts flawed action. You are not living at the end of time, at the peak of human knowledge. There are things we know enough about to interpret; there are things we don’t. The former we test; the latter prompts scientific research.
  - reallydude 7y ago
    > at least we wouldn't kill a yet-larger group of false positives through mistreatment Killing? What are you talking about? Yet-larger? What data are you basing this on?
howard941 7y ago
> Breast MRI had a cancer detection rate (CDR) of 10.8 per 1,000 exams compared to mammography’s CDR of 8.2 per 1,000 examinations. However, breast MRI had a biopsy rate of 10.1%, double that of mammography’s 4% rate. [emphasis added] What's going on with the biopsy rate? Is it something as simple/nefarious as recouping the cost of the equipment?
- seren 7y ago
  I have not read the article but I believe that usually routine exams are done with X Ray, because it is quicker and cheaper. However if something is a bit worrying, doctor may ask for a different type of exam, MRI or Ultrasound, to have some confirmation. But since this is rarer people who have MRI are already people at risk, so it makes sense to have a higher rate of biopsy in the end.
nathan_f77 7y ago
I strongly believe that more data is always better. (But more testing is not always better if it's an invasive biopsy.) If more data results in more unneeded biopsies, then just stop taking biopsies! It seems very obvious that the answer is to perform a series of MRI scans over a period of weeks or months, and track the size of the lump. If it's growing rapidly (or more lumps appear), then you would perform a biopsy. I don't even think you need machine learning for this. It just seems obvious that a quickly growing lump is cancer (almost by definition), so you need multiple scans over time to detect the rate of growth. Is this a controversial opinion? Why is better to wear a metaphorical blindfold instead of just being smarter about what you do with the data? Is this because MRIs are expensive and are in high demand, so it's just not practical to do this? EDIT: I updated my comment to remove "more testing is always better".
- arcticbull 7y ago
  Truthfully more testing isn’t always better because the negative consequences of false positives often outweighs the value of tests. It’s the reason you don’t get prostate exams until you’re middle aged. Humans are weird and lumpy and all different. Testing can be bad for you until you until the math works out, and (risk of disease * consequences of missing it) exceeds (risk of false positive * consequences of exploring/treating). It’s just a numbers game.
  - nathan_f77 7y ago
    That makes sense. What do you think about taking regular MRI scans and tracking a growth over time? If biopsies were reserved for fast-growing lumps, then there shouldn't be any harm in collecting a sequence of images. I know MRIs are expensive and take a long time, but I'd gladly jump into an MRI machine for a few hours once a year. And then maybe once every 6 months when I'm in my 60s. I know that humans are weird and different, and all of us have weird lumps and spots that show up on a scan. My proposal is to just track each spot and keep an eye on them over a period of months or years. We already do this with mole mapping, and MRI scans allow us to do "mole mapping" for our entire body. From an interview about mole mapping [1]: > Dr. Curtis: So, generally, what I tell patients is if they have a lot of moles, they should get mole mapped, or if they even have a lot of funny looking moles to them. They might not have a ton, but at the same time, they still might have enough that they are curious about them and they're hard to track, if they're hard to know if they're new or changing. > Interviewer: Let's talk about the benefits of having this procedure done because there are a lot of them. First and foremost, it can save lives. > Dr. Curtis: Yes, it can. It can save lives in the way that we can find melanoma earlier and thinner when it is the absolute most survivable. > Interviewer: And what are some of the other benefits as well? > Dr. Curtis: So you can catch new moles that could be just benign, not changing, that are not melanoma, which are important to know about. You can also tell if your moles are going away. As you get older some of your moles do go away and it can track that. So it gives you peace of mind. And it can reduce the number of biopsies as well on patients. [1] https://healthcare.utah.edu/the-scope/shows.php?shows=0_3wgc6sob https://healthcare.utah.edu/the-scope/shows.php?shows=0_3wgc...
mbell 7y ago
A related issue is thyroid cancer. Diagnosis rates started increasing dramatically almost everywhere in the world in the mid 80's. Diagnosis rates in the US for example have tripled since 1980, in South Korea they have gone up 13x since 1993. Meanwhile the mortality rate has been completely flat. The most likely cause of this is increase in both screening and the sensitivity of testing [1]. There is also a current debate about if we should be screening / treating thyroid cancer the way we are, i.e. it seems like we're detecting a lot of innocuous thyroid cancers and then operating without need resulting in unnecessary life long complications for the person. [1] https://www.bmj.com/content/355/bmj.i5745 https://www.bmj.com/content/355/bmj.i5745
lotu 7y ago
From the article it sounds like most of the harm of false positives from the MRI is the extra stress of the biopsy and/or waiting for biopsy results. As such it feels rational to try to treat the stress/anxiety with well know methods like talk therapy. Prescheduling an appointment for after the MRI/Biopsy might greatly reduce the stress of patients. Of course this runs into the cost "problem". The rest is pure speculation based on how it appears these procedures are portrayed. Patients think of the MRI as yes/no for cancer and when comes back as yes they get understandably upset. If instead the MRI biopsy are presented as a single procedure (ideally done together, but money) the MRI is just getting targeting information needed for the biopsy not providing a yes/no decision. If it turns out there is nothing to biopsy the patient gets a happy surprise no-one is ever upset about this. (Again problem of money)

29 points by howard941 7y ago

It's the same results for starting mammograms at 40 vs 50. They're now recommending to start at 50, unless you have a family history, because they found a lot of false positives in women who started getting mammograms at 40 who didn't have high risk.

makmanalp 7y ago
I have two questions: 1) From the POV of the patient, how bad / invasive is getting a biopsy? Wouldn't you always want the low-risk biopsy over having discovered a problem too late? From a public health / insurance perspective, I get that you're trying to lower costs and time wasted, which are sadly conflicting goals :-( 2) It's always been so shocking to me that the reaction to "we get false positives" is not "we need to pour money for research into much better diagnostic techniques yesterday" and instead it's "well I guess we'll just not look then".
- deleted 7y ago
  [deleted]
- momokoko 7y ago
  Considering that this was funded by the Patient-Centered Outcomes Research Institute[1], which was started as part of the Affordable Care Act, my guess is that this was indeed done to help reduce overall health care costs from unneeded procedures. [1] https://www.pcori.org https://www.pcori.org
- joshgel 7y ago
  These are interesting questions. If biopsy was totally benign you'd be right. But there are complications and rarely serious complications of breast biopsy. "How bad / invasive is getting a biopsy?" perhaps you are willing to accept those risks, but you have to also accept the risk that you are getting treated for cancer you don't have. Pathology isn't perfect [0]. Should we invest more in getting better results? Yes, and we are. But, we also have to come up with a risk/benefits strategy for the technology we have now for the patients we have now. Everything in medicine is risk/benefit because our data and our interpretation of that data isn't perfect. 0: https://jamanetwork.com/journals/jama/fullarticle/2203798 https://jamanetwork.com/journals/jama/fullarticle/2203798
- bregma 7y ago
  > how bad / invasive is getting a biopsy? About the same as getting a prostate biopsy, except you can lie on your back instead of on your side while they shove several large hollow needles into your flesh to cut out pieces of a very sensitive gland.
  - lotu 7y ago
    I don't think comparing it to prostate biopsy helps most people. I assume they anesthetize you so you don't actually feel pain just really weird, possibly upsetting tugging right? Afterwards you take some regular pain killers for a few days. This doesn't feel like a big deal to me but I'm likely wrong. Maybe it is only a big deal for some people like how how people who are claustrophobic freak out in the MRI.
    - bregma 7y ago
      Prostate biopsies are usually done without any anaethesia, just a bug gun up the bung that fires multiple needles and retracts. Breast biopsies maybe use sedation and maybe a local bit of lidocaine, maybe not, depending. It doesn't make a lot of sense to stick a needle in so you don't feel a needle sticking in, but they're different gauge needles.
  - walshemj 7y ago
    Depends on where, I have had kidney biopsys its painless but does take a team of 3 and you spend most of a day flat on your back (taking up a hospital bed) being monitored every 15 mins
- jedberg 7y ago
  > It's always been so shocking to me that the reaction to "we get false positives" is not "we need to pour money for research into much better diagnostic techniques yesterday" and instead it's "well I guess we'll just not look then". I think it is both. I think we tell people not to get bad diagnostics while also putting a lot of research into making the diagnostics better so we can tell them to get the diagnostics again.

arkades 7y ago

Countdown to “but more data is always better.”

deleted 7y ago
[deleted]
jdashg 7y ago
Is it not the saddest thing that our outcomes are so poor that deliberately starving ourselves of data is the safest course of action? Sure, people will die of cancer we could have caught, but at least we wouldn't kill a yet-larger group of false positives through mistreatment?? A system with this-perverse of an outcome is broken.
- EdwardDiego 7y ago
  I suspect your comment is not super related to the article, as very very few people die from biopsies.
- arkades 7y ago
  It’s not a broken system. It’s a limitation of the current state of human knowledge. Perfect information about X without the state of knowledge to interpret that information prompts flawed action. You are not living at the end of time, at the peak of human knowledge. There are things we know enough about to interpret; there are things we don’t. The former we test; the latter prompts scientific research.
- reallydude 7y ago
  > at least we wouldn't kill a yet-larger group of false positives through mistreatment Killing? What are you talking about? Yet-larger? What data are you basing this on?

howard941 7y ago

> Breast MRI had a cancer detection rate (CDR) of 10.8 per 1,000 exams compared to mammography’s CDR of 8.2 per 1,000 examinations. However, breast MRI had a biopsy rate of 10.1%, double that of mammography’s 4% rate. [emphasis added] What's going on with the biopsy rate? Is it something as simple/nefarious as recouping the cost of the equipment?

seren 7y ago
I have not read the article but I believe that usually routine exams are done with X Ray, because it is quicker and cheaper. However if something is a bit worrying, doctor may ask for a different type of exam, MRI or Ultrasound, to have some confirmation. But since this is rarer people who have MRI are already people at risk, so it makes sense to have a higher rate of biopsy in the end.

nathan_f77 7y ago

I strongly believe that more data is always better. (But more testing is not always better if it's an invasive biopsy.) If more data results in more unneeded biopsies, then just stop taking biopsies! It seems very obvious that the answer is to perform a series of MRI scans over a period of weeks or months, and track the size of the lump. If it's growing rapidly (or more lumps appear), then you would perform a biopsy. I don't even think you need machine learning for this. It just seems obvious that a quickly growing lump is cancer (almost by definition), so you need multiple scans over time to detect the rate of growth. Is this a controversial opinion? Why is better to wear a metaphorical blindfold instead of just being smarter about what you do with the data? Is this because MRIs are expensive and are in high demand, so it's just not practical to do this? EDIT: I updated my comment to remove "more testing is always better".

arcticbull 7y ago
Truthfully more testing isn’t always better because the negative consequences of false positives often outweighs the value of tests. It’s the reason you don’t get prostate exams until you’re middle aged. Humans are weird and lumpy and all different. Testing can be bad for you until you until the math works out, and (risk of disease * consequences of missing it) exceeds (risk of false positive * consequences of exploring/treating). It’s just a numbers game.
- nathan_f77 7y ago
  That makes sense. What do you think about taking regular MRI scans and tracking a growth over time? If biopsies were reserved for fast-growing lumps, then there shouldn't be any harm in collecting a sequence of images. I know MRIs are expensive and take a long time, but I'd gladly jump into an MRI machine for a few hours once a year. And then maybe once every 6 months when I'm in my 60s. I know that humans are weird and different, and all of us have weird lumps and spots that show up on a scan. My proposal is to just track each spot and keep an eye on them over a period of months or years. We already do this with mole mapping, and MRI scans allow us to do "mole mapping" for our entire body. From an interview about mole mapping [1]: > Dr. Curtis: So, generally, what I tell patients is if they have a lot of moles, they should get mole mapped, or if they even have a lot of funny looking moles to them. They might not have a ton, but at the same time, they still might have enough that they are curious about them and they're hard to track, if they're hard to know if they're new or changing. > Interviewer: Let's talk about the benefits of having this procedure done because there are a lot of them. First and foremost, it can save lives. > Dr. Curtis: Yes, it can. It can save lives in the way that we can find melanoma earlier and thinner when it is the absolute most survivable. > Interviewer: And what are some of the other benefits as well? > Dr. Curtis: So you can catch new moles that could be just benign, not changing, that are not melanoma, which are important to know about. You can also tell if your moles are going away. As you get older some of your moles do go away and it can track that. So it gives you peace of mind. And it can reduce the number of biopsies as well on patients. [1] https://healthcare.utah.edu/the-scope/shows.php?shows=0_3wgc6sob https://healthcare.utah.edu/the-scope/shows.php?shows=0_3wgc...

mbell 7y ago

A related issue is thyroid cancer. Diagnosis rates started increasing dramatically almost everywhere in the world in the mid 80's. Diagnosis rates in the US for example have tripled since 1980, in South Korea they have gone up 13x since 1993. Meanwhile the mortality rate has been completely flat. The most likely cause of this is increase in both screening and the sensitivity of testing [1]. There is also a current debate about if we should be screening / treating thyroid cancer the way we are, i.e. it seems like we're detecting a lot of innocuous thyroid cancers and then operating without need resulting in unnecessary life long complications for the person. [1] https://www.bmj.com/content/355/bmj.i5745 https://www.bmj.com/content/355/bmj.i5745

lotu 7y ago

From the article it sounds like most of the harm of false positives from the MRI is the extra stress of the biopsy and/or waiting for biopsy results. As such it feels rational to try to treat the stress/anxiety with well know methods like talk therapy. Prescheduling an appointment for after the MRI/Biopsy might greatly reduce the stress of patients. Of course this runs into the cost "problem". The rest is pure speculation based on how it appears these procedures are portrayed. Patients think of the MRI as yes/no for cancer and when comes back as yes they get understandably upset. If instead the MRI biopsy are presented as a single procedure (ideally done together, but money) the MRI is just getting targeting information needed for the biopsy not providing a yes/no decision. If it turns out there is nothing to biopsy the patient gets a happy surprise no-one is ever upset about this. (Again problem of money)