"The women [in this trial] were advised of the increased [sensitivity] of MR scans based on previous studies," Dr. Berg says.

Reasons for refusal


Although claustrophobia topped the list of reasons for not attending, there were other problems, such as money.

In the study, ACRIN offered to pay for all MR exams not covered by the patient's insurance, so in theory the scan cost the women nothing. But Dr. Berg says expenses were still an issue, as the patient could need additional testing or a biopsy following the scan that their insurance would not have covered.

"In general," she says, "it's a much bigger issue. We don't usually have a study picking up the cost if insurance won't cover it."

Women can be billed up to several thousand dollars for MR breast screenings, Dr. Berg explains. And because of the high cost of the scans, many insurers are scrutinizing the modality carefully. "They're denying it more and more," she says, even though "we have a lot of data to say it's an excellent test for finding early breast cancer before it spreads to lymph nodes."

Interestingly, the new black box warnings on gadolinium-based contrast agents didn't scare off many patients. These agents, used to light up the blood-gorging tumors, are thought to trigger extremely rare, but potentially fatal, adverse reactions in patients, especially those with poor kidney function. Because of the low dose used and careful screening, this virtually never happens in breast MR patients. And in the study, only a handful listed this as their reason not to show up. "I think there was more fear of the needle than the gadolinium," Dr. Berg says.

But lack of motivation, a typical complaint in medical studies, doesn't appear to account for the fall-off in participation here, according to Dr. Berg. She notes that the women in the study were highly motivated, in that all had already undergone mammography and ultrasound exams before being scheduled for an MR scan, a requirement of the study protocol.

But Dr. Berg does note that as this was the third test the women were getting, some might have felt they had enough. "Having the ultrasound was already more than the usual care," she says. "That might have given them some sense of security for not needing an MRI to find something else."

Open sesame

So, with MR scans providing a potentially life-saving early warning of breast cancer, how can doctors convince more women to take them?

Open MR seems like the answer, as its less-confined designs could ease claustrophobic fears. But Dr. Berg believes current technology, rarely stronger than 1.0 Tesla, isn't good enough.

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