Lee Jiyon, Tanaka Elaine, Eby Peter R, Zhou Shouhao, Wei Wei, Eppelheimer Christine, Loving Vilert A
1 Department of Radiology, Breast Imaging Section, NYU Cancer Institute, Breast Imaging Center, New York University School of Medicine, 160 East 34th St, 3rd Fl, New York, NY 10016.
2 Department of Surgery, University of California, San Diego, La Jolla, CA.
AJR Am J Roentgenol. 2017 Apr;208(4):923-932. doi: 10.2214/AJR.16.17038. Epub 2016 Dec 27.
The purpose of this study is to determine which patient- and tumor-related and clinical variables influence dedicated breast surgeons' and general surgeons' referrals for preoperative breast MRI for patients with newly diagnosed breast cancer.
Surgeons who perform breast surgery responded to a survey from June 16, 2014, through August 11, 2014. Participants self-identified as breast or general surgeons and provided professional practice details. They used Likert scores (range, 1-7 with increasing likelihood to order MRI) to weigh numerous patient- and tumor-related and clinical variables. Mean likelihood scores were calculated and compared using a linear mixed model. A p ≤ 0.05 was considered statistically significant.
Two hundred eighty-nine surveys from 154 (53%) breast surgeons and 135 (47%) general surgeons showed an overall likelihood to refer for patients with a BRCA mutation (mean Likert score, 6.17), familial (mean Likert score, 5.33) or personal (mean Likert score, 5.10) breast cancer history, extremely dense breasts (mean Likert score, 5.30), age younger than 40 years (mean Likert score, 5.24), axillary nodal involvement (mean Likert score, 6.22), tumor that is mammographically occult (mean Likert score, 5.62) or fixed to the pectoralis (mean Likert score, 5.49), tumor that is a candidate for neoadjuvant treatment (mean Likert score, 5.38), multifocal or multicentric disease (mean Likert score, 5.22), invasive lobular carcinoma (mean Likert score, 5.20), T3 (mean Likert score, 4.48) or T2 (mean Likert score, 4.41) tumor, triple-negative breast cancer (mean Likert score, 4.66), a patient who is a candidate for mastectomy requesting breast conservation therapy (mean Likert score, 5.27), and radiologists' recommendations (mean Likert score, 5.19). Across all patient ages, breast surgeons referred more often than did general surgeons (mean Likert score, 4.32 vs 3.92; p = 0.03), especially for patients with BRCA mutation (mean Likert score, 6.39 vs 5.93; p = 0.01) and tumors smaller than 1 cm (mean Likert score, 3.84 vs 3.40; p = 0.002). Breast surgeons referred less often than did general surgeons for multifocal or multicentric disease (mean Likert score, 5.02 vs 5.44; p = 0.001). Breast surgeons and general surgeons similarly weighed other variables.
Preoperative breast MRI referral trended with certain higher risk patient- and tumor-related and clinical variables and were nonuniform between the breast surgeons and general surgeon cohorts. Selection bias could affect outcomes analyses for preoperative breast MRI.
本研究旨在确定哪些患者相关、肿瘤相关及临床变量会影响专业乳腺外科医生和普通外科医生对新诊断乳腺癌患者进行术前乳腺磁共振成像（MRI）检查的转诊决策。
进行乳腺手术的外科医生于2014年6月16日至2014年8月11日期间对一项调查做出回应。参与者自行认定为乳腺外科医生或普通外科医生，并提供专业执业细节。他们使用李克特量表评分（范围为1 - 7，分数越高越有可能开具MRI检查单）对众多患者相关、肿瘤相关及临床变量进行权衡。计算平均可能性评分，并使用线性混合模型进行比较。p≤0.05被认为具有统计学意义。
来自154名（53%）乳腺外科医生和135名（47%）普通外科医生的289份调查问卷显示，对于有BRCA突变（平均李克特量表评分6.17）、有家族性（平均李克特量表评分5.33）或个人（平均李克特量表评分5.10）乳腺癌病史、乳腺极度致密（平均李克特量表评分5.30）、年龄小于40岁（平均李克特量表评分5.24）、腋窝淋巴结受累（平均李克特量表评分6.22）、乳腺钼靶检查隐匿（平均李克特量表评分5.62）或与胸大肌固定（平均李克特量表评分5.49）的肿瘤、适合新辅助治疗的肿瘤（平均李克特量表评分5.38）、多灶性或多中心性疾病（平均李克特量表评分5.22）、浸润性小叶癌（平均李克特量表评分5.20）、T3（平均李克特量表评分4.48）或T2（平均李克特量表评分4.41）肿瘤、三阴性乳腺癌（平均李克特量表评分4.66）、要求保乳治疗的乳房切除术候选患者（平均李克特量表评分5.27）以及放射科医生建议（平均李克特量表评分5.19）的患者，总体上有转诊进行MRI检查的可能性。在所有患者年龄组中，乳腺外科医生的转诊频率高于普通外科医生（平均李克特量表评分4.32对3.92；p = 0.03），尤其是对于有BRCA突变的患者（平均李克特量表评分6.39对5.93；p = 0.01）和肿瘤小于1 cm的患者（平均李克特量表评分3.84对3.40；p = 0.002）。对于多灶性或多中心性疾病，乳腺外科医生的转诊频率低于普通外科医生（平均李克特量表评分5.02对5.44；p = 0.001）。乳腺外科医生和普通外科医生对其他变量的权衡相似。
术前乳腺MRI检查转诊与某些较高风险的患者相关、肿瘤相关及临床变量有关，且在乳腺外科医生和普通外科医生队列之间并不一致。选择偏倚可能会影响术前乳腺MRI检查的结果分析。
