Second Opinion Following Routine Breast Imaging Supports Diagnostic Accuracy

By Donna D’Alessio, MD ,

Monday, October 16, 2017

Asymptomatic women who undergo routine breast cancer screening with imaging may be uncertain of the next steps when an unexpected suspicious finding or cancer is reported in the context of their annual visit with a primary care doctor in the community setting.

For these women, the option of getting a second opinion from a breast-imaging specialist can be reassuring and beneficial, as research has shown that breast-imaging specialists detect earlier-stage cancers. (1) Such second-opinion consultations can help women make treatment decisions. In a significant number of cases, it will impact the care they were originally prescribed.

The Breast Imaging Service at Memorial Sloan Kettering (MSK) has a dedicated team of breast-imaging specialists who consult with people seeking second opinions for breast-imaging exams.

At MSK, we have investigated the effect of such second-opinion consultations on patient care. In looking at our own patient outcomes, we noted the significant impact of second-opinion reviews of breast imaging exams obtained from institutions that do not specialize in cancer care. We specifically aimed to determine if such second-opinion reviews at a dedicated cancer center detected additional cancer and prevented unnecessary biopsies.

In our study, presented at the 2016 annual meeting of the Radiological Society of North America and recently published in the American Journal of Roentgenology, we reviewed 200 outside breast-imaging studies — including mammography, breast ultrasound, and breast MRI — and identified a change in interpretation in 28 percent of them. Overall, 26 new recommendations led to a change in clinical management, including sparing women either biopsy or additional imaging on the basis of benign imaging findings. Twenty new biopsies were performed, yielding 10 malignancies and four high-risk lesions. Most significantly, surgical management was changed to mastectomy for 60 percent of those in whom new sites of malignancy were found. Biopsy was averted in 4 percent. (2)

Real-time breast ultrasound exams after second-opinion reviews of outside static breast ultrasound images led to a change in management in 32.5 percent of people studied.
Donna D'Alessio, MD
Donna D'Alessio, MD

We have expanded our investigation of the impact on clinical management of second-opinion reviews of breast imaging at a cancer center by looking at the performance of real-time breast ultrasounds after second-opinion reviews of static images obtained at outside institutions. We aimed to evaluate the utility of performing such real-time exams by determining how often additional cancers were found and unnecessary biopsies were averted. Preliminary, as yet unpublished, results from our study of 209 people suggest that performing real-time ultrasound exams for questioned findings on review of outside static breast ultrasound images led to the detection of additional cancers in 24.5 percent of the additional biopsies performed after repeating the ultrasound examination. These preliminary findings are in keeping with our original study. In addition, this expanded review suggests that almost 15 percent of the originally recommended biopsies were canceled after real-time ultrasound examinations were performed at our center with more than 50 percent of the people in whom biopsy was averted showing stability of findings during long-term follow up. Overall, real-time breast ultrasound exams after second-opinion reviews of outside static breast ultrasound images led to a change in management in 32.5 percent of those included. These findings will be presented at the 2017 annual meeting of the Radiological Society of North America in Chicago.

Studies have shown that breast-imaging specialists, like those on the Breast Imaging Service at MSK, have a higher cancer detection rate on mammograms than general radiologists do. (1), (3) Our studies support these findings, and patients benefit from these ongoing investigations. (2)

People who would like second-opinion consultations at MSK for any breast-imaging studies may submit them for review in a number of ways. As part of our team approach to breast disease management, everyone seeking a new consultation with a breast surgeon at MSK undergoes a reinterpretation of their outside imaging studies by a specialized breast radiologist before or at the time of the consultation with the surgeon. Breast-imaging studies may also be submitted through the Department of Radiology’s Breast Imaging Service. People at an increased risk for breast cancer may also submit their imaging studies through MSK’s RISE program - Risk Assessment, Imaging, Surveillance, and Education.