What Would It Take to Change Brain MRI Surveillance in Metastatic Breast Cancer?

At the American Society of Clinical Oncology (ASCO) meeting, a phase III trial was presented evaluating whether routine brain MRI surveillance can improve outcomes for patients with metastatic breast cancer and help guide future screening recommendations.

In this exclusive MedPage Today video, Kamran Ahmed, MD, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, discusses the evidence needed to support routine brain MRI surveillance, the potential impact on treatment decisions and quality of life, and the challenges that must be weighed before changing clinical practice.

Following is a transcript of his remarks:

We have a phase III study that’s ongoing to help answer the question of whether brain MRI surveillance in stage IV breast cancer is necessary. That will hopefully help provide additional evidence of whether the NCCN [National Comprehensive Cancer Network] guidelines regarding brain MRI surveillance should be changed.

I think that we want to see some sort of clear benefit. We are looking at overall survival in this study. What we’re also looking at is quality of life, so quality-of-life questionnaires are being completed by patients. We’re also looking at the types of treatment that’s being recommended for patients when they are diagnosed. So is there a difference when patients are diagnosed when they’re asymptomatic versus when they’re symptomatic? So differences in terms of the types of radiation therapy that are being recommended to patients, if there’s more patients who are being recommended to have surgical resection of their brain metastasis if they’re being diagnosed symptomatically.

So I think all of those are reasons then to potentially consider doing asymptomatic surveillance. Now we also have to balance surveillance with the negative consequences that can arise from having additional imaging, so “scanxiety,” or anxiety that is related to patient’s imaging, that has to be balanced.

There’s the potential that also asymptomatic disease can be treated fine without additional changes in systemic therapy or local therapy. More of the medications that patients are being offered in the stage IV setting also may have intracranial activity, like trastuzumab deruxtecan [Enhertu] that can already have some activity.

So then what is the true benefit of having the diagnosis if asymptomatic disease can already be treated? Are we exposing patients to unnecessary risks from additional local therapies, changes to their systemic therapy? And then also incidental findings that might be discovered on an MRI. So all of those are negative consequences of MRIs as well too.

And then there’s obviously a cost to doing these MRIs and an additional impact on the healthcare system as well too. So we really have to make sure that the negative consequences of doing MRIs are balanced out by the positive impact. So that’s what we are hoping to see with this study.