Real-time breast ultrasound after second opinion helps detect new cancer, avoid unnecessary biopsies

Real-time breast ultrasound following second-opinion reinterpretation of an original study leads to a change in the clinical management of nearly 33 percent of patients, researchers report report in the current edition of Clinical Imaging, and detects additional cancers in 5 percent of women.

Second-opinion reviews are common in the U.S., Elizabeth A. Morris, MD, and colleagues at Memorial Sloan Kettering Cancer Center in New York, said—especially in specialized, tertiary care cancer centers. In these cases, specialists reassess the diagnostic accuracy of breast imaging studies, address questions raised by referring physicians and offer their clinical opinion on the case. Rarely, the authors said, do treatment courses remain the same.

“Re-evaluation of outside studies at comprehensive cancer centers frequently leads to a change in management,” Morris, a radiologist and chief of the Breast Imaging Service at Sloan Kettering, wrote. “However, while re-evaluation may detect new cancers, an increase in the number of false positive lesions is also expected. Second opinion review may lead to an elevation in costs, anxiety and prolonged time between diagnosis and treatment.”

Part of that higher price tag might be because radiologists providing a second opinion often also recommend a real-time ultrasound re-evaluation, since all they have to work with is static images performed at a different time and place.

“The ultrasound images reviewed are a screenshot of what the technologist or radiologist noted during an ultrasound exam originally performed in real time,” Morris et al. said. With a fresh scan, radiologists could better characterize any lesions present and avoid misdiagnosis.

Morris’ team performed a retrospective study of 209 patients whose initial breast ultrasound studies had been sent to Sloan Kettering for a second opinion between January 2013 and May 2014. Within three months of the hospital receiving the outside study, the women underwent real-time breast ultrasound. 

The third review of the studies seemed to make a sizeable impact, the authors said. Real-time ultrasound after a second opinion led to a change in management in 32.5 percent of patients, while doctors found additional cancers 5.3 percent of the time. Additional biopsies were performed in about a fifth of cases—a quarter of which tested positive for cancer—but the added ultrasound allowed one-sixth of patients to avoid unnecessary, prescheduled biopsies.

Morris and her colleagues said the third review helps mitigate discrepancies over BI-RADS, the content of which many doctors dispute. It acted as an extra layer of protection for the patient.

“Real-time breast ultrasound was found to be an important tool in the management of patients at our comprehensive cancer center,” the authors wrote. “Although additional false-positive lesions may be detected on real-time breast ultrasound, a great number of patients will benefit in finding additional cancers or avoiding unnecessary biopsies.”