Efficacy of Targeted Axillary Dissection With Radar Reflector Localization Before Neoadjuvant Chemotherapy.

INTRODUCTION: For clinically node positive breast cancer patients treated with neoadjuvant chemotherapy (NAC), targeted axillary dissection (TAD) can be used to stage the axilla. TAD removes the sentinel lymph node (SLN) and tagged positive nodes, which can be identified via radar reflector localization (RRL). As it can be challenging to localize a previously positive node after NAC, we evaluated RRL prior to NAC. METHODS: We performed a retrospective chart review of breast cancer patients with node positive disease treated with NAC who underwent TAD with RRL. We compared retrieval of radar reflector and clip, timing of localization, and, if a node was positive, whether the radar reflector node or SLN was positive. RESULTS: Seventy-nine patients fulfilled inclusion criteria; 32 were placed pre-NAC (mean 187 d before surgery) and 47 were placed post-NAC (mean 7 d before surgery). For pre-NAC placement, 31 of 32 radar reflectors and 31 of 32 clips were retrieved. For post-NAC placement, 47 of 47 radar reflectors and 46 of 47 clips were retrieved. There was no significant difference in radar reflector or clip retrieval rates between pre-NAC and post-NAC groups (P = 0.41, P = 1, respectively). Thirty of 32 patients with pathologic complete response avoided an axillary lymph node dissection. Of 47 patients with a positive lymph node, 32 were both the SLN and radar reflector node, 11 were radar reflector alone, and four were the SLN. CONCLUSIONS: RRL systems are an effective way to guide TAD, and RRL makers can be safely placed prior to NAC.

United States insurance coverage of immediate lymphatic reconstruction.

INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Lymphoscintigraphy Using Tilmanocept Detects Multiple Sentinel Lymph Nodes in Melanoma Patients.

BACKGROUND: Technetium-99m-labeled Tilmanocept, a multivalent mannose, is readily internalized by the CD206 surface receptor on macrophages and dendritic cells which are abundantly present in lymph nodes. We want to examine the drainage patterns of Technetium-99m-labeled Tilmanocept to sentinel lymph nodes (SLNs) in melanoma patients following the 10% rule. METHODS: Multi-center retrospective review of patients with cutaneous melanoma undergoing SLN biopsy using Technetium-99m-labeled Tilmanocept between 2008 and 2014 was conducted. Statistical methods were used for data analyses. RESULTS: Of the 564 patients (mean age of 60.3 and 62% male) with preoperative lymphoscintigraphy showing at least one SLN, several primary tumor sites were included: 27% head/neck, 33% trunk, 21% upper extremity and 19% lower extremity. For the head/neck primary site, 36.5% of patients had multiple draining basins; for the trunk site, 36.4% of patients; for the upper extremity site, 13% of patients; and for the lower extremity, 27.4% of patients. A median of 3 (range 1-18) SLNs were identified and resected. Overall, 78% of patients had >1 SLN identified by Technetium-99m-labeled Tilmanocept. In a multivariate model, patients with >1 SLN were significantly associated with age, Breslow depth, tumor location and higher AJCC tumor stage. A total of 17.7% of patients (100/564) had a positive SLN identified. A total of 145 positive SLNs were identified out of 1,812 SLNs with a positive SLN rate of 8%. Positive SLN status was significantly associated with younger age, greater Breslow depth, mitosis rate, higher AJCC tumor stage, presence of ulceration and angiolymphatic invasion. CONCLUSIONS: Using the 10% rule, Technetium-99m-labeled Tilmanocept detects multiple SLNs in most melanoma patients.

Enhanced Recovery After Surgery and Postoperative Nausea and Length of Stay in Mastectomy Patients With Reconstruction.

INTRODUCTION: Surgery is a mainstay of curative breast cancer treatment and is associated with postoperative nausea and vomiting (PONV) negatively impacting the patient experience. Enhanced recovery after surgery (ERAS) protocols are a combination of evidence-based strategies applied to traditional perioperative practices with the goal to reduce postoperative complications. ERAS protocols have been traditionally underutilized in breast surgery. We investigated if the implementation of an ERAS protocol was associated with decreased rates of PONV as well as length of stay (LOS) in patients undergoing mastectomy with breast reconstruction. METHODS: We conducted a retrospective chart review case-control study in which we compared PONV and LOS between ERAS cases and non-ERAS controls. Our data set consisted of 138 ERAS cases and 96 non-ERAS controls. All patients were >18 y old and underwent mastectomy with immediate implant or tissue expander-based reconstruction between 2018 and 2020. The non-ERAS group consisted of procedure-matched controls that were treated prior to implementation of the ERAS protocol. RESULTS: In univariate comparisons, patients who underwent the ERAS protocol had significantly decreased postoperative nausea (mean 37.5% of controls versus 18.1% of ERAS, P < 0.001) and shorter LOS (1.21 versus 1.49 d, P < 0.001). Using a multivariable regression to control for potential confounders, ERAS protocol was associated with less postoperative nausea (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.13-0.5), LOS 1 d versus > 1 d (OR = 0.19, 95% CI = 0.1-0.35), and less postoperative ondansetron use (OR = 0.03, 95% CI = 0.01-0.07). CONCLUSIONS: Our results indicate that implementation of the ERAS protocol in women undergoing mastectomy with immediate reconstruction is associated with improved patient outcomes in postoperative nausea and LOS.

Screening Practices for Breast and Nonbreast Cancers in High-Risk Mutation Carriers.

INTRODUCTION: Women with breast cancer often undergo genetic testing and may have a pathogenic variant associated with multiple cancers. This study examines the current screening practices for breast and nonbreast cancers in mutation carriers. METHODS: An institutional retrospective chart review of patients with BRCA1, BRCA2, ATM, CHEK2, BARD1, BRIP1, PALB2, and TP53 mutations were identified. Adherence to recommended screening based on National Comprehensive Cancer Network guidelines was analyzed. RESULTS: Six hundred sixty-two patients met inclusion criteria: 220 patients with BRCA1, 256 patients with BRCA2, 58 patients with PALB2, 51 patients with ATM, 48 patients with CHEK2, 14 patients with BRIP1, 10 patients with BARD1, and 5 patients with TP53. Overall, 214 (46%) of eligible patients completed recommended breast imaging. Of 106 patients eligible for pancreatic cancer screening, 20 (19%) received a magnetic resonance cholangiopancreatography and 16 (15%) received an endoscopic ultrasound. On multivariable analysis, age was associated with improved breast imaging adherence: patients in age groups 40-55 (adjusted odds ratio 2.05, 95% confidence interval 1.18-3.55) and age 56-70 (adjusted odds ratio 2.16, 95% confidence interval 1.18-3.95, P = 0.012) had better adherence than younger patients. CONCLUSIONS: Increases in genetic testing and updates to National Comprehensive Cancer Network guidelines provide an opportunity for improved cancer screening. While recommended breast cancer screenings are being completed at higher rates, there is a need for clear protocols in this high-risk population.

Factors Mediating Racial/Ethnic Disparities in Delayed Treatment of Breast Cancer.

BACKGROUND: Despite improvements, disparities in breast cancer care have led to an inequitable distribution of treatment delays and worse outcomes among patients with breast cancer. This study aimed to quantify the contribution of mediators that may explain racial/ethnic disparities in breast cancer treatment delays. PATIENTS AND METHODS: We conducted a retrospective analysis of patients from the National Cancer Database with stage I-III breast cancer who underwent surgical resection. Mediation analyses estimated the extent to which racial/ethnic disparities in the distribution of patient characteristics account for racial/ethnic disparities in delayed treatment. RESULTS: Of the 1,349,715 patients with breast cancer included, 10%, 5%, and 4% were Black, Hispanic, and other non-white race/ethnicity, respectively. Multivariable models showed that patients in these racial/ethnic groups had 73%, 81%, and 24% increased odds of having a treatment delay relative to white patients. Mediation analyses suggested that 15%, 19%, and 15% of the treatment delays among Black, Hispanic, and other non-white race/ethnicity patients, respectively, are explained by disparities in education, comorbidities, insurance, and facility type. Therefore, if these mediators had been distributed equally among all races/ethnicities, a reduction of 15-19% in the delayed treatment disparities experienced by minority patients would have been observed. Academic facility type was the factor that could yield the largest reduction in time to treatment disparities, contributing to 8-13% of racial/ethnic disparities. CONCLUSIONS: Patients with breast cancer who identified as Black, Hispanic, and other non-white races/ethnicities are exposed to longer treatment delays relative to white patients. Efforts to equalize mediators could remove substantial portions of racial/ethnic disparities in delayed treatment.

Impact of Inequities on Delay in Breast Cancer Management in Women Undergoing Second Opinions.

BACKGROUND: Inequities in breast cancer treatment lead to delay in therapy, decreased survival and lower quality of life. This study aimed to examine demographics and clinical factors impacting time to treatment for second-opinion breast cancer patients. MATERIALS AND METHODS: We performed a retrospective chart review to analyze patients presenting to one academic institution for second opinion of breast imaging, diagnosis, or breast-related treatment. Data from women with stage I-III breast cancer who received treatment at this institution were evaluated to determine the impact of patient demographics and clinical characteristics on time to first treatment. RESULTS: Of the 1006 charts reviewed, 307 met inclusion criteria. Low-income patients averaged 58 days from diagnosis to surgery compared to 35 days for high-income patients (incidence rate ratio [IRR] 0.64, P<0.01). Black patients averaged 56 days from diagnosis to surgery compared to 42 days for White patients (IRR 1.37, P<0.01). Latina patients averaged 38 days from initial encounter to neoadjuvant chemotherapy compared to 20 days for White patients (IRR 1.69, P<0.05). CONCLUSION: Patients with low-income, of Black race and Latina ethnicity experienced increased time to treatment. Additionally, time to mastectomy with and without reconstruction was longer than time to partial mastectomy. Further exploration is needed to determine why certain factors lead to treatment delay and how inequities can be eliminated.

A Population-based Analysis of Lymph Node Metastasis in Extremity Soft Tissue Sarcoma: An Update.

BACKGROUND: Soft tissue sarcomas (STSs) are mesenchymal tumors that may rarely metastasize to lymph nodes. This investigation sought to evaluate regional lymph node metastasis (RLNM) in extremity STS using a national cohort. MATERIALS AND METHODS: This study was a retrospective review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016. A Cox proportional hazards model was used to identify prognostic factors associated with disease-specific survival (DSS). RESULTS: RLNM was present in 3.7% (n = 547) of extremity STS. The rate of RLNM was highest in rhabdomyosarcoma (26.7%), clear cell sarcoma (18.8%), epithelioid sarcoma (14.5%), angiosarcoma (8.1%), spindle cell sarcoma (5.0%), and synovial sarcoma (3.2%). The 5-year DSS probability without RLNM was 69% (standard error: 1.3%) compared to 26% (standard error: 3.6%) with RLNM (P < 0.001). For the historically high-risk extremity STS, advanced age (hazard ratio (HR), 1.036; 95% confidence interval (CI), 1.0-1.04; P < 0.001), higher grade tumors (HR, 1.979; 95% CI, 1.3-3.0; P < 0.001), tumor size greater than 10 cm (HR, 1.892; 95% CI, 1.3-2.7; P < 0.001), primary site surgery (HR, 0.529; 95% CI, 0.3-0.8; P = 0.006), distant metastasis (HR, 4.585; 95% CI, 3.0-6.8; P < 0.001), and RLNM (HR, 2.153; 95% CI, 1.3-3.5; P = 0.003) were each independent disease-specific prognostic factors. CONCLUSIONS: The prognosis of RLNM in historically high-risk extremity STS is poor with a 5-year DSS of 26%. These data support a staging system of STS inclusive of nodal involvement and contribute to the growing body of evidence that characterizes the rates of RLNM in STS.

Microsatellitosis in Patients with Melanoma.

BACKGROUND: Microsatellitosis (mS) in melanoma has been considered a marker of unfavorable tumor biology, leading to the current American Joint Committee on Cancer staging of IIIB/C/D disease, despite few investigative studies of this entity limited by the small sample sizes and incomplete nodal microstaging. We sought to better characterize outcomes and prognostic factors in a multi-institutional cohort of patients with mS and nodal microstaging. METHODS: The Sentinel Lymph Node Working Group cohort included 414 mS patients who underwent sentinel lymph node (SLN) biopsy. Cox regression analysis was used to evaluate the prognostic significance of established clinicopathologic characteristics. Melanoma-specific survival (MSS) of patients with mS was compared with 3002 similarly staged patients from the Surveillance, Epidemiology, and End Results (SEER) Program registry. RESULTS: The median age of the mS cohort was 64.9 years; 39.6% were female. Median thickness was 3 mm, 40.6% of cases were ulcerated, and the SLN positivity rate was 46.7%. Increasing thickness, male sex, and SLN positivity were significantly associated with poorer MSS. Stage IIIB/C/D 5-year MSS rates were 86.3% (95% confidence interval [CI] 79.4-93.3%), 54.1% (95% CI 45.4-59.7%), and 44.2% (95% CI 25.4-63.0%), respectively. MSS survival for the stage IIIB mS cohort was significantly better than a similarly staged SEER cohort (5-year MSS of 70.1%, 95% CI 66.0-74.2%), while no significant difference was observed for the stage IIIC or D cohorts. CONCLUSIONS: SLN metastases are common and are a significant prognostic factor in patients with mS. Survival in stage IIIB patients with mS was considerably more favorable than their stage would otherwise suggest, which has important implications for decisions regarding adjuvant therapy for patients with mS.

Isolated Limb Infusion: A Single-Center Experience with Over 200 Infusions.

BACKGROUND: Isolated limb infusion (ILI) is a minimally invasive technique for delivering regional chemotherapy to an extremity for patients with locally advanced cutaneous malignancies and sarcoma. METHODS: A single-institution, prospectively collected database was analyzed for intention-to-treat with ILI. RESULTS: From 2007 to 2016, 163 patients underwent 205 procedures (201 were successfully completed), and four malignancies were treated: melanoma (72.1% of all ILIs), sarcoma (23.4%), squamous cell carcinoma (SCC; 2.0%) and Merkel cell carcinoma (MCC; 2.5%). A median grade II regional Wieberdink toxicity score was observed, with 88.1% of patients experiencing grade II or less. Median follow-up was 21.8 months, and overall response rate (ORR) was 59.0% for melanoma, 48.9% for sarcoma, 50.0% for SCC, and 60.0% for MCC. A significant difference (p = 0.04) between upper (76.9%) and lower extremity (55.1%) ORR was observed in patients with melanoma. When comparing responders with nonresponders, patients with melanoma had significantly longer in-field progression-free survival (IPFS; 14.1 vs. 3.2 months, p < 0.001), distant metastatic-free survival (DMFS; not reached vs. 25.8 months, p = 0.006), and overall survival (OS; 56.0 vs. 26.7 months, p = 0.0004). Sarcoma responders had a significantly longer IPFS (13.0 vs. 2.7 months, p < 0.0001), but no significant distant metastatic or OS advantage. Over a median follow-up of 19.3 months, sarcoma patients had an overall limb salvage rate of 68.4%. CONCLUSION: ILI is a well-tolerated procedure for patients with locally advanced melanoma, sarcoma, and other cutaneous malignancies. ILI responders had a significantly longer time to IPFS, while melanoma responders also had a DMFS and OS advantage.

Use of axillary lymph node dissection (ALND) in patients with micrometastatic breast cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy is the current prognostic tool for clinically node-negative breast cancer patients. If the SLN reveals macrometastasis, axillary lymph node dissection (ALND) is recommended. However, the use of ALND in patients with micrometastasis is debated. The objective of this study was to assess the utilization of ALND in the treatment of micrometastatic breast cancer. METHODS: An IRB approved, retrospective study of a pooled dataset of breast cancer patients with micrometastatic disease on SLN biopsy was performed. Patients diagnosed from 1999-2016 were identified via query of a single-institution National Comprehensive Cancer Network (NCCN) breast cancer database as well as a prospective tumor board. RESULTS: A total of 91 patients were diagnosed with micrometastatic nodal disease. The median age at diagnosis was 56 y (range: 31-85); median follow-up time was 47 mo (range: 0-203 mo). 42/91(46.2%) patients had ALND of which 37/42 (88.1%) were a second operation; 3/42(7.1%) patients had additional positive nodes found at ALND. 44/91 (48.4%) patients received radiation. 7/91 (7.7%) patients had a recurrence, 5/7 local, including one axillary (2.1%; patient declined ALND). CONCLUSIONS: Given that the risk of lymphedema after ALND ranges between 20%-53%, the morbidity of ALND may far exceed the likelihood of detecting further nodal involvement in women with micrometastatic disease: 7.1% in this series.

Relationship between preoperative breast MRI and surgical treatment of non-metastatic breast cancer.

BACKGROUND AND OBJECTIVES: More extensive surgical treatments for early stage breast cancer are increasing. The patterns of preoperative MRI overall and by stage for this trend has not been well established. METHODS: Using Breast Cancer Surveillance Consortium registry data from 2010 through 2014, we identified women with an incident non-metastatic breast cancer and determined use of preoperative MRI and initial surgical treatment (mastectomy, with or without contralateral prophylactic mastectomy (CPM), reconstruction, and breast conserving surgery ± radiation). Clinical and sociodemographic covariates were included in multivariable logistic regression models to estimate adjusted odds ratios and 95% confidence intervals. RESULTS: Of the 13 097 women, 2217 (16.9%) had a preoperative MRI. Among the women with MRI, results indicated 32% higher odds of unilateral mastectomy compared to breast conserving surgery and of mastectomy with CPM compared to unilateral mastectomy. Women with preoperative MRI also had 56% higher odds of reconstruction. CONCLUSION: Preoperative MRI in women with DCIS and early stage invasive breast cancer is associated with more frequent mastectomy, CPM, and reconstruction surgical treatment. Use of more extensive surgical treatment and reconstruction among women with DCIS and early stage invasive cancer whom undergo MRI warrants further investigation.

Fertility Preservation in Breast Cancer.

As more young women survive breast cancer, fertility preservation (FP) is an important component of care. This review highlights the importance of early pretreatment referral, reviews the risks of infertility associated with breast cancer treatment, and defines existing and emerging techniques for FP. The techniques reviewed include ovarian suppression, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation and transplantation. The barriers women face, such as not being appropriately referred and the costs of treatment, also are addressed. Multidisciplinary, patient-centered care is essential to discussing FP with patients with breast cancer and ensuring appropriate care that includes quality of life in survivorship.

Expanding Eligibility Criteria for Nipple-Sparing Mastectomy.

The use of mastectomy has increased in patients who are high-risk genetic carriers who need or desire mastectomy for prophylactic reasons, as well as for patients who have breast cancer and need or desire mastectomy for treatment of their cancer. Retaining the nipple and skin with a nipple-sparing mastectomy results in improved patient satisfaction as compared with traditional mastectomy, without compromise of oncologic principles. This technique has been performed in patients with small, peripherally located tumors and nonptotic breasts; in recent years, however, consideration has been given to patients with more centrally located, larger tumors, and patients undergoing radiation or with ptotic breasts with the potential for poor cosmetic outcome. As the use of nipple-sparing mastectomy increases, it is important to continually assess the eligibility of patients for this technique.

Breast MRI in the Diagnostic and Preoperative Workup Among Medicare Beneficiaries With Breast Cancer.

PURPOSE: We compared the frequency and sequence of breast imaging and biopsy use for the diagnostic and preoperative workup of breast cancer according to breast magnetic resonance imaging (MRI) use among older women. MATERIALS AND METHODS: Using SEER-Medicare data from 2004 to 2010, we identified women with and without breast MRI as part of their diagnostic and preoperative breast cancer workup and measured the number and sequence of breast imaging and biopsy events per woman. RESULTS: A total of 10,766 (20%) women had an MRI in the diagnostic/preoperative period, 32,178 (60%) had mammogram and ultrasound, and 10,669 (20%) had mammography alone. MRI use increased across study years, tripling from 2005 to 2009 (9%-29%). Women with MRI had higher rates of breast imaging and biopsy compared with those with mammogram and ultrasound or those with mammography alone (5.8 vs. 4.1 vs. 2.8, respectively). There were 4254 unique sequences of breast events; the dominant patterns for women with MRI were an MRI occurring at the end of the care pathway. Among women receiving an MRI postdiagnosis, 26% had a subsequent biopsy compared with 51% receiving a subsequent biopsy in the subgroup without MRI. CONCLUSIONS: Older women who receive breast MRI undergo additional breast imaging and biopsy events. There is much variability in the diagnostic/preoperative work-up in older women, demonstrating the opportunity to increase standardization to optimize care for all women.

Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: A cost-utility analysis of a hospital's initial experience and reflections on the health care system.

BACKGROUND: The combination of Cytoreductive Surgery (CRS) plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has been gaining a considerable interest by surgeons throughout the United States due to the significant survival improvement it provides for peritoneal surface malignancies and the ability to reproduce comparable clinical results in numerous health care centers. However, CRS plus HIPEC has not been sufficiently investigated from the economic standpoint in the United States where a wide variety of health care insurers exists. This study was conducted to analyze hospital/surgeon cost and reimbursement data at a community hospital offering a new peritoneal surface malignancy program, and expand the discussion to analyze future healthcare implementation on this procedure in the United States. METHODS: This is a retrospective economic analysis of an initial CRS plus HIPEC experience at a community non-teaching medical center. This study was conducted using hospital/surgeon cost and reimbursement based on the Office of Finance data at Edward Hospital Cancer Center (Naperville, IL). All patients who underwent CRS and HIPEC between June 2013 and August 2014 were included in this analysis. We aimed to assess CRS plus HIPEC purely from the financial perspective on the initial admission regardless of the patients' advancement of the disease or postoperative adverse events. RESULTS: Twenty-five patients underwent 26 CRS plus HIPEC procedures. Twelve patients had private insurance plans (PRV) whereas 13 were covered by public insurers (PUB). Median overall length of stay (LOS) was 10 days (PRV 10 days vs. PUB 11 days; P = 0.76.) Average hospital cost was $38,369 (PRV $37,093 vs. PUB $39,463; P = 0.67), and average reimbursement for our patient population was $45,243 (PRV $48,954 vs. PUB $42,062; P = 0.53). It was noted that CRS plus HIPEC generated more net profit in patients with private insurance than in those with public plans, however, not statistically significant ($11,861 vs. $2,599 per patient, respectively; P = 0.38). Evaluating surgeon's data, average surgeon's charge was $29,139 (PRV $28,440 vs. PUB $29,737; P = 0.80), and average patients' payment was $8,126 (PRV 9,234 vs. PUB 7,176; P = 0.47). CONCLUSION: CRS plus HIPEC is profitable in the community setting for both the hospital and surgeon. Both private and public insurers reimbursed profitably, though with a greater profit margin from private insurers. As CRS plus HIPEC is becoming more widely recognized as a standard of care for patients with peritoneal surface malignancy, it is increasingly important to understand and report its associated costs and variability in insurance coverage, especially in light of the current healthcare structure changes in the United States. It is strongly encouraged to report and present a wider scope of CRS plus HIPEC economic experiences in a variety of hospital settings to provide further evidence for future healthcare implementations in the United States. J. Surg. Oncol. 2016;113:544-547. © 2016 Wiley Periodicals, Inc.

Factors Associated with Preoperative Magnetic Resonance Imaging Use among Medicare Beneficiaries with Nonmetastatic Breast Cancer.

Preoperative breast magnetic resonance imaging (MRI) use among Medicare beneficiaries with breast cancer has substantially increased from 2005 to 2009. We sought to identify factors associated with preoperative breast MRI use among women diagnosed with ductal carcinoma in situ (DCIS) or stage I-III invasive breast cancer (IBC). Using Surveillance, Epidemiology, and End Results and Medicare data from 2005 to 2009 we identified women ages 66 and older with DCIS or stage I-III IBC who underwent breast-conserving surgery or mastectomy. We compared preoperative breast MRI use by patient, tumor and hospital characteristics stratified by DCIS and IBC using multivariable logistic regression. From 2005 to 2009, preoperative breast MRI use increased from 5.9% to 22.4% of women diagnosed with DCIS and 7.0% to 24.3% of women diagnosed with IBC. Preoperative breast MRI use was more common among women who were younger, married, lived in higher median income zip codes and had no comorbidities. Among women with IBC, those with lobular disease, smaller tumors (<1 cm) and those with estrogen receptor negative tumors were more likely to receive preoperative breast MRI. Women with DCIS were more likely to receive preoperative MRI if tumors were larger (>2 cm). The likelihood of receiving preoperative breast MRI is similar for women diagnosed with DCIS and IBC. Use of MRI is more common in women with IBC for tumors that are lobular and smaller while for DCIS MRI is used for evaluation of larger lesions.