Digital Breast Tomosynthesis (DBT) provides higher quality mammography images and is becoming more vital to breast exams. At RSNA we spoke with Dr. Harmindar Gill, Medical Director of Premiere Women’s Radiology in Bonita Springs, Florida, about the benefits of DBT and what patients get out of having it as part of their exam. Being the first office in Southwest Florida to offer DBT as part of breast exams, Dr. Gill noticed a decrease in patients’ recall rates and found that it’s easier to spot small lesions that go unnoticed by traditional mammography exams. The video below provides more insight on Dr. Gill’s practice and DBT discussion at RSNA.
Among the many trends and buzzwords floating around RSNA 2013, one of the key areas that seems to be popping up everywhere is “tomosynthesis,” which is 3D imaging using X-Ray technology. With enhancements being made to DT technologies, as well as numerous laws being written related to breast density, tomosynthesis is sure to be an important topic in the medical imaging community for a long time to come. Yesterday, Carestream presented “Stationary Chest Tomosynthesis System using Distributed CNT X-ray Source Array,” with the University of North Carolina School of Medicine. The results of this study showed the feasibility of a stationary chest tomosynthesis system. This has the ability to improve image quality and enhance detection of small lung nodules and other chest pathology.
In addition to our presentation, multiple sessions have focused on the benefits of tomosythesis. Two in particular that caught our attention were focused about digital breast tomosynthesis (DBT) and its superiority to conventional mammography in breast cancer detection, and a session focused on how tomosynthesis is more beneficial in detecting lung cancer. The former looked to expand upon the usual benefits of using DBT, which are reduced recall rates, improved diagnostic accuracy, and improved cancer detection. From there, Pragya A. Dang, M.D., of Massachusetts General Hospital, Boston, looked at the data her team collected after using DBT for more than two years. Dr. Dang looked at the cancers in the study using both DBT and conventional mammography. Radiologists then looked at the visibility and morphology of the studied cancers with both tomosynthesis and conventional mammography. The findings showed that the degree of visibility vastly improved using tomosythnesis. An additional benefit that Dr. Dang pointed out was that a higher percentage of the cancers were more definitively characterized as masses compared to asymmetries when using tomosynthesis for diagnosis. In her conlcusion, Dr. Dang presented that when compared to conventional radiology, tomosynthesis allows for increased cancer detectability upon screening because of its improved visibility and the precise morphology of cancers allow for a better lesion diagnostics in initial imaging.
James T. Dobbins III, Ph.D., associate professor of radiology at Duke University, used dual-energy imaging and also looking at a broader range of expertise among radiologists when analyzing lung nodules. Dr. Dobbins saw that tomosynthesis had a threefold improvement in sensitivity, which is consistent with studies done in the past. He concluded that tomosynthesis is much better than conventional radiology when it comes to detecting lung nodules, and offered three options tomosynthesis implementation strategies:
- Using it as a problem-solving tool for suspicious findings on radiography
- Using it as alternative to CT for tracking changes in nodules over time, though Dr. Dobbins did state that additional studies on this would need to be conducted to validate this option
- Implementing it as a lower dose, lower cost model for lung cancer screening
From these studies, it is clear that we have only seen the beginning of DT and DBT. Study after study are showing the benefits of this technology, and as future studies are conducted, it becomes much more likely that we will start seeing wide-spread usage of tomoysnthesis for more accurate and efficienct diagnoses.
The goal of mammography screening is to reduce breast cancer mortality rates by detecting the cancer early enough for efficient treatment to be possible. In Finland, the mortality rates are one of the lowest in the world. One of the reasons is the efficient nationwide screening program.
Finland was the first country in the world to begin a nationwide mammography screening program governed by law in 1987. Beginning with 50-59 y.o. women, the target group was extended to 50-69 y.o. women in 2007. Finland has a high participation rate; almost 90% of the target group undergoes the screening study. Of all the participating women, approx. 3% is recalled to second imaging study and approx. 0.5% is diagnosed with breast cancer and directed to the treatment pathway. Annually, approximately 50 deaths due to breast cancer are prevented by the screening program.
The organizing and funding of mammography screening is the responsibility of more than 300 municipalities. The municipalities typically outsource the screening program as the program is demanding to put up and maintain and not cost-effective to run with low volume of participants. As a result, over 80% of all the nation’s mammography screenings are performed by one operative, a private healthcare service provider, Terveystalo, which has managed to standardize the screening process and obtain large enough volume to maintain very high quality – both clinical and operational quality as well as experienced quality – with low cost.
One of the key points in the process is the utilization of digital technology to allow the primary screening images to be read by specialist radiologists anywhere. This not only promotes equality by putting all the women to be screened in equal position regardless of their location, but also ensures that the specialist radiologists get to screen enough mammograms to maintain high quality in their expertise.
As for the digital imaging technology, it does not necessarily mean FFDM. While it is highly likely that FFDM will be the method of choice in the future, Terveystalo currently uses CR technology for the most part due to its flexibility, cost-effectiveness, and high-enough image quality. Due to advances in detector screen development, the image quality vs. dose levels have met Finnish requirements. Also, tomosynthesis, an inherently FFDM application, is so far not included in the screening process. To meet national requirements, Terveystalo has a technical quality assurance protocol in place, routinely measuring and documenting the whole imaging chain.
From the information technology point-of-view, the backbone of the common nationwide process is a fast and secure nationwide information system. Although screening data cannot be mixed with patient data, the systems, e.g. PACS, can serve both groups simultaneously.
The other key points for the efficient screening process are the high level of standardization and continuous improvement. Apart from the service provider, the process has three important stakeholders:
- Municipalities: appreciate clear contract models, see-through pricing, and reliable and on-demand reporting
- Women to be screened: value flexibility in the scheduling of the imaging study, comfortable and competent imaging study, and clear results without delay
- The national authority responsible for planning and evaluating national cancer screening programs: expect to get the data concerning invitations and findings to further evaluate the statistics, develop the screening program and guiding also political decision-making in the field.
The screening process has to be designed to provide all these and be flexible enough to allow municipality- and consumer-dependent modifications.
Based on experiences in Finland, an efficient mammography screening process is not easy to set up and maintain. However, by combining reliable technology with both medical and process expertise, the results are excellent.
Guest post by Marianne Matthews, editor of Imaging Economics.
I had to chuckle recently when Jockey rolled out its new bra sizing system. Everyone from fashionistas to morning talk show hosts seemed obsessed with the news. It even garnered coverage (pardon the pun) on the front page of The New York Times. While some called the new bra sizing system important, others deemed it unnecessary and even downright confusing.
When it comes to their breasts, American women have a lot more important things to think about. And some of it—like understanding the real implications of breast density—can be as confusing as going from a 34B to a 7-36.
Although 10 states have now enacted breast density notification laws, the issue remains controversial. Proponents say it’s a no-brainer. They point to studies that show that increased breast density correlates with increased breast cancer risk. Experts say those with extremely dense breast tissue have twice the risk of breast cancer compared to those with average breast density. Moreover, dense breast tissue makes it hard to spot cancer on a mammogram.
So why not just enact legislation that mandates informing women of their density?
Well, there are a lot of reasons not to. Some of those opposed say the science is not perfect, density studies are misleading, and density alone is not necessarily a major cancer risk. Others fear the notification legislation will lead to too many tests and unnecessary biopsies. Still others object on principle to the government legislating medical care.
To be honest, I’ve had trouble sizing up the issue myself. Originally, I was all for notification legislation. Then, when I had a mammogram a few months ago, I talked to my radiologist. Turns out, she’s adamantly opposed to the density notification because she believes it will lead to “panic” among women. She’s not the only expert who feels density notification will only confuse women further, perhaps make them think they have cancer, or mistrust mammography altogether. She’s got a point. (There is a great deal of confusion among the highly educated women I know about breast density.)
So, I’ve gone round and round on the issue and come full circle. On balance, I think it’s a good thing. At this point, I see at least three simple reasons to support density notification laws.
First, in today’s society, patients are expected to be their own advocates—and doctors have pretty much made that the case. Doctors spend very little time in office visits actually communicating with patients. We’re expected to arrive prepared with our list of complaints and questions—and cover them all in less than 10 minutes. We’re expected to know our numbers. In some cases, we’re even forced to follow up on test results because all too often the physician’s office doesn’t bother to call with results. So, since we’re expected to be sophisticated patients—which takes some of the burden off of doctors—we need to be informed about our own bodies. That’s as good a reason as any to let women know if they have dense breasts.
Second, there is no turning back. Advocacy organizations are succeeding on Capitol Hill. In addition to the 10 states that already have density notification laws on the books, several more state legislatures have introduced legislation in 2013. What’s more, Federal legislation is under way. My point: You can’t put the genie back in the bottle.
Finally, as a radiologist, if you come out against density notification, you’re probably shooting yourself in the foot. Though I remain loyal to my breast imager, my guess is most women would not find her views all that favorable. In short, it’s politically incorrect for a women’s imaging provider to oppose the density movement.
So, you might as well use the density issue as an opportunity to educate your patients. Talk to her; get closer to her; show her radiology’s value. You can either be viewed as a foe or join the fight. That’s about the size of it.
Breast cancer survivors have joined together in an activity that focuses on support, wellness and competition as way to recover from breast cancer. The diagnosis of breast cancer has brought survivors from around the world together in the unique paddling sport of dragon boating.
Paddling in colorful dragon boats offers an active, health-giving, life-affirming option for breast cancer survivors. Dragon boat racing is a relatively new but rapidly growing international activity. A dragon boat is a long, colorful wooden or fiberglass boat adorned with a dragon head at the front and tail at the back — with room for about 20 paddlers and a drummer. Teams of cancer survivors and their supporters paddle in harmony to the beat of a drum. The sport of dragon boating provides the benefit of vigorous exercise and may help prevent or relieve the symptoms of lymphedema — a common side effect from the effects of breast surgery or radiation.
I recently had the opportunity to coach a group of breast cancer survivors from the Dragonheart Vermont club that plans to send a crew to the U.S. National Championship in September. These contestants will compete to win a chance to represent the U.S. at the 2014 Club Crew World Championships in Ravenna, Italy. The championship has a division for breast cancer survivors and it’s estimated that there are about hundreds of dragon boat breast cancer teams around the world.
Cancer research and treatment has made dramatic strides in the last 10 years. Thousands of activities publicize the ability for survivors to recover from this previously debilitating disease and live normal, active lives. However more research is needed, which is why we all need to support additional research to develop new detection methods and treatments for all forms of cancer.
Please visit the International Breast Cancer Paddlers Commission if you would like to get involved with a local team. The rewards are many!
We would like to hear comments from readers who have participated in these types of events. When did you first hear about dragon boat races and what benefits have you received from being on a dragon boat team?
The challenges with digital breast tomosynthesis are well explained in this article on AuntMinnie, and very real. At Carestream, we have been working with digital breast tomosynthesis data from various vendors to provide solutions for these very same issues. Although there are many different aspects to consider when adding digital breast tomosynthesis, I’ll explain some of the solutions we’ve found and hope others find them to be useful.
Since digital breast tomosynthesis is relatively new, we are finding that the level of support each vendor provides varies significantly. We decided to embrace digital breast tomosynthesis from the start since we believe it will have a place among the various different technologies used to detect breast cancer. Other technologies will continue to evolve to the point where each will have a place as well. The clinical benefits of digital breast tomosynthesis are still being debated by some, but it has rapidly gained supporters in the Radiologist community.
While support continues to grow, two main barriers that exist include reimbursement and dosage. Reimbursement will definitely help encourage widespread acceptance from a business perspective. And, with the various acquisition device vendors working on synthetic 2D images, it appears the dosage barrier can be overcome as well. This may open the door for digitial breast tomosynthesis to be used on a regular basis in the screening environment.
Regarding the storage of the digital breast tomosynthesis data objects, we have found that in addition to the use of lossless compression, adequate network bandwidth and intelligent routing/pre-fetching of data are vital to efficiently move such a large amount of data transparently to the user. This is especially true when reading such procedures across multiple facilities and/or remotely. We are recommending that internal networks support 1 Gigabit, as some of the acquisition device vendors have done..
As mentioned in the AuntMinnie article, earlier digital breast tomosynthesis data may have been stored using a proprietary format. Our current understanding is that the conversion process being provided can be scheduled during the evening or weekend, so there is little or no impact during normal business hours. Although this conversion process can appear to be a daunting task at first, it is important for a site to maintain data that follows the DICOM standard moving forward for interoperability. Otherwise, the task becomes much larger at a later time. The same will be true for synthetic 2D images in the near future.
Another challenge outlined in the article is the additional time needed to read digital breast tomosynthesis images. Similar to when digital mammography was first introduced, users experienced a learning curve not only with reading the images, but also with using the workstations and the tools that they provided. We believe the same is true with digital breast tomosynthesis, where the reading time will decrease as both of these improve. Focusing on the tools provided by workstation vendors, we have found that a key aspect to optimize the reading time is not only through basic tools that automatically scale and position both 2D and 3D images, but also advanced tools that can help localize pathology and allow the user to quickly navigate current and priors studies. It is not enough to just stack a series of tomosynthesis slices and allow the user to scroll through them at will. With traditional 2D mammography, digital breast tomosynthesis, synthetic 2D mammography, and other mammography procedures (e.g. breast US, breast MRI, etc.) being generated, workstations with hanging protocols that can support and display all of these in an efficient manner become extremely important.
As the IHE Mammography Image integration profile is expanded to include digital breast tomosynthesis, our expectation is that the interoperability issues experienced early on will at some point be resolved by most vendors.
The video below shares more information about digital breast tomosynthesis and Carestream’s capabilities in that area.
The 2012 RSNA meeting marked the 30th anniversary of the show from which Debora Wright’s mobile mammography screening business, Inner Images, was born. Three decades later, the current healthcare climate set a different at the meeting, but for Debora and Inner Images, reform has opened doors and growth.
In this video, we speak with Debora from RSNA 2012 about how the move to digital mammography has helped her business’ productivity through this growth period.
Are you excited about the direction mammography is heading? What changes or benefits do you think we might see at next year’s RSNA?
When RSNA opens on Sunday, we can expect digital breast tomosynthesis (DBT) to dominate the attention of providers and radiologists interested in women’s imaging. A scan of the scientific and educational sessions featured in AuntMinnie’s “Road to RSNA 2012: Women’s Imaging Preview” highlights the early evidence of increased cancer detection and lower recall rates, which is driving interest in DBT in spite of lingering questions about reimbursement.
“Doctors are reporting interruptions in their day because not all PACS accept tomosynthesis studies. “It has created a workflow concern for radiologists who have to leave their office or reading room and come out to the tomosynthesis workstation to read the study,” said Monique Rasband, author of the report, Women’s Imaging 2012: Tomosynthesis Makes a Splash.” The doctors do say, however, that this extra time seems worth the effort because of the procedure’s effectiveness, she said.
Comparison tools enable radiologists to use personalized hanging protocols for DBT exams along with other procedures. Specialized tools can further enhance productive reading: automatic positioning of DBT and mammograms eliminates manual manipulations; automatic “same sizing” of DBT and mammograms aid in comparing changes in anatomy; and concurrent magnifying glasses provided close-up comparison of pathology across multiple views and procedures. DBT exams can be viewed in cine mode or by scrolling.
A recent article in the Wall Street Journal on 3-D mammography discussed the potential for digital breast tomosynthesis (DBT) to enhance the detection of cancers. I was reminded of how important it is to not only capture the best breast images possible, but also to have an efficient and effective system that helps radiologists make an accurate diagnosis.
As I revisited the accomplishments our team has achieved in designing a new module that displays DBT exams on our mammography workstation—while also displaying digital mammograms, breast ultrasound, breast MRI and general radiology exams from a single desktop—I was struck by how easy it is (or could have been) to add yet another dedicated workstation to the radiology reading environment and then falsely believe we have actually improved the diagnostic workflow.
We resisted that path. Our team has long demonstrated our commitment to supporting multiple digital breast imaging modalities on our mammography workstations, and we have fiercely resisted the temptation add new, single-use workstations that might seem alluring because of their “dedicated” nature—when in fact they add costs and create inefficiency. Supporting multiple breast imaging modalities—as well as general radiology exams—enables radiologists to deliver a faster diagnosis to referring physicians and can ultimately enhance patient care.
Our smartly designed tomosynthesis module streamlines workflow by allowing healthcare providers to store, route, display and query/retrieve DBT exams from DICOM-compliant acquisition devices, so radiologists have all the tools they need on one workstation. Comparison tools enable radiologists to use personalized hanging protocols for DBT exams along with other procedures, especially the 2D mammograms. In addition, specialized tools that further enhance productivity include: automatic positioning of DBT and mammograms that eliminates manual manipulations; automatic “same sizing” of DBT and mammograms that aid in comparing changes in anatomy; and concurrent magnifying glasses that provide close-up comparison of pathology across multiple views and procedures.
With our advanced system, radiologists can quickly and easily read exams from all modalities and vendors at a single workstation. And working smart is an important element in improving patient care.
How do you view or plan to view digital breast tomosynthesis? What do you think about 3D breast imaging?
Editor’s Note: Sherri Ford is a Mammography Technologist at Premier Imaging in High Point, NC. She has her A.A.S. degree in Radiological Technology and a B.S. in Health Administration. She has over 19 years experience in the mammography field ranging from mammo-screenings, diagnostics, stereo biopsies and needle localizations. She has worked as a PACS systems supervisor and has designed training programs for occupational nurses regarding osteoporosis and bone density testing. Sherri is also a member of ACR, ASRT and HIMSS.
Q: You have a varied experience as a technologist from a PACs supervisor to mammography. What are the major changes you have seen in the mammography workflow?
A: Technology changes everything. While technology is almost always eagerly awaited in mammography facilities, implementing new machinery often results in workflow growing pains. When digital mammography was introduced several years ago, facilities frequently floundered, causing workflow to slow down. The past five years has seen department workflow changes as processes were perfected, allowing more patients per hour. Many facilities have moved to a paperless system further speeding up workflow. As technologists, we have had to learn how to manage exam times, review images for technical quality in a new medium and not lose sight of the fact that our patients are individuals with feelings. Technology creates efficiency, confidence in the screening process and improved image quality but the equipment is costly. To offset the increased costs, schedules are packed tight and patients are streamlined from registration to exam result. Over the past several years, the most noticeable change in mammography workflow is undoubtedly the rapid pace. While increased volumes are a positive trend, indicating women are committed to the fight against breast cancer and health administrators are committed to providing the services, technologists must balance efficiency and compassion.
Q: Has the economic situation over the last few years impacted how you do mammography?
A: Healthcare was one of the last industries to respond to the economic crisis and is one of the last industries to recover as economic conditions slowly improve. When unemployment peaked many lost their health insurance but not their need for healthcare. Health organizations were faced with the problem of meeting level or increased demand for services with severely diminished revenue streams. Mammography tends to be a loss leader for many health organizations to begin with and the downturn in the economy hit just on the heels of acquiring new digital equipment, further compounding financial challenges. Most mammography centers responded to the conditions by increasing volumes and reducing payroll hours to address cost control but savvy administrators marketed the services to attract new mammography patients and retain the existing ones. Programs became available to provide low or no cost mammograms with the expectation these patients would be a source of referrals, sending new patients to the organization for other health needs.
Q: Do women have specific requests for technology they have heard about and if so what are they asking for?
A: Breast cancer screening relies most heavily on mammography primarily because the system has proven to be successful, accessible and cost efficient. However, mammography does not find all cancers and research continues to find new methods for screening and diagnosis. Periodically, patients will hear or read about new technologies and ask if they are available. Most of the time, patients will ask me about screening methods that do not require compression but rarely mention specific technologies. As healthcare becomes more transparent, however, this may change because the public will have greater access to information about diagnostic testing. Also, patient requests for new technology increase when it is introduced into the community.
Q: Is your facility doing digital breast tomosynthesis?
A: With the recent FDA approval of Breast tomosynthesis, breast cancer screening has a remarkable new tool to aid in earlier detection, especially in women with dense tissue. Despite the success stories tomo has produced, it is not widely utilized in the US yet. Health insurance does not reimburse for tomo exams at this time, considering the technology investigational and many facilities cannot absorb the cost. Some facilities pass the cost on to the patient as an up charge to a mammogram, usually offering the patient the option of having the tomo and paying or declining the exam. I recently had the opportunity to observe several tomo exams and believe this technology will become the industry standard for screening. My facility is not currently offering tomo but is evaluating the technology. Breast tomo offers new possibilities in breast cancer screenings and should be embraced with excitement and anticipation.