Sizing Things Up

Marianne Matthews, Editor, Imaging Economics

Marianne Matthews, Editor, Imaging Economics

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.

Dragon Boat Racing Offers Breast Cancer Survivors a New Way to Get Fit While Building Comradery

Cristine Kao

Cristine Kao, Global Marketing Manager, Healthcare IT, Carestream

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?

Dragon Boat Team

Dragon Boat Team

Solutions to Making Digital Breast Tomosynthesis Widely Accepted in Mammography Imaging

Ron Muscosky, Worldwide Product Line Manager, HCIS, Carestream

Ron Muscosky, Worldwide Product Line Manager, HCIS, Carestream

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.

[youtube http://www.youtube.com/watch?v=31DX2Y_UOh0?rel=0&w=560&h=315]

Healthcare Reform Opens Doors for Mobile Screening Mammography Services

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?

RSNA ’12 Preview: Digital Breast Tomosynthesis and PACS Integration

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

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.

For providers who have adopted or on the cusp of offering DBT, however, we expect the discussions in the exhibit halls to extend beyond potential clinical benefits to the IT considerations raised by DBT early adopters. For example, DiagnosticImaging.com reported earlier this Spring on a KLAS report that highlighted the PACS integration challenges of DBT:
“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.
While capturing the best breast images possible is important, it is just one piece of the care continuum. For DBT to succeed the reading environment must help radiologists make a fast, accurate diagnosis with minimal disruption to the diagnostic workflow.

 

At RSNA, we’ll be demonstrating our Digital Breast Tomosynthesis (DBT) Module for our CARESTREAM Vue Mammo Workstation that lets radiologists read all procedures from a single desktop. The workstation displays digital breast tomosynthesis studies, traditional mammograms, breast ultrasound, breast MRI and general radiology exams to help equip radiologists to work efficiently from a single desktop.

 

Here a quick video overview of how it works:

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.

If digital breast tomosynthesis is on your agenda at RSNA, swing by the Carestream booth (#2636) to get hands on with our DBT module or schedule your appointment now. 

Reading Digital Breast Tomosynthesis Exams From a Single Desktop

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

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?

For Mammography Tech Technology Has Changed Everything

Sherri Ford, RT(R)(M)(BD)

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.

Ask Anne: Changing Mammography Techniques for Digital Technology

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

One of the most common questions I receive for my “Ask Anne” feature here on Everything Rad is, “How will I need to adapt my positioning techniques when I move from analog imaging to digital?”

This month, Brigitte Hurtienne, chief radiographer at the Mammography Reference Center at the University Clinic in Munster, Germany, offered to share her experience:

Art of positioning

Whether using an analog or digital mammography system, the art of positioning is very similar. But digital imaging has advantages: the dynamic range afforded by digital mammography (16,000:1) is far superior to analog imaging (100:1).

The optical densities (OD) displayed on film are limited to 100 shades of gray, not all of which can be displayed at any time because the OD of the film is limited and fixed, and is determined by the x-ray exposure technique.

In a digital image the dynamic range depends on the computer’s window/level attribute and the radiologist can

Brigitte Hurtienne

Brigitte Hurtienne, Chief Radiographer, Mammography Reference Center, University Clinic in Munster, Germany

manipulate a digital image through 16,000 shades of white-gray–black.

So, in the digital technique, we often can make more skin wrinkles visible. Skin wrinkles may produce pseudoarchitectural distortions or may obscure surrounding structures.

Good positioning, at least for the mediolateral oblique view without skin wrinkles, is, therefore, very important. If hand pressure is discontinued before sufficient compression is applied, it will result in a poor separation of tissue and a downward-sloping of the breast contour, sometimes creating a skinfold in the inframammary ridge. An inadequate positioning technique in this region using suitable picture processing algorithms can lead to a loss of information.

Careful hand work – smoothing out the breast with the entire palm of the hand forwards and upwards, support with the ball of the thumb during compression, and smoothing out the inframammary ridge – prevent a sagging of the breast to the caudal and a wrinkle-free presentation of this region. Insufficient picture processing can be avoided in most cases.

Artifacts

There are also some differences in the types of artifacts that are seen in analog vs. digital imaging. In the analog world, we differ between film and screen handling artifacts and positioning artifacts. These artifacts are more common and can occur by improper handling of films and screens. Improper handling of films and screens could be exposures from creases, dirty screens, dust, scratches or from the object table, grid and static artifacts.

Some artifacts may be seen on both analog and digital systems, such as patient related artifacts (e.g. motion artifacts) and hardware related artifacts (e.g. x-ray tube filter defects and antiscatter grid defects).

Especially in the digital world, there are artifacts due to software processing errors or digital detector deficiencies. Pixel artifacts such as dead pixels or groups of dead pixels and dead lines can be caused by an imperfect detector.

Dust in the compression paddle, a not properly adjusted exposure, and problems with the image processing to a high noise level are further sources of an improper result. Problems with the reconstruction at the workstation can be the result of an improper display or problem with the sending of the images to the workstation.

Have you adjusted your technique for digital? What advice do you have for other radiographers or mammographers? 

Researchers Favor Annual Mammograms With No Family History

Stamatia Destounis, MD, FACR

Stamatia Destounis, MD, FACR, Elizabeth Wende Breast Care

Editor’s note:  Doctors at the Elizabeth Wende Breast Care in Rochester NY recently presented a study in Vancouver on breast cancer risk factors in women under 40.  Stamatia Destounis, MD, FACR, the study presenter at the ARRS annual meeting in Vancouver, answers three quick questions about the study’s reception and the continuing breast screening controversy.

Q:  At the American Roentgen Ray Society Annual Meeting you presented your finding on the ideal age for women to begin screening mammograms and the appropriate intervals between screenings. How were your findings received at the conference?

A: There was interest and enthusiasm at our results which revealed that women in their 40’s with no family history of breast cancer benefit from having a yearly screening mammogram, as a considerable number of the cancers diagnosed in this age group were through screening mammography, and 64% of these women had invasive breast cancers with 26% of these having metastatic lymph nodes. These are cancers that need to be found and can’t wait for women to be fifty before starting to have a screening program.  Controversial recommendations from some Organizations have recently argued that women in their 40’s don’t need screening mammography until they are 50 and our data do not agree with them at all.
Q: The screening debate seems to have new twists and turns often. For physicians speaking with confused patients, how would you recommend guiding the discussion?

A: Most women don’t have a family history of beast cancer when they are diagnosed with breast cancer. We believe that a screening mammogram yearly starting at age 40 saves lives as many well organized and regulated trials have revealed in the last 20-30 years. We recommend a yearly mammogram for women in their 40’s and our own review just presented in Vancouver revealed that a considerable number of women in their 40’s with no family history of breast cancer were diagnosed with a screening mammogram, revealing approximately two thirds of these patients having invasive breast cancer and a third with metastatic breast cancer.

CARESTREAM Vue Mammo Workstation

Q: Do you feel the screening debate is harmful to women’s health? Has the media attention impacted screening rates?

A: I think women and their health care professionals are getting confused by the controversy surrounding screening mammography and the constant media frenzy with controversial and conflicting analyses, data collections and personal opinions. There are many opinions, and emotion regarding breast cancer and this adds to the continued controversy.

The future of breast imaging is in the making.

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

Q: Are you seeing more young radiologists going into mammography services? 

A: At mammography conferences and continuing education courses around the world, I’ve been seeing younger participants than in the past. In fact, I’d say that more than half of the radiologists attending a recent seminar in Brazil were under the age of 40.

This is a great trend for the future of our field!

Historically, breast imaging in general—and mammography in particular—has been viewed as a difficult and unglamorous vocation.

It involved the monotonous task of looking at primarily normal images. It has been characterized by a high rate of recalls and retakes, as well as low reimbursement and higher risk of litigation. Compared to interventional radiology and other specialties, it just didn’t have the “wow” drawing power.

So what is attracting today’s up-and-coming radiologists to this area of specialty?

The multi-modality nature of breast imaging may be part of the answer, with mammography, ultrasound, MRI, and molecular imaging being used in tandem for screening and diagnosis. In addition, advances in digital technology are making this a cutting-edge discipline with appeal for younger medical school graduates.

Beyond just the technology, though, there is the point on which we all can agree: screening mammography saves lives. And saving lives is a strong motivator for anyone in the field of medicine.

If you have an open fellowship in breast imaging, let me know. Together, let’s do all that we can to encourage these future luminaries in the making.

What motivated you to go into the field of breast imaging? Who supported you in your efforts?