The World Cancer Research Fund expects the number of breast cancer cases to reach about 2.1 million globally by the end of this decade. Breast imaging is the primary method of diagnosis for a vast majority of breast cancer patients globally.
ICE Magazine reached out to imaging leaders to find out the latest on breast imaging. Participants in this Director’s Circle article on breast imaging are:
- Dr. David Bodne, radiologist, Advanced Southern Imaging
- Richard Reaven, M.D., scientific advisory board member, Koning Health
- Amy Reed, mammography supervisor and regional QA/QC coordinator, University Hospitals Tripoint Medical
- Michele Robbins, BA, CRA, RDMS, RVT, associate director of women’s imaging at Banner Imaging
Q: How has breast imaging changed over the years?
Bodne: The goal for breast imaging has remained constant, find cancer early to have a positive outcome from treatment. Over time, the technology has also remained fairly consistent, using compression to hold the breast in place while an image was formed by the interaction of breast tissue and X radiation. The major change has been in the development of protocols to make and work up findings. The other change has been the increasing involvement of groups pushing for increased availability and compliance. The “find a cancer as small as the period at the end of a sentence” campaign was very effective. With increasing compliance, the detection rate of early-stage cancers has increased over time. The change from film to digital allowed us to manipulate images to help us detect subtle findings, with improved detection. Tomosynthesis, essentially polytomography of the breast, helped us better detect a certain finding. More significantly, it was supposed to decrease our false positive rates. This last point is very operator dependent. It does seem our diagnostic schedules have dramatically increased since the inception of DBT. An interesting side note is the public misconception about DBT requiring less compression, the Holy Grail of breast imaging. Unfortunately, compression will always be necessary for upright breast imaging. With the introduction of MRI, we found improved sensitivity with some loss of specificity, leading to increased call backs for findings. Scanning prone, of course, didn’t require compression to maintain a fixed position. Ultrasound also developed as an indispensable tool in our armament, becoming the workhorse for both supplemental imaging and procedures. The current mammographer is overwhelmed with the growth in numbers of exams, the complexity of the patients, the growth and variety of procedures performed, and the non-interpretive work done, such as speaking with patients and referring physicians and our technologists. No wonder new technologies are looked at with a cynical and weary eye.
Reaven: The fundamental technologies of breast imaging have not changed that dramatically over the last 15-20 years. We are still using mammography (X-ray), ultrasound and MRI primarily. With the advent of tomosynthesis (so-called 3-D imaging, which is a misnomer), the same underlying mammographic technology is used. The only difference has been the added ability to tilt the detector 15 or so degrees in one projection and then the other. This has allowed radiologists to peek around the corner, similar in fashion to a now outdated technology used in chest X-rays to peek up around the clavicle to look at the lung apices. We all know that mammography has its limitations, and tomosynthesis is no exception. An innovative technology that I think can change the game is dedicated computed tomography using a mammographic detector to ensure that radiation dose is in line with traditional mammography. This can allow true 3-dimensional imaging as opposed to projectional data, which can dramatically improve spatial resolution similar to the difference between a chest X-ray and cross-sectional chest CT. We all use chest X-ray to evaluate for pneumonia, effusion or pneumothorax, however when we want to evaluate for potential lung cancer we rely exclusively on cross-sectional chest CT examinations.
Reed: We have had many exciting changes in breast imaging since I began doing mammography in 2006. I would have to say the biggest change was moving from film to digital imaging, and that has brought its own advancements such as CAD and tomosynthesis. Not only have these changes allowed us to increase our department productivity, but also we have been able to enhance the patient experience by reducing the time from a 30-minute screening exam to just under 15 minutes.
Robbins: Breast imaging has undergone significant advances over the years including digital mammography, tomosynthesis (3D mammography), contrast enhanced mammography (CEM) and utilization of AI for enhanced mammography interpretation.
Q: How can an imaging department stay current on the latest guidelines for mammography?
Bodne: By providing appropriate staffing and technology for the radiologist, the physician is able to monitor the center while performing the myriad tasks confronting us daily. Burnout, however, is always possible, and is the growing concern currently. With a diminished workforce and a growing demand, there needs to be exploration into ways to meet current goals and guidelines more efficiently. One area might be use of mid-levels such as APPs or NPs to perform appropriately assigned tasks. Newer technologies are being explored to address some of the ongoing challenges such as screening dense breasts and cost-effective high-risk screening. It would also be helpful to test effectiveness of guidelines over time to avoid piling on of ineffective ones and on the fly ability for improvement in order to better achieve the common goal of early treatment for early disease.
Reaven: Attending national and international meetings can allow radiologists and imaging professionals to maintain current recommendations and become aware of current trends. Reading journals, attending journal clubs and speaking directly with colleagues can also help us remain aware of recent developments in the field. It is always important to frame the new information obtained in a clinical setting and to ensure these trends can be adapted to the clinical workflow. Teaching our referring physicians, providers and the public about the benefits of breast imaging remains a central role for our profession.
Reed: I think it takes a team to stay current on the latest guidelines for mammography and breast imaging. We have bi-weekly lead tech meetings that include representation from the 27 sites that perform breast imaging in our health system. The techs bring anything they want to discuss to the Zoom call. We take anything that cannot be solved at that meeting to a breast imaging TRIAD that meets monthly that consists of directors, managers, supervisors, radiologists and physicists to discuss any policy or protocol changes. Having the routine input from such a wide network of people gives us the ability to learn from each other.
Robbins: With 17 Banner Imaging sites ACR accredited in performing mammography including our 7 ACR designated Comprehensive Breast Centers we rely heavily on our lead QC mammographer to ensure we are aware of any guideline changes and remain in compliance.
Q: What tips can you share to help create an efficient workflow during Breast Cancer Awareness Month and throughout the year?
Bodne: Find a way of cloning the radiologist, at least in number of useful hands-on deck. Appropriate utilization of mid-levels, for example. Also, technologies to help us improve compliance while enhancing our efficiency. If we can find a way to better improve our confidence in normal findings, we might be able to decrease our false positive screeners and increase effective utilization of diagnostic slots. If we can find a way to more readily assess screening findings at the time of the diagnostic exam, it should decrease the time spent coming to a conclusion and providing a recommendation for the patient. The workflow is only as efficient as the radiologist and the technologist doing the work.
Reaven: Communication is key. Many women think about breast imaging only during Breast Cancer Awareness Month. We need to reframe the conversation in order to ensure that more women think about breast health throughout the year and that they are regularly imaged in order to detect breast cancer at its earliest and most treatable stage. Staffing can also be an issue, so making sure there will be adequate staff before, during, and after Breast Cancer Awareness Month is imperative. Compliance is also an issue nationwide. We know from MQSA and Medicare data that only around 55% of eligible women regularly receive breast imaging evaluation. Offering various options and innovative, FDA approved technologies can dramatically improve compliance. We know that cancers are out there (1 in 8 women in their lifetime), our job is to find them early so they can be treated effectively.
Reed: Efficient workflow during Breast Cancer Awareness Month and throughout the year can be a struggle at times but can be best approached by taking the time to look at your schedules ahead. Do not wait until you have a backlog to add extra timeslots, open the extra before you get to October. We check our scheduling templates every Monday to see how many days we are out and make adjustments as needed. Think outside of the box when you staff for these times of the year.
Robbins: Support staff is critical to maintaining an efficient workflow. Our support staff consists of our breast coordinators, IR schedulers, medical imaging assistants and front desk team members.
Q: What new technology has you excited about the future of breast imaging?
Bodne: Something I was briefly introduced to many years ago seems to be coming into its own. Breast CT has been capturing my imagination since I started being involved with it earlier this year. A perfect storm of personal situations brought me back in contact. What I’ve found, so far, is it helps me be more confident in making BI RADS 1 and 2 calls on screening. It helps me quickly locate findings at call back, improving my efficiency for diagnostic exams. It helps me also quickly make the findings for procedures, many performed with CT guidance. The ability to give IV contrast is proving to be comparable in diagnostic abilities to what I’m reading contrast mammography is able to provide. I’m able to evaluate implants on exams, possibly becoming a replacement for MRI for this indication. IV contrast exams have also revealed small cancers in dense breast tissue. Since attenuation seems to be comparable to tissue density, perhaps CAD or AI might prove useful in aiding us in diagnosing these women more effectively at the time of their screening exam. And the possibilities are likely to be as endless as what we’ve found over the years with CT used for imaging other areas of anatomy. Let’s see where our academics might take this as it’s introduced into the global women’s centers. Did I mention, women might have found their Holy Grail, hopefully increasing compliance?
Reaven: The Koning Vera dedicated breast CT imaging device is the most exciting breast imaging development in recent history. This compression-free imaging can be used without or with contrast, is biopsy capable, does not involve breast compression, uses radiation dose equivalent to mammography, and offers improved cross-sectional imaging quality. No other imaging modality offers these things in one package.
Reed: Contrast enhanced mammography has been exciting to learn about for the future of breast imaging! We will have 4 locations performing this new technology by the end of September. CEM finds cancer that could be missed on regular mammograms or ultrasounds. It is a safe, fast and effective alternative to breast MRI and breast MRI with contrast when the patient cannot tolerate an MRI. We are working on getting the information shared with the providers in our area.
Robbins: The advancements in AI and potential applications of artificial intelligence in breast imaging are exciting in both areas of interpretive AI (cancer detection) and non-interpretive AI such risk assessment, density quantification and image quality assessment.
Q: What else should ICE Magazine readers know about breast imaging?
Bodne: It’s the area where I believe we’re going to see the dreams of the forefathers and foremothers of breast imaging realized.
Reaven: Breast imaging has the ability to impact lives in profound ways. Without early detection and intervention, breast cancer can be a devastating disease with profound morbidity and mortality implications. When found early in its most treatable stages, women, men and their families can be offered a new lease on life. The happiness that early detection can deliver and the positive impact that can have on families is truly inspiring. Those of us who work every day in the breast imaging space can be and should be proud of those efforts.
Reed: Breast imaging has very compassionate technologists that are committed to their roles and their patients from the minute they walk in the door in the morning until sometimes even at the grocery store on the weekends! To have a former patient come up to you and thank you personally for your care, for finding their cancer or even for taking extra time with their mother is the best feeling in the world.
Robbins: With mammography remaining the gold standard in breast cancer screening the current recommendation of the Society of Breast Imaging is that woman at average risk for breast cancer begin annual screening mammograms at age 40. •
