Mammography can trace its roots back more than a hundred years to the radiographs of mastectomy specimens showing the spread of a tumor—as reported in 1913 by Albert Salomon, a German surgeon. But while improvements in software and technology have certainly brought mammography into the digital age, up until 10 years ago it was the modality of mammography that bore the primary burden of identifying breast cancer.
That has changed quite dramatically in recent years as the “Are You Dense” movement gained support; now in 27 states, laws require physicians to notify women who have dense breasts. Also, in many of these states, physicians must offer additional screening to women with dense breasts, defined as containing more than 50% fibroglandular tissue. The options for additional screening include Digital Breast Tomography (DBT), full-breast ultrasound, and breast MR. Full-breast ultrasound is the recommended initial follow-up because it is not as expensive or as invasive as an MRI, yet still may catch up to 30% more cancer in women with dense breasts. MRI is recommended for women in a high-risk category: who have had cancer or whose mothers have had cancer, who have the BRCA1 or BRCA2 gene, or who had radiation for Hogkin’s disease as teenagers.
The impact on women’s breast centers and their PACS is quite dramatic because the number of women affected is so substantial. A recent study performed by the Breast Cancer Surveillance Consortium, involving 365,426 women, reported that 47% of the women aged 40 to 74 had dense breasts. But it also stated that breast density should not be the sole criterion for deciding whether supplemental imaging is justified.
Because the additional modalities generate large files, especially DBT, and because breast studies must be retained for extended periods (varying by state), the additional storage requirements—always an issue with the higher-resolution mammograms (as compared to general radiography)—are significantly increased with the added screening studies from 3D modalities. A typical FFDM four-view study can take up to several hundred megabytes uncompressed--but DBT can run several times that and full-breast ultrasound can also run to a gigabyte or more.
Carestream PACS V12 and above can take much of the time-consuming labor out of tracking tumors across these modalities and over time with the Carestream lesion-management feature. This allows radiologists to click on a tumor, measure its volume, and register it across modalities, including DBT, Breast MR, and Full-Breast Ultrasound. And tracking the tumor growth over time according to RECIST standards is automatic, once the radiologist clicks on it. Note: Keep in mind that even if you purchased the lesion management feature to make your oncology workflow more productive, your mammographers may not be aware of how much time it could save them in tracking breast lesions—especially if they’re now reading multiple modalities with increased frequency. Carestream’s PACS does a good job of integrating these additional modalities into the workstation and into the reports to the referring physician.
As new research is under way and active discussion continues, referring physicians must understand the new requirements and must be prepared to order additional screening for women identified as having dense breasts. Radiologists who read the studies may require additional training in the new breast modalities. PACS administrators in facilities that treat women should be aware of the new modalities and their requirements for increased storage.
Carestream participates in workshops around the world to help mammographers practice reading the new modalities and increase their proficiency.
A typical mammography clinic sponsored by Carestream, led by Lazslo Tabar, M.D., in October 2016 in Phoenix, Arizona. Dr. Tabar is a Professor of Radiology at University of Uppsala School of Medicine, Sweden; Medical Director of the Department of Mammography, Falun Central Hospital, Sweden; and Consultant Radiologist for numerous comprehensive breast centers in the U.S.
Clinical Development Manager, Women’s Healthcare, Carestream
Anne Richards has been involved in women’s health clinical education at Carestream and, before that, at Kodak since 1996. She is a pioneer in healthcare information systems for mammography and has provided significant input to help make the Carestream mammography PACS workstations the technological achievement that they are today.