By Terry Lynn Bucknall, CRA
I’ve been in the world of imaging for 42 years, and of all the modalities that I’ve worked in, breast imaging has evolved exponentially more than any other. We’ve progressed from capturing an image with industrial film, to Xerox processing, to film screen, to digital acquisition, and currently 3D imaging (tomosynthesis). Along with the growth and developing technologies comes controversy and debate as to whether the newer methods will result in statistically significant improvements and whether our current practices are in the best interest of our patients.
My talk at the 2016 AHRA Spring Conference in Chicago will touch on the latest developments that are affecting how we deliver care to our patients. The most recent controversy is the United States Preventative Services Task Force (USPSTF) 2016 recommendation that women have biennial mammogram screenings between the ages of 50 and 74 years. The recommendations have been argued and debated by the American Cancer Society, the American College of Radiology, and Society of Breast Imaging. This entire topic has caused much confusion for our patients and providers. Fortunately, recent congressional legislation was passed that placed a moratorium of two years before adopting the recommendations, which may place barriers to patients accessing lifesaving screening procedures.
Ironically, the debate of when to begin screening comes at a time when we are making significant imaging improvements. Hologic’s tomosynthesis (3D) unit received FDA approval in 2011, along with GE in 2014, and Siemens in 2015. Hologic’s C-View software application, which creates 2D images from the tomo views, was FDA approved in 2013.
Like most new technology, the implementation of 3D mammography creates challenges for facilities in terms of reimbursement, workflow, and education for the patient, provider, and imaging center staff. Patients question the radiation dose and may not want to pay an additional fee for the new service. The facility and radiology group may need to decide if they will charge the patient an additional fee that is not covered by the patient’s insurance, as many private insurers continue to label the technology “investigational.” The good news is that 3D mammography has been proven in studies to detect more invasive cancers at an earlier stage and reduce the recall rate from screening studies.
Breast tissue density is another “hot topic” that challenges facilities. Twenty-four states in the US now have legislation in place mandating that facilities communicate the patient’s tissue density in the MQSA required patient results letter. We may be faced with the decision to implement tissue density software, which makes the analysis of density more accurate and takes the subjectivity away from the radiologists’ interpretation, allowing for consistency among multiple readers at a site.
Tissue density also opens up the question of implementing screening breast ultrasound, and how to educate our patients and providers on the advantages of screening ultrasounds as an additional screening tool. Another question is whether to perform hand-held US procedures or invest in a dedicated Automated Whole Breast Ultrasound (AWBUS) system. That decision will change a facility’s workflow, scheduling, and resources, and could lead to a possible capital investment.
In addition to tomosynthesis, papers introduced at RSNA 2015 also support the use of MRI and Contrast Enhanced Mammography in certain instances when detection of breast cancer is not confirmed on ultrasound or other traditional mammography studies. Facilities are given the challenge of deciding how and when to put these modalities to use, taking into consideration standard of care and best practices.
Lastly, outpatient imaging centers, especially breast centers that choose to become accredited by the National Accreditation Program for Breast Centers (NAPBC), are challenged to implement a high risk assessment program, which includes genetic testing. Genetic labs have been busy approaching imaging centers and introducing the concept of creating programs that determine a patient’s need for testing depending on their family cancer history. The labs are not just testing for BRCA mutations associated with breast and ovarian cancer, but panels of genes that could identify a patient’s additional cancer risk including colon, lung, prostate, and more. The patient benefits by learning their personal medical management options while the potential for downstream revenue for a facility can be realized in additional screening such as MRI and colonoscopy.
I hope to see you at the conference and look forward to sharing more great info in my session, “2016 Hot Topics and Current Trends in Breast Imaging.”
Terry Lynn Bucknall, CRA is the director, women’s imaging services at the Henry Mayo Newhall Hospital Sheila R. Veloz Breast Center in Valencia, CA. She can be reached at firstname.lastname@example.org.