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Women’s Imaging — Cautious
Acceptance of New Technology If you present new technology to clinicians, they will use it, won’t they? That’s certainly the intent of scientists who create the technology used in leading-edge breast imaging equipment and of the companies that manufacturer it. But according to Edward M. Smith, ScD, FACNP, professor of imaging sciences at the University of Rochester Medical Center, it’s not necessarily the case. As the director for the department’s second annual Women’s Imaging conference, his experience has been that clinicians are not as accepting of the new technology in the marketplace as the general population may imagine. “Something we learned from last year’s conference is that even the vendors felt clinicians were not ready for the new digital imaging technology,” Smith says. He adds that while clinicians understand they need to make the transition from film to digital, they don’t comprehend the benefits, especially in productivity and workflow. “They thought the benefit would be to increase productivity,” he says. “They weren’t thinking of the diagnostic improvements of new technology.” One early adopter of digital imaging technology, Philip F. Murphy, MD, a radiologist with Elizabeth Wende Breast Clinic (EWBC) in Rochester, N.Y., agrees that there is a degree of confusion among clinicians when it comes to making the switch from film to digital. “Findings look different on digital images when compared to film images,” Murphy says. “Confidence in image interpretation depends a great deal on experience and pattern recognition, in seeing things in a certain way. If that way changes, you need to train your brain to recognize a different set of patterns. This is a time-consuming process that is in part related to patient volume. When starting with digital, we would occasionally use a comparable film image to help us understand what we were seeing on the digital image. Our confidence in digital mammography has grown, and we now routinely move to digital imaging from suspect film findings.” EWBC was the nation’s first freestanding breast imaging center. It is accredited by the American College of Radiology and certified by the FDA. Murphy says the clinic conducts approximately one half of its 80,000 exams per year digitally—most of the diagnostic work and roughly one half of the screening. “We are a very high volume breast imaging practice,” Murphy says. “Because of the high volume and early adoption of evolving digital technology, the transition from film-screen to digital mammography has been and continues to be long and often quite difficult. When possible, we triage mammography studies to digital or film-screen mammography based on age, breast tissue pattern, history of breast disease, and history of prior mammogram study type. If we feel the patient may benefit from a digital examination, we take advantage of the technology.” There have been numerous breast imaging tools introduced in the marketplace over the past 10 years, each with its specific benefits to patients with a breast cancer diagnosis. Within that time, traditional mammography has evolved to digital mammography but not without certain concerns, Smith says. Initially, the price of the tools was an issue, with a digital mammography system and tools costing as much as $300,000 to $400,000, according to Smith. However, the same equipment today costs roughly one half as much. “There is also a frustration with productivity,” Smith says. “There is a myth that digital mammography is not as productive. They think it takes more time to perform and complete the analysis. Productivity is a big issue.” Murphy says he has experienced an increase in the time it takes to interpret digital images compared with film images. All screening mammography studies in the practice are double reads. “One radiologist might pick up on something the other radiologist doesn’t,” Murphy says. Smith adds that with film-screen mammography there may be less information available for a radiologist to review, but it appears in a prearranged form. “With digital mammography, there are so many things you can do with the image,” he says. While mammography is the first line of defense in the fight against breast cancer, digital mammography enhances that 2D image of breast tissue with additional readings. The image itself is clearer than a film version and can be enlarged or manipulated to obtain the best view possible. The digital images can be circulated across the network for review by all physicians involved in the patient’s diagnosis and treatment. In addition, radiologists can use computer-assisted detection software to help interpret digital mammograms. There are a number of breast imaging technologies beyond traditional and digital mammography, all in various stages of development and clinical use. Some are considered alternative procedures; others are used in conjunction with standard procedures, while at least one is still in the research stage. Ultrasound. Because ultrasound images are captured in real time, they can show the structure of breast tissue, as well as blood flow and any other movement. Ultrasound breast imaging is a painless procedure used for diagnostic exams rather than screening exams. Breast MR. Breast MR is typically prescribed for breast cancer staging. This procedure is also useful in imaging dense breast tissue and for viewing breast abnormalities that can be felt but are not visible with conventional mammography or ultrasound. In general, MR is a complement to a diagnostic mammogram and does not replace screening mammography. However, earlier this year, the American Cancer Society recommended MR as a screening tool for certain women at high risk of developing breast cancer. Breast-specific gamma imaging (BSGI). BSGI involves injecting a small amount of radioactive tracing agent that is temporarily absorbed in a patient’s body and concentrates in cancer cells. A specially designed gamma camera takes pictures of the breast to help radiologists see any abnormal cellular activity. BSGI has a high specificity and is typically used for women who have a questionable finding on their mammogram, dense breast tissue, scar tissue from previous surgery, breast implants, or other reasons that make them poor candidates for mammography. PET/CT. A PET scan detects the metabolic signal of actively growing cancer cells in the body, and a CT scan provides a detailed picture of internal anatomy that reveals the location, size, and shape of abnormal cancerous growths. Combining the results of PET and CT scans into one image can provide complete information on cancer location and metabolism. Tomosynthesis. Digital tomosynthesis, currently available only for research purposes, creates computer-generated 3D pictures of the breast using multiple x-ray pictures from many angles. The breast is positioned the same way as in a conventional mammogram but with less pressure applied—just enough to keep the breast in a stable position during the procedure. Cone beam CT. This research technology creates 3D axial CT slices of a patient’s breast tumor, enabling physicians to compare these images with initial treatment planning images to more precisely target the radiation. Physicians can make position adjustments if necessary. The hope is that this technology will lead to more highly customized radiation treatments, where higher doses are directed at the tumor while sparing the patient’s normal body structures. The limitations of mammography—though it remains a valuable primary screening tool—is one reason researchers have pursued these other tools. “There are many tools available,” Smith says. “Everyone needs to determine the best diagnostic options, combine the results, and make the best analysis. If they don’t understand the benefits of a new procedure, we need to show them how to make an intelligent decision as to which technology to use.” Another challenge concerning the acceptance of new breast imaging technology can be a lack of standards for image storage and retention, Smith says, particularly when a hospital or imaging facility is transitioning from film-screen mammography to digital mammography. “There is some confusion as to how long to save old digital breast studies,” Smith says. “If a woman comes in five years in a row to the same facility for her mammograms, those images are saved. Come the sixth year, her films from the first of those five years can be deleted. But if she visited that facility every other year, her films would be held for 10 years. With breast MR, the protocols are not the same.” Physicians also need to contend with the IT aspect of digital imaging data. Much like any computerized method of analysis, large image files are difficult to move and view, Murphy says. It can take minutes for an image file to open for viewing. Sharing files can be cumbersome as well, as all computer systems within a practice need to “talk to each other,” according to Murphy. “Historically, breast imagers haven’t had a need for a sophisticated IT department,” he explains. “We need to train our staff to deal with the new and evolving technology and learn when to ask for help.” Also, there is the individuality of the many practitioners involved in the day-to-day process of diagnosing and treating women with breast cancer, and clinicians may conduct the same diagnostic procedures differently. Overall, Murphy recommends that a practice considering making the transition from film to digital mammography take time to learn about the new technology—including options, strengths, and weaknesses—in order to have realistic expectations. Consider the volume of work conducted on an annual basis and use that to help determine when and how to most quickly transition to a digital world. “Start with one or two machines while maintaining film-screen mammography capability,” he says. “Once you develop a comfort level with the new technology and if resources allow, a quick transition may help to lessen the pain of a protracted transition.” — Kathy Hardy is a freelance writer and editor based in Phoenixville, Pa. Women’s Imaging
2008 Conference With that in mind, Edward M. Smith, ScD, FACNP, professor of imaging sciences at the University of Rochester Medical Center, has gathered a faculty of imaging experts and clinicians to present a variety of imaging topics—from digital mammography to the management of osteoporosis—during the Women’s Imaging 2008 conference scheduled for February 3 to 6 in San Antonio. This second annual conference will offer educational forums that present women’s imaging as an umbrella covering the total body. According to Smith, the two imaging procedures that continue to draw the most interest in diagnosing breast cancer are digital mammography and breast MR, both of which will be covered in depth for physicians and technologists by an internationally recognized faculty. Smith says that if attendees attend the appropriate lectures, they can earn sufficient credits to satisfy the didactic continuing education requirements for digital mammography and breast MR. “Our conference faculty members were selected for their expertise, of course, but also because they have different viewpoints,” Smith says, “for example, their approach to breast MR.” It’s these differences of opinion that provide attendees with the opportunity to hear alternative approaches to reaching a diagnostic decision—this is the essence of education. Smith says last year’s conference was more technological in nature, but with attendee and faculty feedback, “we learned that a more clinical approach would be more appropriate.” Included this year will be workshops designed to demonstrate the basics of transitioning to a digital environment. “With this multimodality workshop, we will allow attendees the opportunity to use new equipment and conduct a complete hands-on comparison between different exhibitors’ workstations. Attendees will get a feel for which tools can make life easier.” They will also have the opportunity to participate in both MR- and ultrasound-guided breast biopsy workshops. For more information, visit here. — KH
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