October 2014

Automated Breast Ultrasound: Groups Discuss How They Started Their Screening Program
By Kathy Hardy
Radiology Today
Vol. 15 No. 10 P. 24

Technologists become an important part of the education campaign, providing patients with the information they need to then talk to their referring physicians about what it means to have dense breasts.

Automated breast ultrasound (ABUS) is starting to take its place in the breast imaging world as an approved adjunct to screening mammography in women with dense breasts. Imaging centers are carefully researching their options before establishing their own ABUS programs. While dense breast notification mandates are taking hold in a growing number of states, those laws are not necessarily spurring radiologists to immediately adopt the technology.

Centers that have installed and are using ABUS considered factors such as increased sensitivity and consistent workflow, along with costs, when making the decision to adopt. This diagnostic tool is crossing over to the screening side, which could influence adoption rates.

“We were looking at how best to provide adjunct screening for women in our population with dense breasts and who have other risk factors for breast cancer,” says Monica Saini, MD, a diagnostic radiologist who specializes in breast imaging with Santa Fe Imaging in Santa Fe, New Mexico. “We asked ourselves: What would be the most beneficial for our community? What would they be comfortable with?”

Saini and the eight other members of her practice used a methodical process for evaluating ABUS and determining if there was a place for this technology in their practice, which is certified as an ACR Breast Imaging Center of Excellence. Located in a northern New Mexico community with a population of 70,000, they were concerned about finding the right solution for their patients’ needs. No one wants to adopt new technology for the sake of having new technology, she says. The evaluation process at Santa Fe Imaging started by looking at what was happening at academic centers around the country.

“This is a data-driven process,” Saini says. “By looking at work under way at academic locations, where studies in ABUS are under way, we could see that the data is showing that ABUS is a good secondary technology for women with dense breasts. The more studies that are done, the more comfortable we are with the process. We don’t want to implement new technology and then create false-positive findings.”

Saini says the group also reached out to breast imaging centers in communities of similar size to Santa Fe to learn what works best in settings similar to their own.
“We wanted to know what centers comparable to ours in size and patient population were doing as well,” she says. “We don’t want to adopt new technology that isn’t a good fit for our practice and our patient population.”

Once they decided to adopt ABUS, the Santa Fe team began to evaluate vendors. After some site visits and conversations with other users, they went with GE Healthcare’s Invenia system, which they have been using for less than one year. This is the rebranded version of the SomoVu ABUS system that GE Healthcare acquired with its purchase of U-Systems. With the technology’s acquisition, Santa Fe Imaging became the first facility in New Mexico to offer 3D automated whole-breast ultrasound as a screening supplement to mammography for women with dense breasts.

“We liked that we could view the scans in rapid fashion while obtaining a whole-breast view,” she says. “There are also fewer artifacts with this version of the system than with the first version.”

Trial Participation
At Northside Medical Center in Youngstown, Ohio, diagnostic radiologist Richard Barr, MD, was part of the team involved in evaluating ABUS for use in their breast imaging process. According to Barr, utilizing ABUS was a logical transition, as Northside Medical was part of the ACR Imaging Network (ACRIN) 6666 study, which assessed the effects of adding annual screening breast ultrasound to annual screening mammography. The study involved the use of handheld ultrasound.

“We had done a large amount of handheld ultrasound breast screening,” he says. “Referring doctors knew we were a part of the ACRIN study and because of that, they continue to send their patients to us for ultrasound. With that, it seemed natural for us to adopt the whole-breast ABUS technology.”

Northside Medical selected the ACUSON S2000 Automated Breast Volume Scanner manufactured by Siemens Healthcare of Malvern, Pennsylvania. Taking an overall approach to breast imaging, Northside is evaluating the scanner for diagnostic studies as well as adjutant screening exams. In addition, after screening with the Automated Breast Volume Scanner device, if they see an area of concern, Barr says they examine that area more closely with a handheld ultrasound.

Incorporating any new technology into an imaging practice involves several steps. Saini says educating office personnel, patients, and referring physicians in the community was a good place to start. Management created scripts for scheduling staff and technologists to use when speaking with patients about ABUS.
“This is especially important with our technologists,” Saini says. “They can see dense breast tissue in a mammogram and discuss that with the patients.”

Technologists become an important part of the education campaign, she adds, providing patients with the information they need to then talk to their referring physicians about what it means to have dense breasts.

Reaching Referrers
“There is a marketing component to the ABUS integration process,” Saini says. “We’ve met with local physicians and introduced them to the technology. We want referring physicians to be a part of the conversation when it comes to their patients. Once we reached all of our providers, we then started informing our patients that we have this new technology by including a flyer in the mailing with their reminder letters. This is where we address the issue of dense breasts and how ABUS can help in the screening process, along with mammography.”

Barr agrees that informing community medical professionals about how their patients may benefit from the technology goes a long way toward gaining their acceptance and support of ABUS in breast cancer detection. “Our referring doctors are seeing the value of whole-breast ultrasound,” he says. “They are referring more patients to us.”

Neither New Mexico nor Ohio are among the 19 states with dense breast notification laws in place, but there is a bill in the Ohio legislature, according to http://www.AreYouDenseAdvocacy.org. However, information about how dense breast tissue can lead to difficulties in detecting cancers with routine mammography alone is widely known. As women hear and read news about various risk factors for breast cancer, they ask their gynecologists about what they should do regarding their annual mammograms and other imaging options.

“Patients are savvy,” Saini says. “They’ve heard about the risks associated with dense breast tissue and want to know if this applies to them. We find that word of mouth can be a good tool in disseminating information as well.”
When evaluating the productivity of a screening program, centers look at both technical and clinical workflow. While users see ABUS as having the potential to increase workflow on the technical side, the clinical aspect can lag during the early stages of adoption.

Working ABUS into an imaging practice is a learning process, according to Saini. In the case of Santa Fe Imaging, mammography technologists are cross-trained in performing ABUS exams. There is some similarity between mammography and ABUS devices as each involves manipulating a large plate to collect the images. Once technologists are trained and become comfortable performing ABUS exams, the entire process can take about 20 minutes.

In addition, utilizing one technologist for the entire process enables the practice to maintain continuity of care for its patients, she says.

“We want patients to have one technologist take them through the whole process,” Saini says. “They stay with the patient from the mammography suite to the ABUS suite. That gives our patients a level of comfort as they go through what can be a stressful event for some women.”

At Northside Medical, Barr says they train mammography technologists and sonographers to use ABUS, which may help speed workflow because either technologist may be free to set up the exam. “It’s time consuming to complete a large number of handheld ultrasound breast screenings,” Barr says. “With ABUS, the time savings have not been huge, but we may see more time saved as we train more technologists and spend more time with the system.”

To accommodate both screening and diagnostic ABUS within the overall practice workflow, Barr says his practice designates two days per week for ABUS screenings. Diagnostic breast scans are conducted during the remaining days of each week.
Ergonomics also plays a role in the ABUS adoption decision-making process, Barr says. The handheld ultrasound process can take a toll on sonographers’ wrists and hands. It’s not unusual for ultrasound technologists to suffer from repetitive stress injuries after many years in their profession. Automation ultrasound can reduce the risk of those injuries.

One challenge with incorporating ultrasound into the breast screening process is to complete screening mammography and supplemental breast ultrasound without recalling patients. However, Saini says ABUS enables them to offer screening mammography and whole-breast ultrasound in one workable visit. Doing both exams takes longer than mammography alone, but one 20- or 25-minute visit is usually more convenient than a return visit for screening ultrasound. Some patients may not make the second appointment, according to Saini.

“When we first started using ABUS our goal was to have the patient come in only once for breast screening,” she says.

Ongoing Assessment
Given that theirs is a small practice in a small community, Saini says she and the other radiologists in the group are always evaluating new technology and approaches to breast imaging. About every six months they review their needs and the needs of their patients.

“If you can take that kind of time to plan a strategy for how to incorporate new technology, that’s a good thing,” she says. “We keep reviewing data until we’re confident to take the next step. We want to stay on top of cutting-edge technologies for our patients, but we also want to use them in the best way possible.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. She writes primarily about women’s imaging topics for Radiology Today.