As the 2011 RSNA begins to wind down, we wanted to take a step back and provide an update on breast imaging. Knowing the strategic importance of breast imaging to many hospitals, administrators and physicians continue to look for new technologies that will allow them to reduce patient anxiety and increase detection.
As screening mammography has been under greater scrutiny of late, attention has shifted to other modalities that could play a greater role in diagnosing breast cancer. Because of its widespread adoption by breast centers, many of these are based on digital mammography. Nearly all presenters note that mammography is highly likely to be unseated as the modality of choice for screening due to digital mammography’s proven ability to reduce breast cancer mortality, affordability, and accessibility. However, more options exist for diagnosis, as current methods miss lesions in some patients.
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For breast cancer patients, detecting and diagnosing their condition is traditionally a lengthy process requiring multiple imaging scans. A source of frustration and anxiety for women, this process can take several weeks from initial mammogram to final diagnosis.
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A new study published in the British Medical Journal is reigniting the debate over mammography as a screening tool. Lead author Dr. Phillipe Autier looked at historical data from 1980 to 2006 to determine the impact of screening mammography on breast cancer-related mortality in six European countries. The greatest decrease in mortality over this 26 year period was seen in women ages 40 to 49. However, there was not a correlation between decreases in mortality and the availability of screening mammography in these countries. Accordingly, the authors have concluded that there is no impact on breast cancer mortality as a result of screening mammography. Rather, the authors infer that improved treatments for breast cancer and efficiencies in healthcare are more likely responsible for this decrease.
This and other studies published on the efficacy of screening mammography seem at odds with new recommendations from the American College of Obstetrics and Gynecology (ACOG). This week, ACOG released updated guidelines recommending screening mammography annually for all women over 40. ACOG revised its earlier recommendations of annual screening at 50 due to new evidence that more aggressive tumors have shorter sojourn times (time from detection to symptoms) in women under 50, and that reductions in mortality due to screening are similar for women in their 40s and 50s. ACOG emphasizes the importance of communicating the risk of false positives to women receiving screening mammography as this risk increases with more frequent imaging. This high false positive rate is also referenced in the widely-discussed USPSTF guidelines from 2009 that recommend biennial screening at age 50.
This issue is likely to lead to increasing consumer confusion regarding the effectiveness in screening mammography at lowering the rate of mortality for breast cancer. Therefore, it is imperative that providers are open about the risk of false positive exams with patients. While many in the radiology community are concerned about the number of unnecessary exams, ACOG notes that many patients are aware of this risk and are well-adept at coping with anxiety that results from biopsies and other downstream procedures.
Alternatively, using more specific screening technology, such as tomosynthesis, may help to decrease breast cancer-related mortality. Some radiologists suggest using breast MRI to screen for all patients, though it is already plagued by a high false positive rate and will be prohibitively expensive for many providers (and payers). Tomosynthesis promises to improve on the recall rate from screening mammography though it is not yet clear if this will reduce the number of breast cancer related deaths over a long period of time.
As vendors release new products and upgrades to existing technology it will become increasingly difficult to determine the relative effectiveness of each product. Research cannot keep pace with innovation so it will be left to individual physicians and hospitals to determine the relative merits of each new tool.
Technology Insights is continuing to track the screening mammography pipeline to provide up-to-date guidance on right-fit investments in the ever-changing breast imaging market.
Just the other day we received a request from a fellow Advisory Board member seeking assistance in determining how imaging technologies are utilized across the continuum of care for breast cancer. This was an interesting request in that, despite the development of national guidelines and protocols, there still exists considerable variation in how breast cancer patients are managed. This variation is the result of institution-specific protocols, technology availability, local breast cancer incidence rates, and numerous other factors.
Further, arriving at actual figures can be a challenge due to the limited availability of claims-based data to evaluate the indications and clinical history for why the procedures are conducted. Literature reviews can also be challenging to identify this information as most clinical studies examine the efficacy of certain modalities with finite patient inclusion/exclusion criteria, and as such, it can be very difficult to extrapolate those findings to the general population.
However, after examining clinical guidelines, journal articles, our own Outpatient Imaging Market Estimator, and expert consensus, we arrived at the following conclusions.
We hope this information proves helpful as organizations plan for new and emerging breast imaging technologies and service offerings. Using this and other data, Technology Insights shall be developing a "Downstream Breast Imaging Calculator" - an interactive tool by which users can input screening mammography volume and other institution-specific diagnostic parameters to determine the volume potential for downstream diagnostic modalities, including mammography, ultrasound, MRI, BSGI, and PET. Stay tuned in the months ahead for the release of our new tool! For additional questions regarding breast imaging modalities and how they are utilized, please contact Brian Maher at email@example.com.
Just a few short months ago, the United States Preventative Services Task Force (USPSTF) nearly turned the world upside down by recommending against the screening of women starting at age 40 for breast cancer. Immediately refuted and viewed by clinicians and industry alike as the first sign of "rationing care" in the health reform era, two prominent professional societies recently released new recommendations reinforcing the existing guidelines to begin regular screening for breast cancer at age 40.
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