Breast Ultrasound Screening Marches into Practice

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 - Marla R. Lander, MD
Marla R. Lander, MD, a breast radiologist at Desert Comprehensive Breast Center in Palms Springs, Calif., reviews a mammogram screening exam and ultrasound screening exam acquired on an automated system.
Source: Desert Comprehensive Breast Center.
More states are pondering the legislative bandwagon mandating breast ultrasound screening for women with heterogeneous or dense breasts. While lawmakers debate the merits of ultrasound screening, some breast imagers are transitioning from handheld ultrasound screening to automated ultrasound systems to image women with heterogeneous or dense breasts.

Legislation spurs demand

Jefferson Radiology in Hartford, Conn., launched a breast ultrasound screening program in 2005, encountering a lukewarm reception. "Anecdotally, 5 to 10 percent of women wanted ultrasound screening prior to 2009," recalls Jinnah A. Phillips, MD, director of breast imaging.

However, in October 2009, Connecticut became the first state to pass breast density legislation, which requires providers to notify women if their mammogram reveals dense breast tissue. It also requires insurers to cover adjunctive testing, such as screening ultrasound or MRI for these women.

"After the law passed, we saw overwhelming demand," says Phillips. Within a few months of its passage, the practice had a backlog of more than 500 patients requesting ultrasound screenings. At that point, Jefferson Radiology added automated breast ultrasound screening to its handheld ultrasound screening program. To keep up with increasing demand, the practice would have had to eliminate other ultrasound studies. The automated breast ultrasound system provides the throughput to image 25 to 30 patients daily, says Phillips.

The automated screening model can succeed without legislation and reimbursement. Susan J. Ward, MD, radiologist with Renown Breast Health Center in Reno, Nev., decided to integrate automated ultrasound into practice after reviewing a study published in the European Journal of Radiology in March 2008, which showed breast ultrasound screening doubled the cancer detection rate among women with dense breasts compared with mammography.

In October 2010, the center installed an automated system while seeking to educate women and referring physicians about breast density and screening ultrasound. The practice modified its screening mammography patient letter to add information about breast density.

"Patients and referring physicians were confused at first," admits Ward. "In the last six months, medical and popular literature have addressed the topic, and we've added posters and pamphlets. Now, women understand the importance of screening ultrasound."

The effort led to a spike in ultrasound volume. In Nevada, where women pay out of pocket for the study, the practice has scanned 110 women since formally launching the program in November 2010. However, most studies were requested in the last six months.

Ward estimates that half of the 10,000 mammograms she reads annually indicate heterogeneous or dense breast tissue. "I've been frustrated for a long time because you can only see so much on the mammograms in these cases." The challenge has been exacerbated by increasing constraints on screening MRI. Beginning in 2010, some payors started re-categorizing breast MRI as experimental for anyone with less than a 25 percent risk of breast cancer and tightened reimbursement parameters.

Ultrasound can provide another screening option for women with dense or heterogenous breast tissue.

Marla R. Lander, MD, a breast radiologist at Desert Comprehensive Breast Center in Palm Springs, Calif., participated in a three-year study that provided 3D ultrasound to women with breast density greater than 50 percent. "About 98 percent of women jumped on the screening opportunity when offered," she says.

Plus, patients continue to return for ultrasound screenings. "Women like ultrasound because it is more comfortable [than mammography], and our discovery rate of cancer is higher. Women feel more secure with the additional study and referring physicians appreciate the supplementary coverage," she says.

In the trial, Lander detected 30 cancers in 1,006 screening patients and 1,050 diagnostic patients using automated ultrasound from January 2005 to July 2007. She estimates that mammography would have detected three to six cancers in a similar screening cohort of 1,000 patients.

Screening in practice

Three dimensional breast ultrasound screening systems automate image capture and provide more consistent image quality than handheld studies. Studies depend less on the sonographer's skill and automation ensures the study covers every plane, says Phillips.

At Jefferson Radiology, the automated protocol entails three views of each breast,  and the appointment is completed in 15 to 20 minutes. The software reconstructs the images into a cine loop or coronal reformats, with most experienced imagers completing review in three to seven minutes. Any findings are marked with annotations to provide a roadmap if a targeted diagnostic ultrasound is required.

According to Lander, the learning curve for automated 3D ultrasound lasts one to three months, and may be associated with increased callbacks, which drop after the initial period.

Other issues include efficiency glitches associated with hybrid ultrasound and multimodality workflow.

Jefferson Radiology offers both automated and handheld ultrasound screening. Handheld studies are read from the PACS workstation, while automated scans are read at a separate workstation next to the PACS workstation. The radiologist reads ultrasound studies in conjunction with current and previous mammograms. "We're working with the ultrasound vendor to develop a more enterprise-friendly system. If it were web-based or thin-client, we could better distribute the screening workflow," shares Phillips.

As pioneers refine their practices and lawmakers mull legislation, the automated screening breast ultrasound market could expand. Such systems offer a standardized, efficient model, enabling practices to tailor their breast imaging programs to population subsets.