Interpreting the Spectrum: Breast Imaging & IT Options Abound
 The hybrid reading room model at Eastern Radiologists’ Breast Imaging Center in Greenville, N.C., keeps radiologists focused on image interpretation to maximize productivity.

While digital mammography has monopolized the breast imaging limelight over the last 18 months, a host of other breast cancer imaging and IT options have quietly performed. Although no single technology meets all needs, each holds a critical place in the spectrum. In addition, all have upped the ante, delivering essential imaging and workflow improvements to enable better patient care, higher profit margins and greater efficiency. Consider:

  • Breast imaging practices tap into mammography reporting software to hyper-charge workflow and eliminate paper.
  • Improved MRI technologies fine-tune resolution and scanning time for great flexibility and earlier detection.

Lower cost options like breast-specific gamma imaging and ultrasound are proving their merit, adding to the array of choices and carving new niches like ongoing therapeutic monitoring.

As the breast cancer imaging evolution marches forward, Health Imaging & IT offers a guide to the 21st century breast imaging practice.

Meeting the efficiency challenge

“Breast imaging facilities are being squeezed on all ends: manpower shortages, reimbursement cuts and increasing technology costs,” says Bruce Schroeder, MD, director of Eastern Radiologists Breast Imaging Center in Greenville, N.C. Practices must meet dual challenges to survive and turn a profit: operate at a highly efficient level and provide high-quality patient care. Eastern Radiologists examines every aspect of workflow in its ongoing quest to squeeze every ounce of productivity from its practice.

The practice’s analysis begins with the basics. Breast imaging interpretation workflow consists of three components on the radiologist’s part: patient selection, image analysis and reporting. Attending to selection and reporting can generate a hefty payoff, says Schroeder. For example, Eastern Radiologists uses CCOW (Clinical Context Object Workgroup) to link its Mammography Reporting System (MRS) mammography tracking and reporting software to its GE Healthcare Seno Advantage mammography workstation. The HL7 protocol allows for automatic synchronization between the reporting system and the image viewing software. “It’s twice as fast because the radiologist doesn’t have to pick through the worklist,” says Schroeder. Instead, the physician inputs the patient’s barcode into MRS and CCOW opens the appropriate mammogram or ultrasound study for viewing. “This is a differentiating technology. If I spend 15 to 20 seconds finding a patient in the worklist, it translates into one-third of the time it takes to read a mammogram,” calculates Schroeder. The practice tested a similar syncing progress to pull analog mammograms to the alternator and hopes to fully implement the concept later this year.

Another example of the practice’s “every 10 seconds counts” credo is its rich use of MRS’ template system. Normal studies can be completed with single or double letter codes. The practice enhanced the system with a shareware keyboard expander that allows users to create templates for additional categories like left lumpectomy. The investment in robust workflow analysis reaps dividends. “Radiologists at breast imaging practices that put all of the pieces together can focus on their primary job of image analysis, provide state-of-the-art care, regain their time and stay profitable,” asserts Schroeder.

On the Horizon
The breast cancer imaging horizon is bright. Several new technologies under development promise to add to the breast imaging arsenal. Options under development include:
  • Whole-breast ultrasound. Although American College of Radiology Imaging Network (ACRIN) 6666 trial tied screening ultrasound to a relatively high callback rate and low positive predictive value, SonoCine believes screening ultrasound will be feasible. The company’s investigational technology separates data acquisition and review. The system interfaces with conventional ultrasound systems, adding computer guidance of the probe and custom review software to allow radiologists to adjust images for speed, size, brightness and contrast. Early data show a favorable callback rate and positive predictive value. On the economic front, it is expected that ultrasound could be more cost-effective than breast MRI for high-risk screening.
  • Molecular breast imaging (MBI, also known as sestamibi or scintimammography) shows promise as an alternative to breast MRI for high-risk women and those with dense breast tissue. Advantages of MBI include lower cost and more straightforward image review. A recent study from The Mayo Clinic in Rochester, Minn., found comparable sensitivity over 90 percent and specificity of 50 percent with MRI and MBI.
  • Breast tomosynthesis is edging closer to clinical reality. The technology is expected to improve on mammography’s accuracy by acquiring and reconstructing a series of thin slices of breast tissue. Look for the first commercial systems later this year or early in 2009.

Less paper, less staff, more profits

When Women’s Diagnostic Center in Louisville, Ky., deployed digital mammography in April 2007, the practice boosted MagView mammography tracking and reporting software with RadView for demographics, billing and appointment control. The new software automates CPT and ICD9 code creation. “We’ve become so much more efficient,” says Practice Manager Cris Vittitoe. The practice increased its daily patient volume from 60 to 70 to 80 to 90 after deploying digital mammography and RadView. Plus, as patient volume increased, Women’s Diagnostic Center trimmed its staff. Front-office staff went from seven to five, mammography techs from eight to seven and transcriptionists from two to 1.5 FTEs.

Women’s Diagnostic Center continues to tap into MagView’s capabilities to improve its practice. For example, earlier this year Vittitoe customized the software to barcode encounter forms and eliminate paper encounter forms to accelerate the move to a paperless practice. Other pieces of the paperless puzzle include six Motion Computing C5 Tablet computers, which will be deployed later in 2008. Patients will input demographic data upon arrival at the center. “Data will flow into MagView to eliminate one more piece of paper and another job,” explains Vittitoe.

Streamlining the digital/analog hybrid environment

Any practice that transitioned to digital mammography can attest to the pain of a hybrid environment. Radiologists are forced to work in a dual configuration, reviewing current digital studies and comparing them to analog images. The hybrid reading room is cluttered with workstations and alternators. Not only is the arrangement inconvenient and inefficient, it also impacts the recall rate as hybrid comparisons can be challenging.

The Radiology Imaging Center at Mount Sinai Hospital in New York City, eased its recent transition to digital mammography with the iCAD Inc. TotalLook MammoAdvantage digitizer. “The digitizer streamlines the analog-to-digital comparison process, and it saves time,” says Laurie Margolies, MD, assistant professor of radiology. A dedicated clerk digitizes two years of analog priors for all digital cases, relieving radiologists of the burden of searching through paper files and hanging films. Instead, they focus on their primary task: image interpretation. What’s more, time-savings benefits multiply because radiologists are more apt to review analog priors, which, in turn, lowers the recall rate.

Diagnostic options abound and advance

Breast imagers have a wealth of diagnostic imaging options at their disposal. The common threads among all options: each plays a valuable role and all are on a continuous improvement path.

Take for example breast MRI. “Over the last several years, we’ve seen a large explosion and interest in breast MRI,” notes Dan White, MD, medical director of Mount Carmel Imaging Center in Columbus, Ohio. White attributes the upswing to two factors: new American Cancer Society guidelines recommending annual breast MRIs for high-risk women and improved equipment. In addition, breast MRI fills other roles. University of California, Irvine Medical Center uses Aurora Imaging Technology Aurora Breast MRI to fill multiple diagnostic roles including post-diagnosis to determine the extent and size of breast cancer and to determine residual disease after biopsy.

Mount Carmel Imaging Center uses GE Healthcare Signa MRI equipped with VIBRANT technology in conjunction with Sentinelle Medical coils. VIBRANT, coupled with the newest eight-channel coils, helps counter the competing needs of breast MRI imaging. The optimal breast MRI produces detailed, high-resolution images, which requires a longer acquisition time. The challenge, however, is that malignancies enhance early and rapidly, so abnormal tissue tends to blend into normal tissue during longer acquisition scans. Higher coil technology allows more signal, which can be exchanged for higher resolution or shorter time. “We can characterize cancers better and earlier, find in situ cancer and better differentiate benign and malignant tissue. We’ve found otherwise invisible cancers with this technology,” explains White. He expects additional improvements when Mount Carmel deploys a 16-channel coil later his year.

Breast MRI partially shares its niche with breast-specific gamma imaging. The George Washington University Medical Center employs Dilon Technologies Dilon 6800 Gamma Camera for multiple indications including newly diagnosed breast cancers, high-risk screening and equivocal mammographic results. “It’s analogous to breast MRI with several advantages. It’s easier for the patient and yields fewer false positives,” explains Rachel Brem, MD, director of breast imaging and intervention. The system delivers other advantages, too. Specifically, Dilon produces four to six images for optimal correlation with mammograms, initial investment is a fraction of an MRI scanner and radiologists can read results in 30 seconds.  Plus, reimbursement is stable, and the small files can be read on a standard PACS workstation. “This is a wonderful and easily integrated adjunctive technology,” sums Brem.

On a roll

Breast imaging and IT are expanding, delivering essential improvements to the process. The right combination of tools and processes allows radiologists to bypass time-consuming clerical tasks and focus on their primary role of image interpretation. Improved productivity translates into increased revenue. At the same time, auxiliary imaging technologies continue to carve diagnostic niches, improving diagnosis and treatment. 

Ultrasound Meets Next-generation Imaging Demands
Kansas University Breast Cancer Prevention Center in Westwood, Kansas, exemplifies the state-of-the-art breast cancer facility. The new center is equipped with digital mammography, breast MRI and four Philips Healthcare iU22 ultrasound systems. The center not only serves a large high-risk population, but also employs neoadjuvant therapy. The therapeutic model poses unique imaging demands as it requires ongoing monitoring of changes in tumor volume. Ultrasound is ideally suited to neoadjuvant model, says William Smith, MD, director of breast imaging.

Neoadjuvant therapy bypasses the traditional excisional biopsy. Instead, the patient undergoes a needle biopsy. The tissue is examined for markers before the team determines the therapeutic approach. Smith explains the rational for the approach. “If we remove the tumor and lymph nodes, we also lose the gauge to measure the success of therapy. Leaving the mass within the breast provides a metric to visually determine whether or not the first line treatment is working.” There is a hitch. Neoadjuvant therapy requires improved breast cancer imaging. “Traditional imaging and measurement tools are not acceptable for neoadjuvant therapy. Imaging must provide precise data about tumor volume on a regular and ongoing basis,” states Smith.

Ultrasound is an ideal platform because it’s economical, convenient, pain-free and lacks radiation. In 2007, Smith challenged Philips to tweak the iU22 to meet neoadjuvant needs. The imaging challenge is two-fold as the solution needs to precisely measure tumor volume and differentiate scar tissue from active cancer. Philips’ answer, its 3D volumetric space application, measures vascular density and may be the earliest way to determine therapeutic success.  

The system meets other breast cancer imaging demands as well, says Smith. “Every day we are challenged to increase patient throughput and maintain or improve quality.” The reality of patient throughput prohibits radiologists from interrogating masses when the patient is in the room. At Kansas University Medical Center, Philips’ iU22 image clips are saved to PACS, so the radiologist and sonographer can review the files thoroughly after data acquisition. On the quality front, it’s critical for the sonographer to spend as much as time as possible looking for cancer rather than typing data during the initial study. Philips iU22 incorporates a one button prompt protocol to lead the sonographer through the breast and locate the probe. “It saves about 180 keystrokes per scan and results in greater consistency,” sums Smith.

While ultrasound plays a central role in the neoadjuvant model, applications could expand to include greater roles in high-risk screening in the future.