The 102nd Scientific Assembly and Annual Meeting of the Radiological Society of North America took place from 27 November to 2 December 2016 in Chicago. On Monday, 28 November, RSNA announced the results of a large study that found no evidence supporting age-based mammography cut-off. The research team, led by Cindy S. Lee, MD, assistant professor in residence at the University of California, San Francisco, studied screening mammography in more than 3.6 million women in 39 US states over a seven year period. Dr. Lee and her team concluded the benefits of mammography increase up to patient age 90.
These findings are important because they offer a compelling argument that could change the current mammography guidelines in the United States. In 2009, the United States Preventive Services Task Force (USPSTF) ruled there was not enough evidence to support mammography screening in women over the age of 75.
In the RSNA session Value-based imaging and the ACO model, Rodney Owen, MD challenged radiologists to influence population health through screening programs. Screening programs, he argued, provide the largest opportunity for radiologists to directly affect population health outcomes. Dr. Owen said the USPSTF and its mammography guidelines created controversy amongst the radiology community and gave radiologists a chance to speak up and positively influence the future of population health management.
A major theme at RSNA was that of radiologists finding their place in the changing US healthcare structure. The US government continues to promote value-based healthcare and population health management rather than traditional fee-for-service plans. Radiologists struggle to measure their positive impact on these population health metrics. Current healthcare metrics focus on measurable outcomes like reduction in heart disease, diabetes, and obesity. PMPM (per member per month) high technology spending was chosen as the typical radiology metric for population health, but radiologists agree this metric does not provide a satisfactory link between medical imaging, healthcare expenditures, and patient outcomes.
As a result, screening programs, particularly for breast cancer, are becoming increasingly important to radiologists. Coupled with the recently announced findings on the benefits of mammograms past age 75, breast screening technologies and studies are increasing in popularity. The medical imaging industry has responded with the creation of several new technologies to improve breast cancer screening. Automated breast ultrasound (ABUS) emerged in 2008, and has matured and improved. Companies including GE Healthcare, Hitachi Medical, and Siemens Healthineers showcased their latest ABUS systems at RSNA this year. While total unit sales of their systems are less than 500 to date, these companies offered intriguing evidence to support the widespread use of ABUS for breast screening.
Two of the most common arguments against breast ultrasound screening are long exam times and sonographer error and ABUS systems offer solutions to both problems. The average manual breast ultrasound exam takes about 30 minutes whereas ABUS imaging can be completed in less than 5 minutes. Additionally, the automated aspect of ABUS systems helps prevent operator error by standardizing the ultrasound probe’s placement and movement on the breast.
The case for breast ultrasound as a supplemental tool to diagnose cancer in dense-breast patients continues to grow. About half of women undergoing a mammogram have dense breasts, which means their breast tissue primarily consists of connective tissue and milk ducts rather than fat. Mammograms can cause radiologists to miss abnormalities in dense breast patients because both cancer and dense tissue appears white on the x-ray. Ultrasounds show cancer as black and dense tissue as white, making diagnosis easier. These additional tests have effectively improved patient care; an estimated 3-4 additional cancers detected per 1,000 dense-breast patients using ultrasound after a negative mammogram. Since dense-breast patients are more likely to develop cancer than non-dense patients, these ABUS screenings may offer radiologists a great opportunity to positively influence population health.
Currently, 27 states have passed laws requiring healthcare providers to inform dense-breast patients about their increased risk for false-negative mammograms and give information about additional screening options including breast ultrasound. Four states suggest healthcare providers offer dense breast tissue notification and education and ten more states have introduced similar bills. The attitude amongst RSNA members and exhibitors was that a national mandate for education and awareness for breast ultrasound is on the horizon. Until then, expect sales of ABUS systems to slowly grow as providers become more comfortable with the technology and patients become increasingly aware of its benefits.