As literature continues to emerge about the potential of contrast-enhanced digital mammography (CEDM), this author reviews clinical and practical benefits of the modality and pertinent steps for adding it to your diagnostic armamentarium.
When it comes to annual breast cancer screenings, clinicians continue to contend with several issues including a lack of compliance on the part of women, lack of access to mammography for indigent and remotely located populations, and difficult to decipher mammograms.
Consider, for example, women with dense breast tissue. Approximately 50 percent of women undergoing mammograms have dense breasts.1 Dense breast tissue makes it more difficult to interpret a mammogram as cancer and dense breast tissue both appear white in the X-ray of the breast. Very dense breasts may increase the risk that cancer won't be detected on a mammogram.
Often, these women must undergo supplemental breast cancer screening that may include 3D mammography, breast MRI, breast ultrasound, molecular breast imaging and, most recently, contrast-enhanced digital mammography (CEDM).
Contrast-enhanced digital mammography offers several advantages as a supplemental screening tool. However, as recently as 2017, CEDM was available at just a small number of breast imaging centers. Experts say the technology appears to be gaining some traction. This is reflected in the increasing number of installations as well as more scientific literature on the topic.2 Today, multiple vendors have mammography systems capable of performing and meeting the growing demand for CEDM.
Even so, many imaging centers and radiology practices today are still slow to adopt CEDM due to various barriers that make implementation a challenge. Accordingly, let us take a closer look the benefits of the technology and ways providers can smoothly and efficiently implement CEDM into their breast imaging practice.
Assessing the Clinical Advantages of CEDM
Contrast-enhanced digital mammography uses a dual-energy technique performed after the IV administration of iodinated contrast agent to identify abnormalities on the basis of angiogenesis as well as morphologic features and density. Approved by the Food and Drug Administration (FDA) in 2011 for adjunctive use in a diagnostic setting, the combination of morphologic and physiologic information provided by CEDM has demonstrated superior sensitivity and specificity in diagnosing breast cancer in comparison to digital mammography alone. A study by Lobbes and colleagues showed a sensitivity of 100 percent, specificity of 87.7 percent, a positive predictive value of 76.2 percent, and a negative predictive value of 100 percent for CEM in the diagnostic setting.3
While CEDM is currently being used to stage newly diagnosed breast cancer and evaluate response to neoadjuvant chemotherapy, it is also a promising technique in the supplemental evaluation of patients with inconclusive findings and the screening of certain patient populations.4
There are several clinical benefits associated with CEDM. For example, use of CEDM for supplemental screening may benefit women with an intermediate to high lifetime risk of breast cancer, including women with dense breast tissue. Initial studies suggest that, for dense breast tissue, CEDM performs better than 2D mammography for detecting malignancy and avoiding false-negative results.5
In addition, CEDM may serve as an alternative modality for patients who are unable to undergo breast MRI due to contraindication or inaccessibility. Common contraindications to MRI include metallic implants, claustrophobia, inability to lie prone or still, and weight limitations.
Recognizing the Practical Benefits with CEDM
Beyond the clinical advantages, there are several other reasons for women’s imaging centers to adopt CEDM into clinical practice. These include patient comfort, efficiency, cost, and accessibility.
As breast imagers know, patient comfort—physical and mental— should never be underestimated. It can literally mean the difference between a woman refusing a test—which may lead to a missed diagnosis—or saving a life. Women are accustomed to the mammography unit, and the CEDM procedure takes place on the same equipment, alleviating anxiety associated with unfamiliar modalities.
It is also no surprise that patients prefer faster procedures. Fewer images are needed for CEDM. The image acquisition time for CEDM is just 7 to 10 minutes versus 30 to 60 minutes for breast MRI. An increased patient toleration of CEDM can lead to increased throughput, less interpretation time for radiologists and increased efficiency in one’s practice.
For any practice, cost is always a concern. Contrast-enhanced digital mammography has proven to be both affordable and accessible. CEDM is less costly than a full or abbreviated MRI protocol with researchers noting the total cost of CEDM is approximately four times less than that of a full screening MRI.6 The costs, space and safety requirements of an MRI magnet limit its widespread availability. Conversely, CEDM can be implemented at preexisting mammography sites with relative ease, resulting in increased patient access.
Four Steps to Ensuring a Smooth Implementation of CEDM
There are several considerations associated with adopting CEDM. However, with proper planning, any women’s imaging provider can smoothly implement CEDM into practice and reap numerous clinical and business benefits. Here are some key steps to consider as you plan CEDM implementation.
• Assess your current mammography system. Begin the process by evaluating your mammography system and getting a clear understanding of its features and capabilities. Fortunately, several current generation mammography systems already have CEDM capability. Talk with your vendor about the cost and process of implementation. In the case of Fujifilm’s ASPIRE Cristalle mammography system, for example, acquiring CEDM can be done with a simple software upgrade that takes just a couple of hours.
• Plan staffing requirements. Performing CEDM requires additional equipment and clinical steps such as setting up the contrast injector, talking to the patient to assess for contraindications to contrast administration, creatinine testing, if necessary, and placement and removal of an intravenous line. This may require you to use a nurse or train a staff member to place the IV line. To improve efficiency, some authors have suggested delegating the patient and equipment setup tasks to a trained nurse and a mammography technologist.6
• Turn to your vendor for training and support. Your vendor should be accessible and willing to help educate and train your staff, clearly explaining how the CEDM technology works. The vendor should also be committed to equipment service and support, providing speedy response when necessary so your practice experiences little, if any, downtime.
• Be prepared for adverse reactions. With the right team in place, you will be ready to monitor patients for any adverse reactions. Intravenous contrast material risks include allergic reactions, extravasation events, and contrast-induced nephropathy. While adverse reactions are not common and the majority of cases are mild, staff members must have adequate training on appropriate contrast administration and management of reactions. This should be a top safety priority so ensure there is adequate training.
Spreading the Word About CEDM to Patients and Referring Physicians
• Market your new CEDM capability. Once CEDM is installed at your practice, it’s time to let the world know. Alert both referring physicians and patients of your additional imaging technology. Use your website, social media, and waiting room materials to promote your CEDM capability.
You can even host an on-site event for women’s health referring physicians to learn firsthand about the value of CEDM. Also consider educating the public about the importance of breast cancer screenings as well as the value of CEDM by participating in community health fairs.
The Future of CEDM
Approximately one in eight women will develop invasive breast cancer over the course of one’s lifetime.7 Moreover, about 43,250 women in the U.S. are expected to die in 2022 from breast cancer.7 Today’s women’s imaging providers need an array of tools to catch more cancers and increase women’s odds for survival.
Contrast-enhanced digital mammography is growing in popularity as a multifaceted imaging modality for breast cancer detection. The diagnostic performance of CEDM is superior to conventional mammography and similar to MRI with evidence of fewer false-positive findings.6 Add to this the facts that CEDM is fast, well-tolerated by patients, and cost-efficient.
The role of CEDM in breast cancer screening continues to evolve but as several experts have noted, the procedure offers several advantages as a supplemental screening tool in select patient populations. While implementation presents some challenges, with proper planning, CEDM can be smoothly integrated and prove to be a valuable addition for any breast imaging practice.
1. Mayo Clinic. Dense breast tissue: what it means to have dense breasts. Available at: https://www.mayoclinic.org/tests-procedures/mammogram/in-depth/dense-breast-tissue/art-20123968 . Published February 25, 2022. Accessed October 11, 2022.
2. Neeter LMFH, Raat HPJ, Meens-Koreman SD, et al. The diagnostic value of contrast-enhanced 2D mammography in everyday clinical use. Sci Rep. 2021;11(1):22224. doi: 10.1038/s41598-021-01622-7.
3. Lobbes MBI, Laliji U, Houwers J, et al. Contrast-enhanced spectral mammography in patients referred from the breast cancer screening programme. Eur Radiol. 2016;26(12):4371-4379.
4. Polat DS, Evans WP, Dogan BE. Contrast-enhanced digital mammography: technique, clinical applications, and pitfalls. AJR Am J Roentgenol. 2020;215(5):1267-1278.
5. Covington MF, Pizzitola VJ, Lorans R, et al. The future of contrast-enhanced mammography. AJR Am J Roentgenol. 2018;210(2):292-300.
6. Sogani J, Mango VL, Keating D, Sung JS, Jochelson MS, Contrast-enhanced mammography: past, present, and future. Clin Imaging. 2021;69:269-279.
7. Breastcancer.org. Breast cancer facts and statistics. Available at: https://www.breastcancer.org/facts-statistics . Accessed October 11, 2022.