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The trends and technologies driving mammography in 2019 and beyond.
For decades, mammography has stood alone as the gold standard for breast cancer screening and detection. But, being the go-to strategy for identifying the early-stage or advanced cancers isn’t enough. Work has continued to not only augment the efficacy of mammography, but to also increase its use and reach.
Industry-wide, there are efforts underway to design and implement new technologies and strategies for mammography. And, research is also revealing new ways for the modality to make an impact on saving lives.
Since its creation, mammography has largely been a one-size-fits-all technology, leading to many patient complaints about discomfort and pain. In many instances, these worries have prevented women from scheduling the screening exam. And, to increase utilization, some companies have created horizontal mammography machines; others have added heaters so paddles aren’t so cold.
But, just as each woman is different, so is each breast. One product designed to help meet individual needs is Solis Mammography’s SmartCurve by Hologic, a mammogram paddle that can provide a more personalized screening experience. The curved paddle form fits to the breast, more easily accommodating most patients.
According to Stacy Smith-Foley, MD, medical director for the Breast Center at CARTI, this technology can benefit both providers and patients. The Center has used SmartCurve as the standard for all patients since April of this year.
“On the technical side, technologists can position patients in ways that can include much more tissue than they can with a standard paddle,” she says. “And, for patients, due to the curvature of the paddle, the force of compression is more evenly distributed across the breast.”
Although the curved paddles don’t work well for capturing implant displaced views in women who have breast implants, they do offer benefits for most patients. Improve positioning for the majority of women reduces the number of images needed for diagnosis, and fewer images leads to less radiation exposure, Smith-Foley says.
Alongside the patients, she adds, SmartCurve has also offered her technologists some benefits. While the technology allows them to better position patients, it also keeps them in better ergonomic positions, as well. Their body mechanics improve, and they experience more comfort and less pain throughout the work day, she says.
National Cancer Institute statistics report nearly 60% of women will experience at least one abnormal finding on a mammogram that isn’t malignant during their lives. Being able to reduce the number of false positives in screening can also drive down the number and cost of biopsies.
Recent research published in Radiology (that has also been tested clinically) reveals the use of three-compartment breast image analysis along with mammography radiomics-a form of computer-aided detection that identifies texture characteristics associated with lesions-can more accurately distinguish benign and cancerous findings.
According to Karen Drukker, PhD, research associate professor in radiology at the University of Chicago, the water, lipid, and protein breast component measurements completed as part of three-compartment analysis can pinpoint more malignancies because invasive cancers contain significantly more lipids and water than normal tissue. Tested in 100 patient mammograms, study results revealed this strategy not only improved cancer predictions by between 32% to 50% above visual interpretations, but it also reduced unnecessary biopsies by approximately 30%.
The technique is non-invasive, but it does have an important drawback-it requires exposing patients to a 10% higher radiation dose.
Mammography for Men
Men don’t typically pop to mind as breast cancer patients, says Yiming Gao, MD, a breast imaging specialist at New York University Langone Health. But, more men die annually from breast cancer than from more-widely known testicular cancer, about 500 men and 410 men, respectively. That unfamiliarity-along with a lack of screening-can be deadly.
“Because screening is not indicated in men, in combination with a lack of awareness, male breast cancer often presents at a more advanced stage than in women, and men with breast cancer often don’t do as well as women,” she says.
Most cases of male breast cancer are not identified until the patient is symptomatic, she explains.
Like women, several factors impact a man’s breast cancer risk. A personal or family history of breast cancer, a BRAC1 or BRAC2 genetic mutation, and hormonal imbalances, as well as African-American or Ashkenazi descent can increase likelihood. Consequently, early detection is vital, Gao says, and her recent investigations published in Radiology revealed mammography screening can be critical in those catches.
In her study, mammography detected 2,304 breast lesions. Of the 149 biopsied lesions, 41 (27.5%) were malignant, yielding a cancer detection rate of 18 per 1,000 exams among high-risk men. That’s significantly higher, she says, than the five cancers detected per 1,000 average-risk women. Additionally, cancers pinpointed in men were identified at an early stage before metastasis to the lymph nodes, significantly improving survival prognosis.
Men have less breast fibroglanular tissue that can mask abnormal findings in women. Consequently, according to the results, mammogram screening offers greater clarity for male patients, demonstrating 100% accuracy in detecting cancer and 95% accuracy in distinguishing breast cancer from other findings.
“We have shown mammography has the potential to detect cancers early in men before they become symptomatic,” she says. “Screening certain high-risk men may help improve their individual prognosis.”
Ultimately, Gao says, providers should discuss family history and risk factors with male patients, as well as consider adding breast cancer to their checklist for men who might benefit from genetic counseling and possible screening.
“As for clinical changes, conversations about male breast cancer is a good start,” she says. “And, as we accumulate further data, more tangible clinical guidelines may be able to be provided in the future.”
Based on existing research, adding contrast enhancement to imaging techniques, including mammography, can increase detection of biologically relevant cancers, such as high-grade invasive tumors, when conventional mammography more often misses those diseases. In fact, according to Elizabeth Morris, MD, chief of breast imaging service at Memorial Sloan Kettering Cancer Center, contrast-enhanced mammography can reveal small cancers even in very dense breasts.
In addition to catching more harmful and aggressive cancers, contrast-enhanced mammography is less expensive, she says, and can be easily integrated into office workflow.
In recent years, healthcare-including radiology-has opened the door to more precision medicine strategies that rely on patient-specific information. In many cases, successful individualized care is supported by screening efforts. With breast cancer, these frequently include screening for breast cancer-related genes, mammographic density, family history of breast cancer, lifestyle, hormonal factors, and demographic data.
International research, published in the Journal of the National Cancer Institute, that involved more than 65,000 patients, Morris says, used 77 single nucleotide pleomorphisms, estrogen receptor status, and family history to create a polygenic risk score that determines a woman’s lifetime risk of developing breast cancer. For women with no family history, the lifetime risk is between 5.2% and 16.6%. Women with a first-degree family history have a lifetime risk range of 8.6% to 24.4%.
This polygenic risk score, she says, could be used clinically to more effectively inform targeted screening and prevention strategies. This shift away from more population-based screening to an increasingly personalized approach could help providers offer the most appropriate therapy methods earlier in the treatment process.