Reading Digital Breast Tomosynthesis Exams From a Single Desktop

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

A recent article in the Wall Street Journal on 3-D mammography discussed the potential for digital breast tomosynthesis (DBT) to enhance the detection of cancers. I was reminded of how important it is to not only capture the best breast images possible, but also to have an efficient and effective system that helps radiologists make an accurate diagnosis.

As I revisited the accomplishments our team has achieved in designing a new module that displays DBT exams on our mammography workstation—while also displaying digital mammograms, breast ultrasound, breast MRI and general radiology exams from a single desktop—I was struck by how easy it is (or could have been) to add yet another dedicated workstation to the radiology reading environment and then falsely believe we have actually improved the diagnostic workflow.

We resisted that path. Our team has long demonstrated our commitment to supporting multiple digital breast imaging modalities on our mammography workstations, and we have fiercely resisted the temptation add new, single-use workstations that might seem alluring because of their “dedicated” nature—when in fact they add costs and create inefficiency. Supporting multiple breast imaging modalities—as well as general radiology exams—enables radiologists to deliver a faster diagnosis to referring physicians and can ultimately enhance patient care.

Our smartly designed tomosynthesis module streamlines workflow by allowing healthcare providers to store, route, display and query/retrieve DBT exams from DICOM-compliant acquisition devices, so radiologists have all the tools they need on one workstation. Comparison tools enable radiologists to use personalized hanging protocols for DBT exams along with other procedures, especially the 2D mammograms. In addition, specialized tools that further enhance productivity include: automatic positioning of DBT and mammograms that eliminates manual manipulations; automatic “same sizing” of DBT and mammograms that aid in comparing changes in anatomy; and concurrent magnifying glasses that provide close-up comparison of pathology across multiple views and procedures.

With our advanced sys­tem, radiologists can quickly and easily read exams from all modalities and vendors at a single workstation. And working smart is an important element in improving patient care.

How do you view or plan to view digital breast tomosynthesis? What do you think about 3D breast imaging?

For Mammography Tech Technology Has Changed Everything

Sherri Ford, RT(R)(M)(BD)

Editor’s Note: Sherri Ford is a Mammography Technologist at Premier Imaging in High Point, NC.  She has her A.A.S. degree in Radiological Technology and a B.S. in Health Administration.  She has over 19 years experience in the mammography field ranging from mammo-screenings, diagnostics, stereo biopsies and needle localizations.  She has worked as a PACS systems supervisor and has designed training programs for occupational nurses regarding osteoporosis and bone density testing.  Sherri is also a member of ACR, ASRT and HIMSS.

Q: You have a varied experience as a technologist from a PACs supervisor to mammography.  What are the major changes you have seen in the mammography workflow?

A: Technology changes everything. While technology is almost always eagerly awaited in mammography facilities, implementing new machinery often results in workflow growing pains. When digital mammography was introduced several years ago, facilities frequently floundered, causing workflow to slow down. The past five years has seen department workflow changes as processes were perfected, allowing more patients per hour. Many facilities have moved to a paperless system further speeding up workflow. As technologists, we have had to learn how to manage exam times, review images for technical quality in a new medium and not lose sight of the fact that our patients are individuals with feelings. Technology creates efficiency, confidence in the screening process and improved image quality but the equipment is costly. To offset the increased costs, schedules are packed tight and patients are streamlined from registration to exam result. Over the past several years, the most noticeable change in mammography workflow is undoubtedly the rapid pace. While increased volumes are a positive trend, indicating women are committed to the fight against breast cancer and health administrators are committed to providing the services, technologists must balance efficiency and compassion.

Q: Has the economic situation over the last few years impacted how you do mammography?

A:  Healthcare was one of the last industries to respond to the economic crisis and is one of the last industries to recover as economic conditions slowly improve. When unemployment peaked many lost their health insurance but not their need for healthcare. Health organizations were faced with the problem of meeting level or increased demand for services with severely diminished revenue streams. Mammography tends to be a loss leader for many health organizations to begin with and the downturn in the economy hit just on the heels of acquiring new digital equipment, further compounding financial challenges. Most mammography centers responded to the conditions by increasing volumes and reducing payroll hours to address cost control but savvy administrators marketed the services to attract new mammography patients and retain the existing ones. Programs became available to provide low or no cost mammograms with the expectation these patients would be a source of referrals, sending new patients to the organization for other health needs.

Q: Do women have specific requests for technology they have heard about and if so what are they asking for?

A:  Breast cancer screening relies most heavily on mammography primarily because the system has proven to be successful, accessible and cost efficient. However, mammography does not find all cancers and research continues to find new methods for screening and diagnosis. Periodically, patients will hear or read about new technologies and ask if they are available. Most of the time, patients will ask me about screening methods that do not require compression but rarely mention specific technologies. As healthcare becomes more transparent, however, this may change because the public will have greater access to information about diagnostic testing. Also, patient requests for new technology increase when it is introduced into the community.

Q:   Is your facility doing digital breast tomosynthesis?

A: With the recent FDA approval of Breast tomosynthesis, breast cancer screening has a remarkable new tool to aid in earlier detection, especially in women with dense tissue. Despite the success stories tomo has produced, it is not widely utilized in the US yet. Health insurance does not reimburse for tomo exams at this time, considering the technology investigational and many facilities cannot absorb the cost. Some facilities pass the cost on to the patient as an up charge to a mammogram, usually offering the patient the option of having the tomo and paying or declining the exam. I recently had the opportunity to observe several tomo exams and believe this technology will become the industry standard for screening. My facility is not currently offering tomo but is evaluating the technology. Breast tomo offers new possibilities in breast cancer screenings and should be embraced with excitement and anticipation.

Ask Anne: Changing Mammography Techniques for Digital Technology

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

One of the most common questions I receive for my “Ask Anne” feature here on Everything Rad is, “How will I need to adapt my positioning techniques when I move from analog imaging to digital?”

This month, Brigitte Hurtienne, chief radiographer at the Mammography Reference Center at the University Clinic in Munster, Germany, offered to share her experience:

Art of positioning

Whether using an analog or digital mammography system, the art of positioning is very similar. But digital imaging has advantages: the dynamic range afforded by digital mammography (16,000:1) is far superior to analog imaging (100:1).

The optical densities (OD) displayed on film are limited to 100 shades of gray, not all of which can be displayed at any time because the OD of the film is limited and fixed, and is determined by the x-ray exposure technique.

In a digital image the dynamic range depends on the computer’s window/level attribute and the radiologist can

Brigitte Hurtienne

Brigitte Hurtienne, Chief Radiographer, Mammography Reference Center, University Clinic in Munster, Germany

manipulate a digital image through 16,000 shades of white-gray–black.

So, in the digital technique, we often can make more skin wrinkles visible. Skin wrinkles may produce pseudoarchitectural distortions or may obscure surrounding structures.

Good positioning, at least for the mediolateral oblique view without skin wrinkles, is, therefore, very important. If hand pressure is discontinued before sufficient compression is applied, it will result in a poor separation of tissue and a downward-sloping of the breast contour, sometimes creating a skinfold in the inframammary ridge. An inadequate positioning technique in this region using suitable picture processing algorithms can lead to a loss of information.

Careful hand work – smoothing out the breast with the entire palm of the hand forwards and upwards, support with the ball of the thumb during compression, and smoothing out the inframammary ridge – prevent a sagging of the breast to the caudal and a wrinkle-free presentation of this region. Insufficient picture processing can be avoided in most cases.


There are also some differences in the types of artifacts that are seen in analog vs. digital imaging. In the analog world, we differ between film and screen handling artifacts and positioning artifacts. These artifacts are more common and can occur by improper handling of films and screens. Improper handling of films and screens could be exposures from creases, dirty screens, dust, scratches or from the object table, grid and static artifacts.

Some artifacts may be seen on both analog and digital systems, such as patient related artifacts (e.g. motion artifacts) and hardware related artifacts (e.g. x-ray tube filter defects and antiscatter grid defects).

Especially in the digital world, there are artifacts due to software processing errors or digital detector deficiencies. Pixel artifacts such as dead pixels or groups of dead pixels and dead lines can be caused by an imperfect detector.

Dust in the compression paddle, a not properly adjusted exposure, and problems with the image processing to a high noise level are further sources of an improper result. Problems with the reconstruction at the workstation can be the result of an improper display or problem with the sending of the images to the workstation.

Have you adjusted your technique for digital? What advice do you have for other radiographers or mammographers? 

Researchers Favor Annual Mammograms With No Family History

Stamatia Destounis, MD, FACR

Stamatia Destounis, MD, FACR, Elizabeth Wende Breast Care

Editor’s note:  Doctors at the Elizabeth Wende Breast Care in Rochester NY recently presented a study in Vancouver on breast cancer risk factors in women under 40.  Stamatia Destounis, MD, FACR, the study presenter at the ARRS annual meeting in Vancouver, answers three quick questions about the study’s reception and the continuing breast screening controversy.

Q:  At the American Roentgen Ray Society Annual Meeting you presented your finding on the ideal age for women to begin screening mammograms and the appropriate intervals between screenings. How were your findings received at the conference?

A: There was interest and enthusiasm at our results which revealed that women in their 40′s with no family history of breast cancer benefit from having a yearly screening mammogram, as a considerable number of the cancers diagnosed in this age group were through screening mammography, and 64% of these women had invasive breast cancers with 26% of these having metastatic lymph nodes. These are cancers that need to be found and can’t wait for women to be fifty before starting to have a screening program.  Controversial recommendations from some Organizations have recently argued that women in their 40′s don’t need screening mammography until they are 50 and our data do not agree with them at all.
Q: The screening debate seems to have new twists and turns often. For physicians speaking with confused patients, how would you recommend guiding the discussion?

A: Most women don’t have a family history of beast cancer when they are diagnosed with breast cancer. We believe that a screening mammogram yearly starting at age 40 saves lives as many well organized and regulated trials have revealed in the last 20-30 years. We recommend a yearly mammogram for women in their 40′s and our own review just presented in Vancouver revealed that a considerable number of women in their 40′s with no family history of breast cancer were diagnosed with a screening mammogram, revealing approximately two thirds of these patients having invasive breast cancer and a third with metastatic breast cancer.

CARESTREAM Vue Mammo Workstation

Q: Do you feel the screening debate is harmful to women’s health? Has the media attention impacted screening rates?

A: I think women and their health care professionals are getting confused by the controversy surrounding screening mammography and the constant media frenzy with controversial and conflicting analyses, data collections and personal opinions. There are many opinions, and emotion regarding breast cancer and this adds to the continued controversy.

The future of breast imaging is in the making.

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

Q: Are you seeing more young radiologists going into mammography services? 

A: At mammography conferences and continuing education courses around the world, I’ve been seeing younger participants than in the past. In fact, I’d say that more than half of the radiologists attending a recent seminar in Brazil were under the age of 40.

This is a great trend for the future of our field!

Historically, breast imaging in general—and mammography in particular—has been viewed as a difficult and unglamorous vocation.

It involved the monotonous task of looking at primarily normal images. It has been characterized by a high rate of recalls and retakes, as well as low reimbursement and higher risk of litigation. Compared to interventional radiology and other specialties, it just didn’t have the “wow” drawing power.

So what is attracting today’s up-and-coming radiologists to this area of specialty?

The multi-modality nature of breast imaging may be part of the answer, with mammography, ultrasound, MRI, and molecular imaging being used in tandem for screening and diagnosis. In addition, advances in digital technology are making this a cutting-edge discipline with appeal for younger medical school graduates.

Beyond just the technology, though, there is the point on which we all can agree: screening mammography saves lives. And saving lives is a strong motivator for anyone in the field of medicine.

If you have an open fellowship in breast imaging, let me know. Together, let’s do all that we can to encourage these future luminaries in the making.

What motivated you to go into the field of breast imaging? Who supported you in your efforts?

Finding a PACS that Supports Mammography Modalities; It’s Not As Easy As You Think

Encompass Medical CenterEditor’s Note:  Encompass Medical Group recently installed a CARESTREAM Vue PACS to serve its eight locations in the greater Kansas City area.  Susan Stidham, Director of Ancillary Services at Encompass Medical Group shares her thoughts on PACS support for breast imaging modalities and how it impacted their PACS selection in the guest blog post below. 

Our medical group has six imaging centers (located within our 8 primary care physician offices)  and conducts 12,000 screening and diagnostic mammography exams a year—about one-fifth of our total workflow. When our staff evaluated suppliers for a new PACS, we were shocked to discover how hard it is to find a PACS that supports an efficient mammography workflow.

Some PACS do not support all breast imaging modalities. Demonstrations revealed that others could not display breast exams in full resolution or required five minutes or more to display each exam. The good news is that we found a PACS platform that delivers all the mammography reading capabilities we need:

  • Reading of all breast imaging modalities, including FFDM, CR, MR and general and vascular ultrasound
  • Rapid delivery of full-resolution images to ensure a streamlined reading workflow
  • Specialized mammography reading features and tools including a prelabeled keypad with the most commonly used commands (save, finish exam, mark as read, go to next workflow, turn CAD on/off, etc.) and a programmable mouse. These features facilitate fast, efficient reading for on-site and off-site radiologists.

Our new PACS–CARESTREAM Vue PACS–met our budget requirements and is flexible and scalable enough to serve us for many years. If your staff doesn’t initially find a PACS that meets CARESTREAM Vue PACSall your mammography  needs, keep looking. The PACS of your dreams is out there—you just have to find it.

Does your current PACS address your mammography workflow?

If you are replacing your PACS, have you had a difficult time finding a new PACS that streamlines mammography reading?

Annual National Interdisciplinary Breast Center Conference Stresses “Self-Care” and Continued Education

Julia, Weidman, Marketing Manager, Women's Health & Healthcare Information Solutions, Carestream

The 22nd Annual National Interdisciplinary Breast Center Conference sponsored by the National Consortium of Breast Centers opened yesterday in Las Vegas.

A global audience of nearly 1,000 attendees will participate in more than 120 sessions from 78 world-class presenters focused on the clinical, imaging, administrative and nursing concerns associated with breast health and breast center management.

The celebrity keynote was given by Kelly Corrigan. The New York Times best-selling author talked frankly and engagingly about her battle with breast cancer, and what compelled her to author her book “The Middle Place.”  Ms. Corrigan spoke about the strong bonds she developed with the caregivers who helped her navigate her journey – “the magic we”, and encouraged attendees to “perform the role nobly”.

Elizabeth Clark PhD, ACSW, MPH, executive director of the National Association of Social Workers, delivered the professional keynote “Words that Heal, Words that Harm.”  Ms. Clark raised attendees’ awareness of the context of the words they use, and how powerfully those words impact patients.  Ms. Clark also spoke about the importance of creating communities of hope for cancer patients and the need for caregivers to practice “self-care” to avoid burnout.

Visitors to the Carestream booth shared feedback that this year’s conference featured a nice blend of technology and experience sharing:

“We hear from the best and brightest in the field at this meeting.The multidisciplinary study tracks and discussions about emerging technologies are real learning experiences,” said Bonnie Rush RT (R) (M) (QM) from Breast Imaging Specialists.

Deb Wright, President and CEO of Inner Images was a judge for the poster session:

“Tech-wise there was a lot of molecular imaging. And I was glad to see papers on outreach programs for survivors.”

Dr. Lazlo Tabar commented, “This year’s NCBC has a very interesting program, very comprehensive both for physicians, technologists and nurses.” Dr Tabar also spoke about the sessions he and and Louise Miller RT (R) (M) will hold for technologists focusing on the proper positioning of the breast in screening:

“The radiology technologist is a very important part of the diagnostic team.  They are responsible for proper positioning.”

We’re sure the technologists here at the conference will line up early to get a seat!

Other hot topics like healthcare reform, breast density issues, risk assessment and geonomics and tomosynthesis will be covered throughout the conference, which ends on Wednesday. You can follow the conversation from the conference on Twitter using the hashtag #NCOBC.


Mammography Scheduling Portal Helps Improve Screening Attendance in Denmark

With 200,000 women aged 50-69 years,  a free mammogram every second year and 750 patient appointments each day, the mammography screening program in Denmark’s Capital Region is the largest in the country. It also boasts a 75 percent screening attendance rate.

Key to balancing the demands of scheduling, hospital resources and patient satisfaction? Empowering women to book mammography appointments online at a convenient time and location with the CARESTREAM Vue RIS Portal.

How It Works

  1. Women are sent a letter, questionnaire and leaflet explaining how to access the RIS Portal with a unique, password-protected, secure ID number.
  2. Once in the Portal, the patient navigates through a simple process to modify appointment time, day or location as many times as they like for up to three months. At the same time, the Portal seamlessly communicates with the hospital RIS to book.
  3. A summary screen displays date, time and address details to print for future reference.
  4. Patients can also cancel their appointment for the current screening round or altogether, giving them complete freedom of choice.
  5. The portal allows patients to include comments. Consequently, the hospital can track why some women are choosing not to attend their screening appointments.

This patient-centric solution makes it easier for women to coordinate  busy lives with hospital appointments because they no longer are required to phone the hospital between 8 a.m. and 3 p.m. For Denmark’s health system it means secretarial staff can find a more efficient use for the time they spent writing to non attenders, re-booking and dealing with cancellations.  For radiologists and technologists, it means  one system harmonizes  clinical tools and reports with a scheduling system that encourages quality care in a timely fashion.

Chief Physician Ilse Vejborg, Head of the Mammography Screening Programme, sat down with us at Righospitalet, the main hospital for the capital region of Denmark, to discuss how Vue RIS has become the most used web site in the region and plans for continued improvements.

Come see the CARESTREAM Vue RIS at ECR2012 in Vienna, March 1-5.

What should we do with dense women?

Anne Richards, Carestream Health

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream Health

Women with dense glandular breast tissue present a challenge—and one with high stakes.

Their tissue type is capable of hiding small abnormalities, they have a documented increased risk of breast cancer, and should they have a tumor it is more likely to have certain aggressive characteristics (as reported recently in the Journal of the National Cancer Institute).

As radiologists, you’re aware of these facts. But what about the women whose mammograms you interpret?

My recent post about breast density focused on the Governor of California’s decision to veto legislation that mandates that we inform “dense” women following their mammograms of their breast type and the implications, including the possible benefit of additional screening.

Similar legislation has passed or is pending in several U.S. states, but this veto highlights the importance of radiologists voluntarily providing this information.

Informing a woman of her breast density presents another dilemma. How useful is that information without recommendations on what to do next? What’s more, the medical community has yet to establish a protocol for them, including what modality should be used for follow-up.

For example, trials indicate that ultrasound combined with mammography provides increased detection in dense breast tissue. So should asymptomatic women with dense breasts be screened will full ultrasound in addition to their annual mammogram? Will insurance companies pay for the radiologist’s additional time? Can and should technologists be trained to do this screening instead?

In my opinion, we should not wait for mandates from the government to address this issue. Insurance companies, radiologists, and physicians need to work together to develop a standard of care for women with dense breast tissue. It’s a new horizon for our field—but one that will lead to brighter futures for the patients we treat.

What steps is your practice taking to notify women about the risks associated with dense breast tissue?

Bill Veto Fuels Breast Density Discussion

Anne Richards, Carestream Health

Anne Richards, Clinical Development Manager, Women’s Healthcare

California Governor Jerry Brown recently vetoed bill SB 791 that would have mandated medical providers to notify women if they have dense breast tissue.  Brown stated he was not comfortable with language in the proposal that required women be told they might benefit from more screening.  This legislative move has fueled more discussion about density as an independent risk factor, the challenge dense tissue poses to radiologists interpreting images and patient right to more information about their breast health.

Breast density is an important topic, but this discussion is far from a new one. In fact, the Connecticut General Assembly passed their act in 2009 and several other sates have similar legislation pending.

This past summer at the Society of Breast Imaging (SBI) Postgraduate Course, I sat down with Gerald Kolb, Mātakina International’s VP of Business Development, who shared his thoughts on personalized screening and volumetric breast density assessments:

How is your imaging department or center educating and informing patients about breast density?