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Radiology Life • February 2017

15 | ADVANCE FOR RADIOLOGY LiFE | TECHNOLOGY we’re taking multiple very low dose exposures over an arc.” The data acquired from these low-dose exposures is then reconstructed into a series of images of the breast at different planes within the breast. This allows radiologists to focus on individual layers of breast tissue. “It’s kind of like taking a slice out of a loaf of bread and focusing right at that one area, rather than trying to look at the whole loaf at once,” analogized Monticciolo, who is also a professor of radiology at Texas A&M University College of Medicine and vice chair of Research and section chief of Breast Imaging in the Department of Radiology at Scott & White Medical Center. Numerous studies demonstrate that digital breast tomosynthesis allows for increased cancer detection and decreased recalls. Although tomosynthesis was approved as an imaging modality by the FDA in 2011, it is still not yet considered the standard of care for breast cancer screening.1-2 Currently, about 98% of units are digital mammography, while about 25% to 30% of units are tomosynthesis. “Like all technologies, it takes time for them to be included in the workplace,” Monticciolo said. However, the use of tomosynthesis for breast cancer screening is becoming more widespread. “People who’ve tried it find they have good results with it,” Monticciolo said. “We now have hundreds of peer review (articles) and scientific reports showing the benefits, and they’re pretty consistently demonstrating decreased recall rates and increased cancer detection. And of course we’re very excited about the increased cancer detection, especially because that’s the primary use of mammography.” As with any technology, however, tomosynthesis involves a learning curve, and it’s costly to institute new technology. “We hope that over time the prices will come down and the techniques will improve,” Monticciolo said. One of the downsides of tomosynthesis is that it requires an extra exposure. “You’re doing an exposure in addition to the standard exposure, so you’re really doubling the dose,” Monticciolo explained. “It’s a small dose that you’re doubling, but it’s still more dose to the patient — a lot us were initially concerned about that.” Some manufacturers are addressing this issue by improving the synthesized views, which generate 2D images from the 3D data. The synthesized view reduces the dose so that it’s nearly identical to standard digital screening. “I’m not quite convinced yet myself on the synthesized view, but I talk to breast imagers around the country and I know people who are using only the synthesized view,” Monticciolo said. At present, tomosynthesis is typically performed as an adjunct to conventional digital mammography. Monticciolo’s site usually uses tomosynthesis for women with dense breasts, although some breast imagers use tomosynthesis for everybody. According to Monticciolo, although a small amount of literature has demonstrated a benefit for tomosynthesis in women with fatty breasts, the majority of literature suggests that women with dense breasts benefit the most from tomosynthesis. Although the Centers for Medicare & Medicaid Services offer reimbursement for tomo, most private payers are still uncertain of whether or not to cover tomosynthesis as an additional technique. “We’re really encouraging them to do so — because it’s really no longer investigational,” Monticciolo said. For a while, Monticciolo said, breast imagers wondered if tomosynthesis would really provide a benefit in screening. “I think that was a legitimate question,” Monticciolo said. “Let’s make sure we do enough research to see whether or not we think this has a persistent and lasting effect. Now we have just abundant literature, very large studies, consistently showing increased cancer detection and decreased recall, so I think the benefit’s clear, and we’re really trying to encourage insurance companies to include this benefit for women so that they can have the maximum benefit from mammography.” I think the benefit’s clear, and we’re really trying to encourage insurance companies to include this benefit for women.” — Debra Monticciolo, MD, FACR / FEBRUARY 2017


Radiology Life • February 2017
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