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Committing to Personalized Breast Care
Can Personalized Breast Screening be Achieved?
Mammography has been proven to save lives, but there is growing recognition that breast density is a critical factor in triaging women to the right supplemental screening tool to increase the likelihood of early detection.
At a recent GE Healthcare Breast Imaging Meeting, keynote speaker, Nicole Saphier, MD, Breast Radiologist at Memorial Sloan Kettering Cancer Center in New York, posed the question: can we reduce the cancers that might be missed due to dense breast tissue using risk-based screening protocols?

“In order to optimize screening for each woman, we have to start looking at individual risk profiles and density and use that data to direct women to supplemental screening tools, such as automated breast ultrasound,” said Dr. Saphier.
Radiologists Have to Lead the Way
“Two of my best friends are primary care physicians and they both say ‘they don’t have time.’ They don’t have the time to know the exact risk of their patients, to know what they can afford, and to know what patients want,” said Dr. Saphier. “As radiologists, and as breast imagers, we have to take more responsibility for our patients. We need to come together and determine the best regimen for each patient to make sure that we’re detecting their cancers at the earliest stage possible.”

“We can’t depend on referring physicians to order the right tests because they often do not fully understand breast density and supplemental screening options. They’re depending on us to guide them. It’s our duty to educate referring physicians on the best way to work together to make sure that we are doing the best by their patients.”
The Road to Personalized Breast Care
“With the growing adoption of ABUS and other supplemental screening tools, we are making progress in developing and implementing personalized screening protocols; however, we still have a long way to move beyond the one-size-all approach,” said Dr. Saphier. “Critics of screening continue to argue the mortality reduction associated with early stage cancers detected versus the later stage cancers detected. But when I have a young woman to whom I’m able to give 5 to 10 more years of life because I’ve caught her cancer earlier, that means a lot because it matters to that woman and her family and that is what’s important.”

In the 40% of U.S. women with dense breast tissue, mammography can miss up to one third of breast cancers. This may lead to a delay in diagnosis and a worse prognosis. Multiple studies have now shown that the addition of supplemental screening with handheld ultrasound, ABUS or tomosynthesis to mammography can improve cancer detection in women with dense breasts. “The bottom line is, we need to do what is best for patients. Radiologists need to take the lead to educate them and offer the screening protocol that is best for each patient,” said Dr. Saphier.
Adopting Dense Breast Screening Strategies
As clinical evidence grows about increased cancer detection with supplemental screening tools, density inform legislation expands, and patient demand increases, breast imaging centers face increasing pressure to determine strategies for providing personalized imaging for their dense breast patients.

“In order to select screening tools to implement a personalized screening program, we have to first define the goals for breast cancer screening as defined by the BI-RADS®,” said Marc Inciardi, MD, Associate Professor of Radiology, Breast Imaging Section, University of Kansas Health System, Kansas City. “First of all, we want to have an adequate cancer detection rate, but we want to find them with an acceptable recall rate and Positive Predictive Value (PPV). Finally, we want to find a high percentage of small, node-negative, early stage cancers, which ultrasound does in many respects better than mammography.”

“The Invenia™ ABUS 2.0 is designed specifically to image dense breast tissue and to meet the needs for standardization and consistency in the screening environment. I am very proud of the measurable increase in image quality and clarity we have achieved. The 2.0 system enhances the reading experience for radiologists not only with better image quality, but with new tools, viewing layouts and user experience that better mimics mammography workflow,” says Luke Delaney, General Manager of Automated Breast Ultrasound at GE Healthcare.
Screening Mindset: Finding Cancer and Reducing Callbacks
As an early adopter of ABUS technology, Dr. Inciardi was asked to present his learnings at the recent GE Healthcare Breast Imaging Meeting. He cited several studies that have shown it is feasible to implement ABUS into a high-volume breast screening program, and increase cancer detection while maintaining a low recall rate. “However, it does require changing from reviewing exams with a diagnostic mindset to a screening mindset. ABUS, as well as handheld ultrasound, detect a wide range of benign pathology (in addition to breast cancer) that is “unseen” in the dense tissue by mammography. There is a learning curve in determining which findings are clinically relevant.”

“We’re used to seeing these ultrasound findings with a diagnostic mindset because that was how most of us were trained. It is critical to remember that these are different patient populations. The diagnostic population has an approximate 10 fold higher cancer prevalence than the asymptomatic screening population. It took us a few hundred cases in the SomoInsight trial to learn this and change our mindset, and recalibrate our callback threshold for screening ultrasound,” added Dr. Inciardi.

“We can talk about callbacks in terms of positive predictive value, bilaterality and multiplicity, but I like the analogy of thinking about callbacks as fruit on a tree. If you are willing to pick all the fruit on the tree and have a callback rate of 25 percent, you can find all of the cancers. However, if you want to have a low callback rate, you need to focus on the “low hanging fruit”. From a clinical standpoint, that means focusing on lesions are most likely to have a high PPV; eg, those that are spiculated, have an anti-parallel orientation and have irregular/indistinct margins,” said Dr. Inciardi.

Alison Zupon, MD of Imaging for Women in Kansas City, also provides advice for getting comfortable with reading ABUS. “When you start reading ABUS exams, it is helpful to scan patients already on the schedule for a biopsy. This gives you the opportunity to see how a fibroadenoma, papilloma or cancer presents on ABUS compared to how it presents on handheld ultrasound. To build confidence in dismissing normals, you have to continuously review your callbacks, evaluate any false positives and refine which findings you continue to call back for work-ups.”

“Since we’ve adopted our ABUS program, cancer detection in our dense breast population has increased by 2.6 per thousand, and we’ve maintained a recall rate of 8.1%.” We’ve helped so many women achieve early diagnosis. Before we had ABUS, most of these women would have gone home with a normal result. ABUS has helped us find these cancers while they are small and contained, and that is what it is all about. It’s like any new technology, it takes a bit of time to get confident, but it’s well worth the effort.”
Leveling the Playing Field
Katy Patterson, MD, Division Chief of Breast Imaging at Indiana University (IU), launched an ABUS program two years ago. With 10 dedicated breast radiologists, IU now operates 7 Invenia ABUS units at 7 facilities across the IU Health System. “As the density inform legislation movement continued, our group decided it was time to do more; we needed to have something to offer our patients with dense breasts. Adding ABUS gave us the ability to give women who are dense, especially those who are extremely dense, a level playing ground. They deserve the best chance to have their cancer found as compared to those women who have a fatty breast tissue.”

As the healthcare system in the United States moves closer to achieving personalized medicine, there is a clear need for customizing breast care based on a woman’s individual risk factors. One size does not fit all as evidenced by the limitations of mammography, particularly among women with dense breasts. The goal of any breast screening program is to find cancers early and reduce false positives. Adding 3D ABUS to screening mammography has shown a significant increase in invasive cancer detection with a nominal insignificant decrease in specificity.
We are hosting 2 exceptional Breast Imaging Education and Experience Rooms offering 5 days of experiences including: lectures, panel discussions, hands-on opportunities, patient advocacy and more. Seating is limited, registration is required.
Ultrasound and ABUS
Room –

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Featured event:
Wednesday, December 4, 4:00pm:

“Advancing Breast Care Globally with ABUS Through Clinical Research”, featuring a panel of Invenia ABUS Call for Proposal Awardees
SenoBright™ Experience Room – #5140
Contrast Enhanced Spectral Mammography

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Special World Premiere:
Sunday, December 1st, 4:00pm:

Immerse yourselves in the transformative power of contrast mammography.
Invenia ABUS 2.0 is part of the suite of personalized breast care solutions from GE Healthcare. To learn more please click on the boxes below:
© 2019 General Electric Company.
GE, the GE Monogram Invenia and SenoBright are trademarks of General Electric Company. BI-RADS is a trademark of the American College of Radiology. Third party trademarks are the property of their respective owners.
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