September 27, 2018 -- Paving the way to personalized breast care

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Regular breast cancer screening with mammography translates into a lower stage at breast cancer diagnosis and less-extensive treatment, according to the study, “Impact of Screening Mammography on Treatment in Women Diagnosed with Breast Cancer,” recently published in the Annals of Surgical Oncology.
“Detecting early breast cancer without nodal metastases has been shown to improve overall prognosis and limit morbidity of treatment,” said Arnold Honick, MD, Radiologist, RCI, PLC, Radiology Consultants of Iowa in Cedar Rapids, Iowa. “However, breast density can dramatically impact detection and result in poor prognosis for women with dense breasts. We need effective complementary screening tools to provide the best opportunity to detect breast cancer early.”

An ardent supporter of mammography and breast cancer screening, Prof. László Tabár, MD, Radiologist Professor Emeritus of Radiology: Uppsala University, Faculty of Medicine, Sweden, addressed the need for personalized screening in a recent education session: “Every radiologist who reads a mammogram needs to know that about every third breast cancer is hidden by the dense fibroglandular tissue to the extent that they will miss the disease if only mammography is used. Therefore, another diagnostic tool needs to be added to mammography: We need a personalized, multimodality approach for screening.”
Solving the important problems
Luke Delaney, General Manager of Automated Breast Ultrasound at GE Healthcare, said funding innovation to improve patient care in breast cancer screening is a key priority for the company. With more than 16 years of breast cancer research experience, Delaney believes that innovation starts with understanding which clinical problems remain above and beyond what is being solved with the current technology. He adds that GE Healthcare is investing significant resources to research solutions for three primary problems in screening:
Screening compliance – as an industry, we need to focus on solutions that make the experience easier, more accurate, and more comfortable for women.
Sensitivity (cancer detection) – if cancer is present, we need to find it. This drives our focus on creating the best set of tools for detecting cancer.
False positives (specificity) – we need to accurately identify the women who need more imaging to improve sensitivity, but not subject them to unnecessary exams and anxiety.
“We are continuously collaborating with physicians and patients to identify the right combination of technologies that work together to find as many cancers as possible and keep recall rates and false positives low,” Delaney said. “The way we find answers is through clinical research.”

“While mammography is the only screening modality to have mortality studies, it is not true anymore to suggest that there is only one screening tool. We know that breast MRI helps with high-risk patients and there are a number of large-scale trials that demonstrate the significant value of ABUS for screening women with dense breasts,” said Susan Roux, MD, Medical Director, Carol Hatton Breast Care Center – Monterey Peninsula (CHOMP), Monterey, Calif. “While being a woman who is aging may be the most significant risk factor for breast cancer, 85 percent of my patients with cancer have no family history. More research is needed before we adopt risk-based screening protocols; however, we have to start looking at individual risk profiles and density to better optimize screening for each woman.”
Investing in research
GE Healthcare has embarked on a breast imaging call for proposal initiative to support the pursuit to personalized breast care. The first retrospective call for research was conducted in late summer 2018 and 4 winners have been selected. A prospective call for proposals is underway until October 26th, with the finalists being announced at RSNA 2019. This call is broader and invites any breast imager, radiologist, technologist, or physicist with a hypothesis for prospective research – whether they are a current Invenia™ ABUS user or not.

“We have expectations about how combining technologies could improve outcomes, but that must be validated to demonstrate the value,” said Delaney. “ABUS is getting to a maturity point where there are enough physicians using it at a high enough volume to generate the clinical data to answer a lot of these clinical questions. Part of our effort is to help them do that, to support their ability to quantify their experience with ABUS so that they can share that with others.”

According to Delaney, “we don’t just make equipment; we help solve problems and the better a product is at solving a problem, the more likely it is to be adopted. Our goal is to address those top issues to truly impact patients’ lives.”
The Power of Combining ABUS and Tomosynthesis to Find Small Cancers
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 for women with dense breast tissue. Multiple studies have now shown that the addition of supplemental screening with ultrasound, Automated Breast Ultrasound or tomosynthesis to mammography can improve cancer detection these women.
“Studies have shown that tomosynthesis can improve cancer detection, and decrease recall rates or false positives. With the ability to see through overlapping tissue, tomosynthesis also provides improved localization and characterization of masses,” said Arnold Honick, MD, Radiologist, RCI, PLC, Radiology Consultants of Iowa in Cedar Rapids, Iowa. “However, tomosynthesis is still X-ray based and sensitivity is reduced in women with extremely dense breasts, which means that some masses will still be masked and likely not detected. This is where ABUS, utilizing a different imaging technology, is complementary to mammography and can improve overall screen-detected breast cancer.”

“We now perform tomosynthesis for all screening exams, though we encourage adding ABUS for women with dense breasts. We also suggest ABUS for those women appropriate for or interested in extended screening who are not getting MRI,” said Daniel Kirsch, MD, Director, Breast Imaging and Intervention, Tower St John’s Imaging in Santa Monica, Calif. “We implemented ABUS because it offers a true advance in screening ultrasound evaluation of the breast. This is in large part by virtue of the coronal plane display, which I find analogous to tomosynthesis in the way that changes in the surrounding tissue become evident with many cancers, improving both detection and characterization. With ABUS we can also standardize the exam, and eliminate the variability and subjectivity that is inherent with handheld technologist-based screening.”
Finding small hidden cancers
“Shortly after we instituted ABUS, I was reading a combined DBT and ABUS exam. I reviewed the mammogram first and interpreted it as negative,” added Dr Kirsch. “ABUS showed a small hypoechoic irregular mass in the inner lower quadrant of the left breast, which looked suspicious. On re-review of the tomosynthesis, I could see the lesion but only in retrospect. Without already knowing it was there, the lesion would not have been called prospectively.”

“Not recommending the use of a multimodality approach for screening following the publication of a number of peer-reviewed, very convincing scientific trials can be called 'the substandard of care.' It is simply not fair to send a 'well letter' to a woman with dense fibroglandular tissue when we are aware of the fact that every third breast cancer will be missed hidden in the dense breast tissue. We must use a combination of two 'different types of beams' (X-ray and ultrasound) on all women with dense breast tissue in order to provide a similarly high-quality imaging result to all women, regardless of their risk level,” added Prof. László Tabár, MD, Radiologist Professor Emeritus of Radiology: Uppsala University, Faculty of Medicine, Sweden.
Working toward new standards
“It’s hard to say we have a standard of care for breast cancer screening, when not all states recognize the impact of breast density and inform patients. However, it is slowly evolving as more doctors move beyond X-ray as a one-size-fits-all approach and become more patient-centric. We must continually work to figure out the best tools for that individual woman – what is the best, most efficient way to get the clinical answers you’re looking for? How do we leverage the strengths of modalities like mammography and ABUS and determine the right combination to deliver the right clinical performance that finds the most cancers while minimizing false positives?” said Susan Roux, MD, Medical Director, Carol Hatton Breast Care Center- Monterey Peninsula (CHOMP), Monterey, Calif.

As clinical evidence grows about increased cancer detection abilities of supplemental screening tools, density inform legislation expands, and patient demand increases, breast imaging centers will need to determine their own strategies for providing personalized imaging for dense breast patients. Invenia ABUS is a tool that is designed for screening and can help provide efficiency, reproducibility, increased cancer detection and in a financially beneficial manner.

“Referring physicians are very busy and often, not well informed about breast density and its importance in the screening environment. As breast imagers, it’s our responsibility to collaborate with patients and clinicians to offer the best screening examinations. If we do this consistently, personalized screening will prove its worth and lead to greater adoption of tailored screening protocols in the future. One facet of that will include a 'menu' of screening modalities including mammography and tomosynthesis, but also breast MRI and ABUS,” concluded Dr. Honick.
Introducing Invenia ABUS 2.0
Supplemental screening with automated breast ultrasound transforms breast care from reactive to proactive – helping clinicians be more confident, and patients avoid potential delayed diagnosis. GE Healthcare is continually investing in the innovation of automated breast ultrasound, and now proudly introduces its next-generation system, Invenia ABUS 2.0.

The new Invenia ABUS 2.0 enhances the exam experience for both operators and patients with new features that help further customize the exam based on the patient’s body habitus. Exam setup and review have become even more streamlined.

The new Invenia ABUS Viewer helps make reading, reporting and archiving efficient utilizing powerful cSound™ Imageforming and an intuitive user interface which can be customized by the user. New features include a three-view layout and easy prior exam comparisons.

Attendees of RSNA 2018 (November 25-29, 2018) will have the opportunity to see the new system. Live demonstrations will take place in the GE Healthcare sponsored workshops at RSNA. Registration is required.

We believe that ABUS has the potential to find significantly more cancers than mammography alone in women with dense breasts, and we have just scratched the surface on the potential of applying ultrasound to this important clinical problem. As breast ultrasound technology continues to advance, we are investing to continually improve Invenia ABUS, ensuring great image quality, workflow and patient comfort, all of which will contribute to early detection and improved outcomes.
© 2018 General Electric Company.
GE, the GE Monogram, Invenia and cSound are trademarks of General Electric Company.

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