Breast Imaging: Better Than Ever
Elizabeth S. Pietras, MD
The latest advanced technology in breast cancer screening and diagnosis, called DBT (digital breast tomography), 3D or Tomosynthesis, creates a layered, 3-dimensional image.
While the patient experience is very similar to traditional digital mammography, the new technology provides a series of thin images that a radiologist can view almost like turning the pages in a book.
The results include better detection of invasive breast cancers and fewer call-backs for false positives.
Elizabeth S. Pietras, MD, is here to explain the latest advanced technology in breast cancer screening and diagnosis.
“DBT – Digital Breast Tomography, 3D, or tomosynthesis” creates a layered, three dimensional image. My guest today is Dr. Liz Pietras. She’s the Director of the Breast Imaging Program at Maine Medical Center. Welcome to the show, Dr. Pietras. Tell us a little bit about the standard mammography and what differs with tomosynthesis.
Dr. Liz Pietras (Guest): Tomosynthesis, as you had mentioned, is considered a 3-D mammogram. The images that we are going to acquire are still a mammogram-based system. If you went in to have a mammogram today you could have the traditional 2-D digital mammogram, where the X-rays come through the breast and are captured on a plate and you make a digital image that’s read on a computer. The difference with the newer 3-D mammogram is it’s still mammogram-based, so you’re going to be in a machine with compression with an x-ray beam coming through your breast tissue but this time, the actual x-ray tube is going to make an arc across your breast and take multiple images over about four seconds. Those images are going to be captured and, with a computer algorithm, make a stack of images that I would look through on a computer like a bunch of pages in a book. I would be going through very thin, approximately 1mm intervals through your breast, looking at the structures throughout the breast tissue in a little bit different fashion.
Melanie: The procedure for women feels about the same as a normal mammogram.
Dr. Pietras: Yes. It’s probably maybe two seconds longer per exposure but the experience, the machine, the room, is all going to look very similar to the patient.
Melanie: Are there certain peoples for who this would be a better option?
Dr. Pietras: If you look at the data – and this has been out since 2011 in the United States. It’s been available since 2008 in Europe. But, if you look at the new data that supports that it’s a better mammogram, my feeling is everybody should be allowed to have this test. I would recommend it for all my screening patients. I think you may see some advantages--which we’re now learning in the newer literature – the more advantages of maybe the denser breast tissue has been in the literature in the news lately – but it’s going to be a little bit better for everybody in the screening population if you take all of the patients coming across. I think it’s a little better for everybody and, certainly, probably better for the dense-breasted patients as well.
Melanie: So, let’s talk about women with dense breasts because they get that letter now from many states. Is this a better way for you to see what’s going on in there? Does it change your view?
Dr. Pietras: Yes. If you take dense breast tissue – which there has been a lot talked about it lately. Dense breast tissue does place a patient at an increased risk of getting breast cancer. It’s not a big risk factor like a genetic abnormality but it does place you at a little above average risk of getting a breast cancer. The unfortunate thing about dense breast tissue is, it often can hide a breast cancer because breast cancers are going to look white on an x-ray image just like a dense tissue. Those patients also are at a little bit disadvantage because we might not be able to see all of those cancers in dense breast tissue that we could more easily see in a fatty breast. That being said, if you take this type of mammogram where the ability to look through the different layers and take away some of the superimposed breast tissue, we may be able to pick up those cancers from the background in some of these patients. It should be more advantageous for those patients. Right now, options for women with dense breast tissue are to rely on their physical exam or to rely possibly on an ultrasound in certain patients. There are some patients that might be at higher risk in general that we might suggest an ultrasound be performed. Digital breast tomosynthesis might help enough that not all those ultrasounds need to be performed.
Melanie: Does insurance cover tomosynthesis?
Dr. Pietras: That’s the tricky part and that is one of my projects right now. Right now, Medicare has accepted it and they do cover tomosynthesis for all their patients, which is nice because in the age group of mammography, that’s plenty of our patients. However, the private insurance companies have not all embraced this as something they are ready to cover at this time. The private payers in my state, most of them do not cover this. They will cover the screening mammogram costs but they will not cover the add-on tomosynthesis piece. We are now working with local providers to try to get that coverage for our patients. It puts us in a more awkward position when we may have to discuss those issues with a patient before they have a mammogram, which we do. We educate patients on that before they go through the test that there may be an added charge. I think that if you look at why some of these companies are not covering it, it is a little bit frustrating because they’re quoting data from the U.S. Task Force, which is good data but some of that data is outdated, at this point. If you look at the literature, one of the things that they site is a concern for covering this is the radiation dose of the 3-D mammogram. We purchased the newest generation of these machines and we’ve had our machines tested and the dose to our patients is going to be the same or, in some instances, a little bit less than the conventional 2-D mammogram. That issue is no longer a medical concern that there may be more radiation because with the new units, that is not a concern. So, that’s one thing I’m discussing with the insurance companies. Also, if you look at the new data in the last year, the data continues to support that this new technology finds more cancers and also allows us to call less patients back for additional views. It’s improving the sensitivity of finding breast cancers and it’s decreasing that false positive rate that we all worry about so much. I think, hopefully, with all of that newer information, some of the local companies will start paying for this. They do pay for it in other states. So, we are, again, going through that route right now to try to get more Maine insurance companies to pay for this.
Melanie: That’s very reassuring for woman to hear about radiation exposure being possibly even less. When you mention the return visit, something every woman dreads. That call that says, “Yes, we’ve found something suspicious.” If they return for a diagnostic study, is that with tomosynthesis as well or does that, then, move onto ultrasound or something else?
Dr. Pietras: Yes. There are a couple of different points to be made there. If we look at a screening mammogram and call someone back, when they come back to the department it depends on what I see, what I would pick for them. All of these new units can still take a 2-D mammogram or a 3-D mammogram. It’s basically just a flip of a switch to go between the two technologies on the same machine. Magnification views, which are magnified views of calcifications in the breast, those are better done with a 2-D system. For those types of patients, I would use the 2-D system. For possible masses or maybe a distorted area in the breast, the tomosynthesis extra views may be very helpful in that setting. When they come, we will pick which one they may need and we can do that easily in the same room. We can actually do it 3-D and a 2-D back-to-back, if they needed something like that. The other thing that’s nice is because we can see things better in the breast with this new modality, I can sometimes go right to ultrasound from that original mammogram and they won’t have to have those extra views.
Melanie: Wow. In just the last few minutes, Dr. Pietras--and it is such interesting information for women as these new advancements take hold--give your best advice for women that need to get their mammogram what you want them to know as the Director of the Breast Imaging Program at Maine Medical Center and, really, your best advice. Why they should come to see you and tell us about that test.
Dr. Pietras: For mammography, I still believe, as does the American College of Radiology, I would like to start screening all patients at age 40. If they have different risk factors or genetic issues, yes, I may see them earlier but, for the average risk patient I would like to start screening patients at age 40. You will see there is controversy in the literature on when to screen. The American College of Radiology still believes we should screen people every year until they are in good health. We believe starting at 40 every year, well into your 70’s or later if you are in good health and fit the screening criteria. If you had to choose between a 2-D mammogram or a 3-D mammogram, I prefer the 3-D mammogram. I think it’s going to give you a little bit of an advantage over the 2-D model. The 2-D model is still good. It’s still “the gold standard” accepted by all insurance companies and all boards and societies out there. You’re not getting a bad mammogram. I still think a digital mammogram is great for the majority of people. The 3-D mammogram is going to give you that little extra edge. So, I may be able to find new cancers sooner. I may be able to find it when it’s smaller and I may be able to help you if you have denser tissue. I think the 3-D mammogram is better if you’re willing to have it. It’s not much longer. It’s a great study. Unfortunately, I do understand, because I take care of lots of Maine patients, that money is an issue and it would be nice if everything could be covered. I also would encourage patients to talk with their own doctors and to talk to their insurance company. See if they can get this covered by the insurance company. I’m going to help go to bat and try to get those tests covered as well with these patients but I’m happy to talk to referring clinicians. We do have some phone numbers for patients to call if they have some questions to talk about some of these issues. I think our big goal is to get all insurance companies to cover the extra costs, sooner than later. Medicare patients, you’re all set. You can have the 3-D mammograms. If you’re a Medicare patient I would come in and ask for that.
Melanie: Thank you so much, Dr. Pietras. I can tell you’re a caring and compassionate physician for women. You’re listening to MMC Radio. For more information you can go to MMC.org. That’s MMC.org. This is Melanie Cole. Thanks so much for listening.