Breast density might be making it harder to find tumors

The sensitivity of traditional mammography is diminished in patients with dense breast tissue because this tissue masks tumors. In fact, Imaging Technology News reports mammograms may miss more than 50% of cancers in dense breasts. This is particularly worrisome because 50% of the population has dense breast tissue.

With such a large number of women at risk for false negatives, 32 states have enacted laws requiring patients to be notified if they have dense breast tissue. These notifications are increasing public awareness, and many women are discovering for the first time that they have the condition. This makes it more important than ever for clinicians to be up to date on the latest breast tissue research, screening modalities and technological advancements.

The influx of notification letters has many women asking about next steps. Physicians have responded by recommending supplemental imaging, and as a result, states that require notifications have seen a surge in supplemental ultrasound and MRI screenings.

In one study, researchers reviewed data from patients with core biopsy-proven malignancy at an outpatient breast center in New Jersey. They compared data from 18 months before implementation of New Jersey’s notification mandate to the 18 months after implementation. What they found was dramatic. The number of screening ultrasounds increased from 1,500 during the time period tracked to more than 11,400 over that same time frame, an increase of 651%. MRI utilization increased by more than 59%, while mammography volume decreased by 6%.

Alongside the renewed focus on supplemental imaging, there’s a fresh focus on advancing imaging technology to better image dense breast tissue.

As the New Jersey study showed, ultrasound is often the next step in imaging when women find out they have dense breast tissue. It’s an effective supplement to mammography, less costly compared to an MRI and it may soon be even more effective.

Speaking to Radiology Today, Alberto Goldszal, Ph.D., chief operating officer of University Radiology, the largest provider of subspecialty radiology and teleradiology services in New Jersey, shared his enthusiasm for ultrasound.

“There are a few ultrasound modalities now dedicated to perform breast screening,” Goldszal said. “The industry is dedicated to this modality, looking at it as being complementary to traditional X-ray-based mammography.”

He says ultrasound can provide a more accurate view of what’s in the breast, better detection of lesions and better diagnosis, while reducing the number of unnecessary breast biopsies, false positives and callbacks.

Facedown ultrasounds in 3D are particularly promising, according to Goldszal. One version approved for diagnostic screening allows women to lie face down on the exam table. It scans the entire breast in two to four minutes, and there’s no breast compression and no radiation exposure.

With this version, the patient lies on a padded table with one breast submerged in warm water while a ring-shaped transducer encircles the breast and pulses low-frequency sound waves through the water into the tissue.

The system captures data from the reflection of sound waves off tissue boundaries and structures within the breast. Signals that transmit through the breast also are captured. During the scanning process, three distinct imaging volumes or sequences are created that show reflection, speed of sound and attenuation.

The repetitive, automatic nature of this modality brings a level of consistency that would be hard to duplicate with a handheld ultrasound. It’s also faster than a handheld scan, which can take 30 to 40 minutes.

Another facedown 3D imaging system that is under development scans the entire breast in one 30-second radial sweep using a recessed scanning cone that houses an extra-long linear probe. Data for each breast are then sent to a radiology workstation as a single 3D volume.

This version enables quick interpretation as well. It delivers images in planes like those from handheld ultrasound exams, except that it has larger fields of view. Radiologists can see each full-field slice in high detail. It presents the entire breast in a single-volume study and images can be reviewed in the same plane as they were captured.

In addition to these ultrasound advancements, artificial intelligence is also making contributions to the advancement of dense breast tissue imaging.

Armed with the right data, AI can assist radiologists in the detection of tumors hidden within dense breast tissue. One team has leveraged a massive database with tens of thousands of medical images and pathology data to develop machine learning algorithms that can identify lesions in dense breast tissue and their characteristics. It also can provide a clinical assessment.

This particular AI software is designed to be compatible with any hardware or diagnostic imaging device, and it is PACS and Digital imaging and communications in medicine (DICOM) compliant.

Advancements such as this require efficient data storage and management systems. The increase in imaging volume triggered by notification mandates underscores the need for storage space that can be rapidly expanded as needed. The volume of imaging and clinical data will only increase over time.

Interoperable data management and storage systems are the leading solution for the growing volume of imaging and clinical data. Whether sites use PACS, vendor-neutral archives or an enterprise imaging solution, investing in an interoperable system ensures providers are prepared for the future. 

Identifying tumors in dense breast tissue remains a challenge. Add in the impact of state notification mandates for dense breast tissue, and demand for imaging improvements is strong. Mammograms, conventional ultrasound and digital 3D ultrasounds help create a fuller picture for more precise diagnosis. New technology looks promising, provided radiology departments have the storage capacity for higher-resolution scans.