Author: Brian Casey

A New Day for Breast Screening

Posted on by Brian Casey

In a breathtaking about-face, the USPSTF said it would reverse 14 years of guidance in breast screening and lower its recommended starting age for routine mammography to 40.

In a proposed guidance, USPSTF said it would recommend screening for women every other year starting at age 40 and continuing through 74. The task force called for research into additional screening with breast ultrasound or MRI for women with dense breasts, and on screening in women older than 75.

The move will reverse a policy USPSTF put in place in 2009, when it withdrew its recommendation that all women start screening at 40, instead advising women in their 40s to consult with their physicians about starting screening. Routine mammography was advised starting at age 50. The move drew widespread condemnation from women’s health advocates, but the USPSTF stuck to the policy even through a 2016 revision.

The task force remained steadfast even as studies showed that the 2009 policy change led to confusion and lower breast screening attendance. The change also gave fuel to anti-mammography extremists who questioned whether any breast screening was a good idea.

That all changes now. In its announcement of the 2023 guidance, USPSTF said it based the new policy on its review of the 2016 update. No new RCTs on breast screening have been conducted for decades (it’s considered unethical to deny screening to women in a control group), so the task force commissioned collaborative modeling studies from CISNET.

USPSTF said the following findings factored into its decision to change the guidance: 

  • Biennial screening from 40-74 would avert 1.3 additional breast cancer deaths per 1,000 women screened compared to biennial screening of women 50-74.
  • The benefits of screening at 40 would be even greater for Black women, at 1.8 deaths averted. 
  • The incidence rate of invasive breast cancer for women 40-49 has increased 2.0% annually from 2015-2019, a higher rate than in previous years. 
  • Biennial screening results in greater incremental life-years gained and mortality reduction per mammogram and better balance of benefits to harms compared to annual screening.

The Takeaway 

As with the FDA’s recent decision to require density reporting nationwide, the USPSTF’s proposal to move the starting age for mammography screening to 40 was long overdue. The question now is how long it will take to repair 14 years of lost momentum and eliminate confusion about breast screening.

Learning Curve in DBT Screening

Posted on by Brian Casey

Digital breast tomosynthesis continues to evolve. First introduced initially as a problem-solving tool in breast imaging, DBT is becoming the workhorse modality for breast screening as well. 

But DBT still requires some adjustment when used for screening. In a study of nearly 15k women in European Radiology, Swedish researchers describe how the false-positive recall rate for DBT cancer screening started higher but then fell over time as radiologists got used to the appearance of lesions on DBT exams.

The Malmö Breast Tomosynthesis Screening Trial was set up to compare one-view DBT to two-view digital mammography for breast screening. Unlike some DBT screening trials, the study did not use synthesized 2D DBT images. DBT images were acquired 2010-2015 with Siemens Healthineers’ Mammomat Inspiration system. 

Findings in the study included: 

  • DBT had a sharply higher false-positive recall rate in year 1 of the study compared to DM (2.6% vs. 0.5%)
  • DBT’s recall rate fell over the five-year course of the study, stabilizing at 1.5% 
  • Recall rates for DM varied between 0.5% and 1% over five years
  • Most of the DBT recalls (37.3%) were for stellate lesions, in which spicules radiate out from a central point or mass. With DM, only 24.0% of recalls were for stellate lesions
  • The number of stellate distortions being recalled with DBT declined over time, a trend the authors attributed to a learning curve in reading DBT images

The authors said that the DBT false-positive recall rate in their study was “in general low” compared to other European trials. They claimed that MBTST is among the first studies to analyze recall rates by lesion appearance, an important point because radiologists may see a different distribution of lesion types on screening DBT compared to what they’re used to with DM.

The Takeaway 

The Malmö Breast Tomosynthesis Screening Trial was one of the first to investigate DBT for breast screening, and previous MBTST research showed that DBT can also reduce interval cancers, which occur between screening rounds. 

The new findings offer further support for DBT breast screening and give hope that whatever shortcomings the technology might have early on in a screening role can be addressed through training and experience. It also confirms recent research indicating that DBT has become the new gold standard for breast screening.

The Value of CT Contrast

Posted on by Brian Casey

If there was a tool available that would automatically improve your job performance by nearly one-third, you’d want to use it, right? (And no, we’re not talking about ChatGPT.) The tool is contrast media, and a new study in JAMA Surgery found that the use of contrast in emergency CT exams improved the diagnostic accuracy of radiologists by 30%.

Radiology has a love-hate relationship with contrast. Contrast media unquestionably improves medical image quality, but it also adds a layer of complexity to imaging operations. Patients have to be screened and monitored for contrast allergies and reactions, IV lines have to be placed, injectors have to be monitored and maintained. 

Radiology researchers and clinicians have explored a variety of methods for non-contrast imaging, in particular in the emergency setting, where the time spent setting up a contrast exam could delay patient care. 

But while the risks of giving contrast are extensively debated, what are the risks of not using it? Researchers from multiple US institutions sought to answer this question in a study of 201 patients who got CT scans in emergency departments for acute abdominal pain over 3 weeks in 2017. All patients were scanned on Siemens Healthineers’ Somatom Force dual-source dual-energy CT scanner.

The original scans were contrast-enhanced, and a dual-energy technique was used to produce non-contrast images. Both sets of images were read by faculty and resident radiologists. Compared to the gold standard of contrast CT at 100%, findings included:

  • Diagnostic accuracy of unenhanced CT was 70%, or 30 percentage points lower than contrast CT
  • Faculty radiologists were more accurate than residents for primary diagnoses (82% vs. 76%), but less accurate for actionable secondary diagnoses (87% vs. 90%)
  • Faculty made fewer false-negative primary diagnoses than residents (38% vs. 62%)
  • False-negative and false-positive results were common (19% and 14%, respectively)

The Takeaway 

Reducing the use of contrast is a worthy goal, but it carries risks of its own, as this study indicates. False-negative interpretations are among the worst kinds of radiology errors with non-contrast exams, and clinicians should weigh the diagnostic penalty of withholding contrast media in the emergency setting, especially given the extremely low rate of contrast reactions in low-risk patients.

GE HealthCare’s MRI Contrast Play

Posted on by Brian Casey

GE HealthCare has expanded its MRI contrast portfolio with the European debut of Pixxoscan. The gadolinium-based contrast agent gives GE another macrocyclic gadolinium-based contrast agent to sell in Europe, in addition to its Clariscan GBCA.

MRI contrast developers have been working to address one of the most persistent problems in MRI: their reliance on gadolinium. Gadolinium works great for lighting up MR images, but it’s a toxic metal that has to be bonded with a chelate – a sort of molecular cage – in order to be used safely in humans. 

Pixxoscan is a macrocyclic GBCA that’s based on gadobutrol, a formulation already used in Bayer’s Gadovist GBCA and that’s now available generically. Macrocyclic GBCAs are considered more stable and less likely to release gadolinium than linear agents. 

Most linear GBCAs have been barred from the European market since 2017. The FDA never took a similar approach, but the US market has largely shifted from linear GBCAs to macrocyclic agents due to safety concerns. 

GE HealthCare highlighted that Pixxoscan is formulated at twice the concentration of gadolinium ions, which reportedly enables it to be used at half the injection volume of other GBCAs. The company also said that the agent’s cage-like macrocyclic chelate provides high kinetic stability. 

Pixxoscan will start shipping initially in Austria, and GE HealthCare expects to expand it across Europe. A spokesperson didn’t confirm plans for a US rollout.   

Pixxoscan’s launch comes as two of GE HealthCare’s competitors, Guerbet and Bracco, are rolling out their formulations of gadopiclenol, a high-relaxivity agent that can be used at half the dose of conventional GBCAs. The companies collaborated on the development of the agent, which Guerbet is selling as Elucirem and Bracco as Vueway. 

The Takeaway

GE HealthCare’s launch of Pixxoscan gives the company another macrocyclic agent to sell in Europe in addition to Clariscan. The question is how the agent will compete with gadopiclenol from Bracco and Guerbet, which are already touting its dose and relaxivity advantages.

ABUS Boosts Breast Screening

Posted on by Brian Casey

Automated breast ultrasound led to sharp increases in cancer detection rates and sensitivity when it was performed as a supplement to screening digital mammography in a study of Asian women. 

In Radiology, researchers from South Korea explain the shortcomings of X-ray-based mammography, which has limited sensitivity in women with dense breast tissue. Handheld ultrasound can be used as a screening supplement, but it has drawbacks of its own, such as longer exam time and operator variability. 

ABUS has been proposed as an alternative, acquiring 3D volumes of the entire breast in an automated mode that’s more structured and standardized. ABUS also provides coronal-plane images that can help differentiate malignant from benign lesions.

But most of the studies validating ABUS have been conducted on Western women, and Asian women tend to have mammographically denser breasts.

So researchers decided to test ABUS as a supplement to digital mammography with 2,301 South Korean women who were screened from 2018 to 2019. Women were first screened with digital mammography (either Hologic’s Selenia Dimensions or Siemens Healthineers’ Mammomat Revelation), then received ABUS scans with GE HealthCare’s Invenia ABUS system. 

For women with dense breasts, screening with ABUS and DM turned in better performance than DM alone in multiple categories, including:

  • Higher cancer detection rate per 1,000 screening exams (9.3 vs. 6.5)
  • Better sensitivity (90.9% vs. 63.6%)
  • Higher AUC (0.89 vs. 0.79)
  • Detection of smaller cancers, with a mean size of 1.2 cm vs. 2.3 cm

On the down side, ABUS + DM in women with dense breasts had lower specificity (86.8% vs. 94.6%), driving higher biopsy rates (3.3% vs. 1.9%) and false-positive biopsy rates (2.4% vs. 1.3%).

The Takeaway

In a time when breast cancer inequities are under the microscope, the new study provides encouraging news that imaging technology can help compensate for the shortcomings of the traditional “one size fits all” paradigm of breast screening. 

The results are also a shot in the arm for ABUS as it seeks to cement a role as a complement to X-ray-based screening mammography, although work remains to be done in improving specificity and recall rates.

Health Inequity & Breast Cancer

Posted on by Brian Casey

The last several years have seen growing awareness of how structural inequities can impact individual health outcomes. Two powerful new JAMA Network Open studies reinforced what we know about structural inequity, particularly as it relates to breast cancer. 

In the first study on April 19 addressing racial differences in breast cancer mortality, researchers looked at over 415k women from 2011 to 2020, finding:

  • Black women between 40 and 49 years old had the highest breast cancer mortality rates per 100,000 person years, at 27 deaths. This compares to 15 deaths for White women, and 11 deaths for other ethnicities.
  • If breast screening were tailored based on risk at age 50, Black women should start screening eight years earlier than White women, at 42 years of age versus 51. 
  • Biennial mammography screening of Black women starting at age 40 would reduce the gap in breast cancer mortality compared to White women by 57%. 

In the second study on April 21, researchers drilled even deeper into structural inequity, focusing on breast cancer outcomes in disadvantaged neighborhoods in a large, racially diverse region in southern Florida that’s home to 6.2M people. 

In all, their study covered 5,027 women with breast cancer, and they categorized neighborhoods into three levels based on socioeconomic status. Findings included:

  • Patients living in the second most disadvantaged neighborhoods were 36% more likely to die of breast cancer (HR=1.36).  
  • Women living in the most disadvantaged neighborhoods were 77% more likely to die (HR=1.77).

The researchers pointed out that their results went beyond merely linking race to health outcomes, as they adjusted for race and ethnicity “as a proxy for structural racism.” They suggested that there could be “unaccounted,” biologic mechanisms related to neighborhood disadvantage that lead to shorter breast cancer survival. The findings echo other studies that have linked patient location to access to imaging.

The Takeaway

Over the past several decades, breast cancer’s dropping mortality rate has been a health policy success story. But the new studies indicate that progress has been uneven, and more attention is needed to ensure that the benefits of improved breast cancer diagnosis and treatment are distributed more equitably.

Headlines from HIMSS 2023

Posted on by Brian Casey

CHICAGO – It does indeed feel like 2019 again at HIMSS 2023, which opened this week in the Windy City. Major stories at the show include generative AI for medical use, consumer cloud players planting their flags in healthcare, and the ongoing need for healthcare IT to help with rising medical procedure volume and growing burnout among healthcare professionals.

But an underlying subtext of this week’s show is that the disruptions and travel restrictions of the COVID-19 pandemic are behind us. At long last the HIMSS show has returned to a sense of normalcy. 

On-site attendance at HIMSS 2022 in Orlando was around 29k, down sharply from the 43k at HIMSS 2019. Early midweek figures from HIMSS 2023 place attendance at 35k; this sounds about right based on the crowded hallways, presentation rooms, and technical exhibits at McCormick Place (and especially the line at Starbucks in the Grand Concourse). 

What are other trends at HIMSS 2023? They include: 

  • Generative AI spreading throughout healthcare. Radiology was one of the first medical specialties to explore the potential of large language models like ChatGPT, but healthcare IT is getting into the act as well. At HIMSS, vendors are inking partnerships to put ChatGPT to work for functions like clinical decision support.
  • Cloud storage providers are in healthcare to stay. After years of dabbling, the large cloud players – Amazon, Google, and Microsoft – appear to be making a major play in cloud-based healthcare, signing partnerships with IT and radiology OEMs.
  • Healthcare IT helping providers. The conversations at HIMSS 2023 are focusing on leveraging technology to help providers cope with rising procedure volume and burned-out staff. 
  • Pathology is finally ready to go digital. The technological challenges to digitizing, managing, and archiving massive whole slide images appear to be solved. Now all that’s left is to convince pathologists to take the digital plunge.

The Takeaway

Prior to the pandemic, HIMSS was perhaps the fastest-growing healthcare conference, and this week in Chicago shows it’s back. The crowded halls are a welcome sign not only for healthcare IT, but also for other medical meetings on the calendar.  

Check out videos from HIMSS 2023 on our LinkedIn page and YouTube channel. And keep an eye out for the editorial teams for Imaging Wire and our sister publications Cardiac Wire and Digital Health Wire in McCormick Place – we’d love to say hello!

Salary Data Reveal Medicine’s Golden Cage

Posted on by Brian Casey

Are you a glass-half-full or a glass-half-empty kind of person? Either way, there’s lots to unpack in the latest data on physician salaries, this time from Medscape. 

Medscape’s survey of over 10k US physicians across over 29 medical specialties found that overall physician salaries have grown 18% over the last five years, to $352k, while specialists made an average of $382k. 

As with last year, radiologists landed in the top 10 of highest-compensated specialists, a finding that’s in line with previous salary surveys, such as from Doximity. Medscape found that radiologists had an average annual salary of $483k in 2023, compared to $437k in 2022. Radiologists had an average annual salary of $504k in the Doximity data. 

Other nuggets from the Medscape survey:

  • “Stagnant” reimbursement relative to rising practice costs has cut into physician income. 
  • The gender gap is narrowing. Male primary care doctors in 2023 earn 19% more than females, compared to about 25% previously.
  • Male specialist physicians earn 27% more than females, down from 31% last year and 33% the year before that.
  • Only 19% of radiologists are women – one of the lowest rates of female participation among medical specialties. 
  • 58% of radiologists feel they are fairly paid.
  • Radiologists report working an average of 49.6 hours a week.
  • 90% of radiologists say they would choose their specialty again, ranking #10.

The Takeaway

On the positive side, physician salaries continue to rise, and medicine is making encouraging progress in narrowing the gender gap. Radiologists seem to be well-compensated and relatively happy, but the specialty has more to do to attract women.

Underlying the raw data is a disturbing undercurrent of physician dissatisfaction, with many feeling as though medicine is a golden cage. In the free-response portion of the survey, doctors described themselves as caught between falling reimbursement and rising costs, with overwork also leading to burnout. 

The Medscape survey shows that addressing physician burnout must become a priority for the US healthcare system, and it can’t be solved merely by boosting salaries. Increasing the number of residency slots is a good first step (see below).

Cardiac Imaging in 2040

Posted on by Brian Casey

What will cardiac imaging look like in 2040? It will be more automated and preventive, and CT will continue to play a major – and growing – role.

That’s according to an April 11 article in Radiology in which Dr. David Bluemke and Dr. João Lima look into the future and offer a top 10 list of major developments in cardiovascular imaging in 2040.

Cardiovascular disease carries a massive medical burden, with over 800,000 myocardial infarctions occurring annually in the US alone. By 2030 almost one-third of deaths worldwide are expected to be due to cardiovascular disease.

Multiple different imaging modalities are adept at identifying both ischemic and nonischemic heart disease, but CT has risen to the top for ischemic imaging, making “quantum” advances in the last decade thanks to its growing prowess in the coronary arteries.

CT’s advances have been so great that the modality occupies seven of the top 10 spots on Bluemke and Lima’s list. In brief, they see: 

  • Coronary CTA becoming totally automated, a development that will no doubt benefit AI developers like HeartFlow (see below).
  • CCTA becoming a preventive tool rather than a gatekeeper to interventional cardiology (also hinted at in a recent study from Denmark). For example, CCTA will be used to track the effectiveness of statin therapy
  • Photon-counting CT flexing its muscles for coronary artery evaluation and routine plaque characterization and quantification
  • Next-generation cardiac CT becoming more like MRI
  • Next-generation cardiac MRI becoming more like CT
Table of Top 10 Cardiovascular Imaging Developments by 2040

They also see a major growing role for software-assisted cardiac CT with AI and other tools. Software-based automation has simplified the “postprocessing nightmares” once common with coronary CT, making it “wonderfully ordinary” to perform. 

The Takeaway

Bluemke and Lima offer a fascinating glimpse of cardiac imaging’s future. But one area they don’t touch on is whether CT’s rising prominence means radiologists will start taking back turf in heart imaging once ceded to cardiologists. Heart specialists haven’t taken over cardiac CT in the same way that they monopolized echocardiography and nuclear cardiology. Could we be seeing a renaissance of radiology in the heart?

Ultrasound Spots Breech Pregnancies

Posted on by Brian Casey

Performing routine third-trimester ultrasound scans on pregnant women could help identify breech pregnancies, giving women the opportunity to consider alternative birth options. UK researchers in PLOS Medicine said the impact was found with both conventional and POCUS ultrasound scanners. 

While the incidence of breech presentation at full term is only 3-4%, when breech births do occur they can result in higher morbidity and mortality for both babies and mothers. 

In the UK, third-trimester ultrasound scans aren’t routinely performed for low-risk women, missing a chance to give them other options like Cesarean birth.

  • Therefore, researchers investigated the effectiveness and impact of these scans at two hospitals, one that used conventional ultrasound scanners and the other employing POCUS units (GE HealthCare’s Vscan Air).
  • At the POCUS facility, scans were typically performed by trained midwives. Women were scanned between 2016 to 2021 at both hospitals.

Performing routine ultrasound scans at 36 weeks reduced the incidence of undiagnosed breech presentation by 71% at the hospital using conventional ultrasound and 69% at the POCUS hospital.

  • The rate of undiagnosed breech presentation dropped from 14.2% to 2.8% with conventional ultrasound and from 16.2% to 3.5% with POCUS.
  • The scans also had an impact on babies’ health. Infants born at either facility had less likelihood of a lower Apgar score (<7) five minutes after birth, and babies were less likely to be sent to the neonatal care unit.

The researchers believe their findings suggest a revision of the UK’s clinical guidelines, which don’t currently call for routine third-trimester ultrasound scans for low-risk women. With respect to POCUS, they said their research was the first to investigate the technology for diagnosing fetal presentation, and their findings support wider use of POCUS in areas where conventional ultrasound isn’t available. 

The Takeaway

What’s really exciting about this study are the findings about POCUS. Maternal-fetal complications are a huge problem in developing countries and places with less access to imaging technology. POCUS scanners could be used by trained personnel like midwives – perhaps with AI assistance –  to identify problems before birth.

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