Breast imagers protest digital discrepancies

In a delicate dance between open discussion and sheer frustration, all players in the digital mammography arena, from users to vendors, wrangled over evolving technology issues during a marathon forum at the SCAR meeting. Among the points of contention was the speed at which the technology is achieving consistent image quality standards.

Breast imagers and their allies confronted vendor representatives during the initial portion of a digital mammography special session at the meeting and demanded more standardization and consistency in the handling of digital breast images.

Although digital mammography could potentially provide important patient benefits, currently available systems require too much time for reading and managing images, users said. And differences in presentation algorithms can change the appearance of an image generated on one digital capture system when it is displayed on another vendor's workstation. Session attendees also asked for a common toolbox on all digital mammography workstations.

Responses from the vendor representatives were, for the most part, muted. Although more than a dozen participated in a panel at the close of the five-hour session, their replies were short and failed to rebut many of the complaints raised in the session.

In pushing for standardization and consistency, breast imagers are contending with commercial imperatives that could be tough to overcome. Vendors try to develop equipment designs and features, including display algorithms, that give them a competitive edge. Regulatory issues have also been a factor. Until now, for example, the FDA, which must approve digital mammography systems, has linked digital capture technology and display algorithms.

Nonetheless, breast imagers insisted that the current situation is untenable.

As digital mammography first evolved, vendors were told to build mammography silos to maintain image integrity, said Dr. Margarita Zuley from the Elizabeth Wende Breast Imaging Clinic in Rochester, NY. But sending mammograms between facilities, moving them into a PACS, or viewing them on a different vendor's soft-copy workstation can be problematic because of the various ways they can be interpreted from system to system.

"We want to be able to pick any gantry based on our specific patient population, view the resulting images on any soft-copy workstation, store the images on any hospital PACS, and then be able to send that image out facility-wide," Zuley said.

Image presentation currently varies from display to display, image processing algorithms vary from vendor to vendor, and mammographers are confined in their choice of processing algorithm, she said.

"This is hurting our patients," Zuley said.

Citing a study by Dr. Eric A. Berns et al that was presented at the 2004 American Roentgen Ray Society meeting, Dr. Judith Wolfman, a radiologist at the Lynn Sage Comprehensive Breast Center at Northwestern University, said that although digital mammography reduced the time needed to image a patient by 33%, it actually increased interpretation time by 59%.

This longer time is like a pencil in the eye when you're reading hundreds of cases a day, said Dr. Dianne Georgian-Smith from Massachusetts General Hospital. Her experience with digital mammography led her to coin the phrase "knobology": the science of learning how to use all the knobs on new digital mammography workstations, which differ from vendor to vendor.

In addition to common toolkits, mammographers requested consistency in display. Breast images have to be presented back to back in the same size every time, and new images should appear the same way as priors, said David Clunie, chief technology officer for RadPharm.

Streamlining the entire digital mammography workflow process is an absolute requirement, according to moderator J. Anthony Siebert, Ph.D., a professor of radiology at the University of California, Davis and SCAR chair. Reducing the amount of image manipulation needed to improve efficiency of interpretation would achieve that goal.

The final 30 minutes of SCAR's five-hour digital breast imaging forum was allotted to a manufacturers' panel discussion. Representatives from more than 15 companies fielded questions from the audience.

During the session, the audience of digital mammography readers barraged vendor representatives with questions. Users expressed concern that the entire field of digital mammography may not survive if the technology does not improve rapidly.

One audience member disputed a statement made earlier in the session that there are 1328 issues in digital mammography. There are actually only four or five, she said, among them window leveling and integrity of images.

"Those are the readers' issues," she said. "I think [manufacturers] are copping out. Is this too hard?"

Another user responded to the possibility that developing mammography technologies could further inhibit workflow.

"I can't be made to work slower. We're already short-handed. We're not given the staff to keep up with reading demands. We're denied residents and fellows. I read 90 studies a day as it is. I would be there all night if workflow slows any further. We need a solution and we need it now," she said.

An IHE-like mammography-specific miniconnectathon was mentioned as one means to inspire more cooperation among vendors. The suggestion provoked a round of applause in the room. Siebert concluded the session by affirming the absolute need to streamline the entire digital mammography workflow process. Reducing the amount of manipulation of images required to improve efficiency of interpretation would be one way to achieve that goal, he said.

"This is essential if digital mammography is going to be accepted," Siebert said.

A similar crisis brought imagers and vendors together 30 years ago. A study done then, which reported that radiation introduced by mammograms may create more cancers than it catches, brought imagers and vendors together to tackle the issue of radiation dose, said Dr. Wendy Logan Young, a veteran breast imager at the Elizabeth Wende Breast Imaging Clinic. As a result, the technology quickly improved.

"We are now on the verge of a digital mammography era. There are still tremendous problems, however, and we need to disseminate that information to others," she said.