Using info from the DMIST study and publicly available data, researchers evaluated the cost-effectiveness of digital mammography screening for breast cancer using digital technology in all women would cost more than $300 000 per quality-adjusted life-year (QALY) gained. Targeting digital mammography on the basis of age or age and breast density costs $26 500 to $84 500 more per QALY gained than film mammography. Density-targeted use of digital mammography in women age 65 years or older costs $97,000 to $257,000 more per QALY gained than film. Of interest, Medicare reimburses $50 more per exam for digital mammography
Hope the CAD will aid in detection of breast cancers at an earlier stage. However, this also results in a higher rate of recall and false positives... Researchers at UCDavis reviewed screening mammograms of 222,000 women and found that with the use of CAD, 32% more women were recalled for additional tests, and 20% more women had an additional biopsy. Many of the cancers identified by CAD were localized, in situ cancers that still have an uncertain mortality risk. Furthermore, everytime CAD is used, the patient incurs additional costs for their mammogram - $15 per person according to Dr. Conwell.
Conventional film mammography uses low energy X-rays that pass through the breast and are absorbed by the film which is then developed. With digital, X-rays are recorded on a digital detector instead of film, and then projected on monitor. Mammography is the last imaging modality to use digital technology; mammography requires high resolution and contrast to produce quality images and thus development of technology to produce digital mammography is very complex, expensive, and time consuming Improving the SNR allows for decreased background noise and “cleaner” image, allowing potential for better cancer detection and less background interference Instantaneous images allow radiologists to assess quality of the image, and can reposition, magnify certain areas of interest, etc while the patient is still in office.
Study conducted in 2003 and published in 2005 DMIST: retrospective study of 49,500 asymptomatic women that compared the accuracy of digital versus film mammography in population subgroups defined by combinations of age, menopausal status, and breast density by using either biopsy results or follow-up information as the reference standard digital mamm was significantly better than film in detecting breast cancer in pre- and perimenopausal women with dense breasts younger than 50 in other subgroups, there was no significant difference in diagnostic accuracy between digital and film mammography in women over 65 with fatty breasts, there was nonsignificant trend toward improved diagnostic accuracy with film over digital
Salomon – first person to use X-ray to study breat tissue. Used X-ray to study breast tissue that had been removed from the body; found that he was able to differentiate between cancerous and benign lesions on X-ray. Did not use this in his own practice. Even with Gerson-Cohen’s published results, mammography did not begin to gain widespread popularity until later in 1960s In 12/05, RSNA held first digital mammography training and self-assessment workshop in the US
Mammography Past & Present Similar equipments were & are still being used, these can be called as old fashioned equipments cone Tube Breast Stand
Mammography In digital mammography screen-film system has been replaced by Detectors to give the digital images
Mammography Present & future CCD camera Work station Equipments look like this
Mammogram These digital mammograms are surely better in resolution & details
<ul><li>Standard views: </li></ul><ul><li>45* Medio lateral Oblique (MLO view)/ Lundgren’s view </li></ul><ul><li>Craniocaudal view (CC view) </li></ul>Left Craniocaudal Right Craniocaudal Right Mediolateral Oblique Left Mediolateral Oblique RCC RMLO LCC LMLO
LAT Left Axillary Tail LCV Left Cleavage LFB Left From Below LLMO Left Lateromedial Oblique LML Let Mediolateral LRL Left Roll Lateral LRM Left Roll Medial LLM Left Lateromedial
<ul><li>Extended CC view / Cleopatra’s view </li></ul><ul><li>Extended CC view- medial or lateral rotation </li></ul><ul><li>True Lateral view </li></ul><ul><li>Axillary view </li></ul><ul><li>Cleavage view </li></ul><ul><li>Paddle compression view </li></ul><ul><li>Magnification view </li></ul><ul><li>Eklund view (for breast implants) </li></ul>
<ul><li>Extended CC view medially rotated </li></ul><ul><li>Extended CC view laterally rotated </li></ul>
<ul><li>CONVENTIONAL CC VIEW </li></ul><ul><li>EKLUND CC VIEW </li></ul>
cost issues <ul><li>Digital mammography is expensive! </li></ul><ul><li>Using digital technology in all women would cost >$300,000 per QALY gained </li></ul><ul><li>Targeted use of digital mammography on basis of age/breast density costs ~$50,000 per QALY gained </li></ul>
Computer-Aided Detection <ul><li>Software program that highlights areas of concern on digital mammograms </li></ul><ul><li>Uses image processing algorithms and decision threshold parameters to detect features in an image likely to be of clinical significance </li></ul><ul><li>Very sensitive – detects 90% of all cancers </li></ul><ul><li>However, has a high rate of false positives (2-4 per study) </li></ul>
Instant Upgrade <ul><li>Improved signal-to-noise ratio </li></ul><ul><li>Ability to magnify, change contrast, or alter the brightness. </li></ul><ul><li>Near instantaneous image acquisition </li></ul>
Courtesy: Magee-Women’s Hospital of UPMC Digital versus Conventional
Digital Mammographic Imaging Screening Trial (DMIST) <ul><li>Retrospective study of 49,500 asymptomatic women </li></ul><ul><li>Assessed accuracy of digital vs film mammograms </li></ul><ul><li>RESULTS: </li></ul><ul><li>Digital mammography significantly more accurate in pre- and perimenopausal women under 50 with dense breasts </li></ul><ul><li>Nonsignificant trend toward improved accuracy with film mammograms in women over 65 with fatty breasts </li></ul>
A Brief History <ul><li>1913 Albert Salomon, German surgeon </li></ul><ul><li>1950’s - Jacob Gershon-Cohen began to advocate widespread use of X-rays for screening </li></ul><ul><li>December 2005 – RSNA brings digital mammography to US </li></ul>
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