Mammography has long been a vital tool in the radiologist toolkit for breast cancer imaging. It is an essential screening and diagnostic modality for the early detection of breast cancer and has helped significantly decrease the mortality rates of the disease since it was first invented.
As technology has continued to evolve, mammography has as well: Evolving from film to digital mammography and then to digital breast tomosynthesis (DBT). Each evolution has continued to address radiologist challenges and patient concerns in hopes of improving cancer detection rates and reducing false positives, thus improving outcomes.
This evolution has led to what just might be the next advancement of breast imaging: Contrast enhanced mammography (CEM). Although it is not a new technology, as it was first developed nearly a decade ago, it has started to recently garner attention thanks to an expanding body of research that underscores its benefits over traditional supplemental imaging.
CEM utilizes the same contrast agent as computed tomography (CT) technology, to help identify lesions in breast tissue. Using the same physical imaging principles as CT and magnetic resonance imaging (MRI), the contrast agent moves throughout the breast tissue via blood flow and accumulates where lesions are forming and growing. The result is a highlighted area that stands out against the breast tissue and has been shown to provide physiological data, in addition to the standard morphological images, that can be useful for diagnosis.
Advocates for CEM argue that it couples the best elements of MRI and mammography. Studies show that CEM and breast MRI both have comparably high sensitivity in the detection of breast lesions.1 However, once CEM is more readily available, it will offer a faster2 and less expensive alternative.3 Conveniently, hospitals and clinics can utilize their existing mammography systems with the contrast agent and yield comparable results to MRI screening.
Enhance Breast Cancer Detection
While mammography has continued to evolve so it can detect more cancers earlier, there remain limitations to the technology. As an anatomical imaging system, mammography can only show so much. For women whose breast images produce inconclusive findings or identify an abnormality, CEM can be an alternative for supplemental imaging instead of MRI.
Traditionally, patients would need to schedule a breast MRI if they needed imaging that utilized a contrast agent. However, this imaging system also has its limitations, as it can be inaccessible to many women — especially those living in more rural areas or those outside the United States in countries with less MRI adoption. Even if a patient can access an MRI system, it can be costly and is not always covered by insurance. This unequal access to MRI can lead to women seeing significant delays in availability or needing to settle for inadequate supplemental screenings.
CEM can help alleviate that burden without compromising image quality, because studies have shown it provides comparable diagnostic performance.4 CEM can be performed as an alternative to breast MRI in women who are at an increased risk of developing breast cancer,5 as it uses contrast media to visualize the breast blood flow similar to that of MRI. However, CEM is a more cost-effective modality compared to breast MRI.3 At just 25% of the cost of MRI,3 CEM provides functional imaging information and highly detailed images to increase diagnostic confidence with sensitivity and specificity to help guide the clinical pathway.
For women who have consistently inconclusive results from mammography, MRI can be a costly and time-consuming supplemental screening. Since CEM has comparably high sensitivity in the detection of breast cancer as MRI,1 it can be used in place of MRI for those at high risk of cancer, such as women who have dense breast tissue.
Breast density, which is fibrous tissue, is a known risk factor for breast cancer. It appears white on a mammogram and can mask small cancers which similarly appear white, which can delay cancer detection. With nearly 50% of American women having dense breast tissue,6 there are significant concerns that this could lead to cancers being detected in later stages, when fewer treatment options are available. Contrast imaging is not adversely affected in dense breast tissue to the same degree as conventional mammography.
For some women with dense breast tissue, MRI can be utilized to help identify lesions following their annual mammograms. A recent analysis of 261,233 screened patients found that MRI is the superior modality for supplemental imaging of women with dense breast tissue in terms of cancer detection rates when compared to DBT and ultrasound.7 With the comparable high sensitivity of CEM to MRI,1 CEM can offer similar benefits for these patients, while being cost-effective.
Other protocols for CEM include evaluating the efficacy of post-neoadjuvant chemotherapy, diagnosing palpable abnormalities, investigating for satellite lesions in both breasts, and preoperative staging of patients with breast cancer.5 This enables existing mammography systems in everyday clinical practices to be used throughout the stages of the breast health journey.
CEM could be a life-saving technology. When faced with inconclusive mammography results or a cancer diagnosis, women need imaging options that provide high-quality images without accessibility barriers. While MRI can be out of reach for many, hospitals and clinics can deliver accurate results for patients with CEM using their existing digital mammography or DBT system.
Deliver a Better Patient Experience
When a patient is called back for supplemental screening, they may feel anxious about the experience. Many are apprehensive of any pain they may experience and worry about the outcomes.
There are ways for hospitals and clinics to help reduce anxiety, and CEM is one of the methods for delivering a better patient experience. When it comes to CEM versus breast MRI, patients greatly prefer contrast mammography over breast MRI for reasons such as faster procedure time, greater comfort, lower anxiety and lower noise level.8 Breast MRI requires patients to spend significant time confined in the imaging tube, experiencing excessive and jarring noises from the system while they lay in an uncomfortable position. CEM offers a faster procedure — eight to 20 minutes of imaging time versus MRI’s 30 to 60 minutes2 — so, patients experience a shorter period of discomfort.
For women who cannot utilize MRI, such as those who experience claustrophobia, CEM provides an alternative that does not compromise on quality. Since CEM has demonstrated similar sensitivity to breast MRI,9 radiologists can use this modality to deliver results that are just as accurate. Women no longer need to balance personal fears and anxieties with high-quality imaging results.
Patients who are at high risk for breast cancer, such as those with dense breast tissue, will benefit most from improved imaging. As radiologists develop a way to triage patients with CEM, it can help offer more cost-effective and time-sensitive options. By adding CEM to the imaging pathway for higher-risk patients, radiologists can divert patients from MRI for quicker imaging results, while also providing more access to those who still need MRI.
Utilizing CEM as a diagnostic tool could help patients feel less anxious about their supplemental screening experiences. Whether they are worried about pain, time or outcomes, this next frontier of mammography could address their concerns and help them receive the answers they need quicker.
Streamline Procedures
Once a lesion is discovered, time is of the essence. CEM enables radiologists to streamline patients into the biopsy procedure with contrast enhanced biopsy (CEBx).
Radiologists can continue to utilize the same contrast agent used for CEM in order to find the lesion that might be obscured on mammography alone. This biopsy technique enables radiologists to pinpoint the lesion by locating where the agent accumulates within the breast tissue, the same way they would expect for CEM. By pairing the same mammography system used for CEM imaging with upright biopsy equipment, radiologists can perform a CEBx to streamline the patient’s journey.
This familiarity with the imaging system not only helps radiologists feel more comfortable, but patients as well. Women can receive their supplemental screenings and CEBx on the same systems that are used for their annual mammograms, alleviating any anxieties about how the technology operates or concerns around visit preparation. Additionally, CEBx is a viable and attractive alternative to MRI contrast biopsy as it can be performed in a fraction of the time,10 helping to improve the overall patient experience.
When paired together, CEM and CEBx can help radiologists not only streamline their own workflow, but also the patient’s breast health journey. By reducing the time patients wait for their supplemental screening, and then potentially a biopsy, radiologists are delivering a better patient experience centered on moving forward.
While additional and larger-scale studies are needed to support full integration of CEM into breast health centers nationwide, it is a promising frontier for breast imaging. CEM is a highly sensitive, accurate imaging modality that couples morphological lesion depiction with functional imaging technology at a fraction of the cost of MRI. This new frontier in breast imaging delivers improved results over existing mammography systems, similar to those of MRI but without some of its limitations, therefore enabling breast cancer to be detected earlier. With more treatment options available for early-stage cancers, CEM and contrast enhanced biopsy could help women lead healthier lives.
Paola Wisner serves as vice president of global research and development for Hologic’s breast and skeletal health division. She has an extensive background in medical technology research and development and a track record of driving innovative and disruptive thinking across organizations.
Andrew Smith, PhD, is the vice president of imaging science for Hologic, Inc. He has been involved in medical imaging research and development for over 20 years, with a current focus on advanced breast imaging technologies such as tomosynthesis. He lectures widely around the world on breast imaging and physics, and is a co- author on over 50 patents and patent applications.
Nikos Gkanatsios, PhD, has been part of Hologic for 22 years in multiple roles within the Breast and Skeletal Health Division. In the past, he acted as head of product management and product development, bringing breast imaging and biopsy solutions to the forefront of women’s health.
References:
1. Gelardi F, Ragaini EM, Sollini M, et al. Contrast-Enhanced Mammography versus Breast Magnetic Resonance Imaging: A Systematic Review and Meta-Analysis. Diagnostics (Basel). 2022 Aug 4;12(8):1890.
2. https://www.radiologyinfo.org/en/info.cfm?pg=breastbimr
3. Patel BK, Gray RJ, A Pockaj BA. Potential Cost Savings of Contrast-Enhanced Digital Mammography. AJR Am J Roentgenol 2017 Jun;208(6): W231-W237.
4. Cozzi A, Magni V, Zanardo M, et al. Contrast-enhanced Mammography: A Systematic Review and Meta-Analysis of Diagnostic Performance. Radiology. 2022 Mar;302(3):568-581.
5. Contrast-enhanced Mammography: State of the Art, Maxine S. Jochelson and Marc B. I. Lobbes, Radiology 2021 299:1, 36-48
6. “What Does It Mean to Have Dense Breasts?” Centers for Disease Control and Prevention, 9 Mar. 2022, www.cdc.gov/cancer/breast/basic_info/dense-breasts.htm.
7. Supplemental Breast Cancer Screening in Women with Dense Breasts and Negative Mammography: A Systematic Review and Meta-Analysis, Heba Hussein, Engy Abbas, Sareh Keshavarzi, Rouhi Fazelzad, Karina Bukhanov, Supriya Kulkarni, Frederick Au, Sandeep Ghai, Abdullah Alabousi, and Vivianne Freitas, Radiology, 2023 January
8. Hobbes M, Taylor D, Buzynski S, et al. “Contrast-enhanced spectral mammography (CESM) and contrast enhanced MRI (CEMRI): Patient preference and tolerance” J Med Imaging Radiat Oncol. 2015 Jun;59(3):300-5. [Epub 2015 Apr 21].
9. Coffey, Kristen, and Maxine S Jochelson. “Contrast-enhanced mammography in breast cancer screening.” European journal of radiology, vol. 156 110513. 10 Sep. 2022, doi:10.1016/j.ejrad.2022.110513
10. GLG Survey, 2018
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