Long Article

Is Contrast Mammography the Holy Grail of Breast Imaging?

Images with life-saving potential

Contrast-enhanced mammography (CEM) is groundbreaking technology for breast cancer diagnosis. It means potentially faster diagnostic tests, images with better specificity (especially in dense breasts), and an enhanced patient experience in comparison to some other breast imaging modalities.

One CEM test takes approximately 7 minutes1 to image both breasts and combines standard digital images of the breast with contrast-enhanced images made possible by the intravenous injection of an iodine-based contrast agent into the arm of the patient. When recombining these images, the technology is able to minimize the background of normal tissue from the picture.

The resulting contrast-enhanced images are remarkable. Subtracting the background information reveals areas with increased vasculature that could indicate the presence of breast cancer.2

In diagnosing breast cancer, CEM has the ability to generate images with an enormous level of sensitivity and specificity is potentially life-saving for women with an intermediate-to-high lifetime risk of breast cancer and, particularly, women with dense breast tissue.2

According to American Cancer Society, around half of women in the U.S. aged 40–59 have dense breasts, a fact that puts them at higher risk of breast cancer than other women.3 This increased risk has led some states in the U.S. to mandate that patients whose mammograms indicate dense breasts be informed in their mammogram summary report, to alert them of their potentially higher risk of developing breast cancer.3 It’s estimated that more than 50 percent of women have high breast density.6 Dense breasts are of particular concern in Japan where a relatively large number of women in their 40's have high-density breasts, yet they are often not informed by their clinicians of the association between breast density and the risk of developing of breast cancer.7

Along with an increased risk, dense breast tissue is also more difficult to evaluate on a mammogram.3 But CEM provides the ability to distinguish dense, normal tissue from suspicious areas with high accuracy and specificity than other imaging modalities, potentially creating a new benchmark in breast cancer detection.

CEM in diagnostics

CEM, pioneered by GE Healthcare and known as CESM, was cleared in 2011 by the U.S. Food and Drug Administration (FDA) for supplementary diagnostic use.4 CEM diagnostic use is supported by numerous studies where CEM had statistically significant sensitivity and specificity in depicting cancerous tumors in comparison with mammography alone, or even mammography and ultrasound combined.4 And in breast cancer diagnosis and treatment planning, CEM has estimated tumor size and disease extent for staging with better accuracy than standard mammography and comparable to magnetic resonance imaging (MRI).4

As a diagnostic tool for breast cancer, CEM offers some significant benefits compared to MRI, including faster imaging and interpretation, less audible noise, and improved patient comfort, particularly for patients with claustrophobia.2 Access to the exam may also be quicker and easier compared to other imaging modalities when patients have to wait several weeks for an appointment, and then more time to wait for the results. With CEM, appointments are much more accessible, and results are delivered with the same speed as traditional mammography. All these factors can translate into less patient anxiety and shorter wait times, all leading to potentially more efficient and effective procedure with high satisfaction reported among patients and clinicians when compared with MRI with contrast (CEMRI).2

CEM and supplemental screenings

When assessed against conventional digital mammography, studies suggest that CEM offers superior clinical results in women and may decrease false negatives. That alone makes CEM a potentially life-saving diagnostic tool for some women.3

Women with hereditary risk factors for breast cancer are often recommended MRI as a first-line screening. Yet, MRI does not always provide the specificity needed to rule out contrast uptakes not related to breast cancer, sometimes leading to additional imaging, biopsies, and increased levels of anxiety and waiting times for patients.5

While CEM may enhance some benign breast masses, which can also lead to false-positive findings, CEM provides high specificity to reduce false-positives and help prevent unnecessary exams. Some study data suggest that patients prefer the experience of CEM to CEMRI, adding support for the role of CEM as a possible alternative to CEMRI for breast cancer staging.4,2

Future considerations for CEM

The growing body of evidence supports the significant accuracy, ease of use, and life-saving potential of CEM, particularly in women with an increased risk of breast cancer. To these women and their healthcare providers, CEM offers a potential new holy grail in breast cancer diagnosis and should be considered for expanded clinical use along the breast cancer care pathway.

 

 References

  1. Data on file GE Healthcare 2017
  2. The Future of Contrast-Enhanced Mammography, American Journal of Radiology, February 2018. https://www.ajronline.org/doi/full/10.2214/AJR.17.18749 Accessed August 2, 2019.
  3. Breast Density and Your Mammogram Report, The American Cancer Society,© 2019. https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html Accessed August 2, 2019.
  4. Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting, American Journal of Roentgenology, January, 2019. https://www.ajronline.org/doi/full/10.2214/AJR.17.19265 Accessed August 2, 2019.
  5. Digital mammography isn't perfect. Here are the top alternative approaches to breast cancer screening. The Advisory Board, January, 2018. https://www.advisory.com/research/imaging-performance-partnership/the-reading-room/2018/01/breast-cancer-screening Accessed August 3, 2019.
  6. Dense Breast Tissue: What It Means to Have Dense Breast Tissues. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/mammogram/in-depth/dense-breast-tissue/art-20123968. Accessed March 12, 2020.
  7. Cancer and Breast Density: What Are Doctors Withholding? Japan Times. https://www.japantimes.co.jp/news/2017/10/25/national/science-health/cancer-breast-density-doctors-withholding/#.XmvUM5NKiu6. Accessed March 12, 2020.

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