0:02

Hello, and welcome to today's Noon Conference co-presented

0:05

by Modality and A A WR.

0:08

The A A WR was founded in 1981 to provide a forum

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for issues unique to women in radiology, radio,

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radiation oncology, and related professions.

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The association sponsors programs that promote opportunities

0:21

for women and facilitates networking among members

0:24

and other professionals.

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A A WR has membership opportunities for those

0:29

who have completed their training.

0:30

Members in training

0:32

and international radiologists learn more about their

0:35

mission and membership@a.org.

0:38

We're thrilled to partner with A A WR on these lectures

0:42

as part of our shared commitment to advancing

0:44

and supporting women in radiology

0:46

and transforming the way radiologists learn and thrive.

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Today, we are honored to welcome Dr. Amy K. Patel

0:53

for a lecture entitled Breast Density Insights

0:56

and Cases from Past, present, and Future.

1:00

Dr. Patel is a board certified breast radiologist medical

1:03

director of the Breast Care Center at Liberty Hospital

1:06

and Associate professor of Radiology at the University

1:10

of Missouri, Kansas City School of Medicine.

1:13

She's immediate past present president of A A WR

1:17

and is actively engaged in numerous societies, publications,

1:20

and speaking engagements.

1:22

Dr. Patel is passionate about women's health advocating

1:25

for equitable breast care,

1:26

and expanding access to care for all patients.

1:29

And we're so glad she's here today to share her expertise.

1:32

At the end of the lecture, please join Dr. Patel in a q

1:35

and a session where she will address questions you may

1:38

have on today's topic.

1:39

Please remember to use the q

1:41

and a feature to submit your questions so we can get to

1:43

as many as we can before our time is up.

1:45

With that, we are ready to begin today's lecture.

1:48

Dr. Patel, please take it from here. Thank

1:51

You very much for having me today.

1:53

I really appreciate it.

1:55

Um, I'm going to go ahead and turn off my video to

1:58

and share my screen as I have a lot of content

2:01

and there's a lot to get through.

2:02

And then at the end, we'll leave some time for a q and a.

2:05

If you have any questions, I'll turn my video back on.

2:08

So today I'm going to talk about a really hot topic, uh,

2:12

particularly in the field of breast imaging, uh, not just,

2:15

you know, in the United States due

2:16

to some recent developments with the FDA

2:20

and Mammography Quality Standards Act,

2:22

but really all over the world.

2:23

So we're going to talk about breast density today,

2:26

and we'll talk a little bit about, you know, how did we get

2:29

to this point with breast density, where we're going,

2:31

where we are now.

2:33

Uh, and again, if you have questions at the end, happy

2:35

to try to answer them to the best of my ability.

2:39

These are my disclosures.

2:42

So today we'll talk, analyze the origins

2:45

of the Mammography Quality Standards Act,

2:46

including its current state.

2:48

We will evaluate the future

2:50

of MQSA regulations when it comes

2:53

to breast density reporting.

2:54

We'll develop a comprehensive understanding about breast

2:57

density, including supplemental screening modalities

3:00

and guidance on communication with patients

3:02

and referring providers.

3:04

Analyze potential implications about breast density

3:07

legislation and federal regulations

3:09

that may have on patients

3:11

and practices, uh, including insurance coverage,

3:14

possible disparities as well,

3:16

and discuss some maybe educational opportunities

3:19

that we could all impart regarding breast density.

3:22

So what is breast density?

3:24

So breast density refers to the attenuation

3:26

of the X-ray beam in concert to the degree

3:29

of breast fibro glandular tissue.

3:32

So we know that there are four categories, uh,

3:35

of breast density that we report,

3:37

and I will go over those in just a moment.

3:40

And basically when we make that determination,

3:43

it's categorized on the basis of the densest area of tissue,

3:46

which could obscure a lesion.

3:48

Now, there are those in the field

3:50

that are subjectively looking at the breast

3:52

and giving one of the four assessments, but the now there

3:56

and has been for a few years now, software

3:59

that calculates volume density, uh, percentages to take away

4:03

that subjectivity in assessing breast density.

4:07

So this is a fatty breast, uh, as many of you know.

4:10

So, uh, whenever we report, uh, an exam, uh,

4:14

and a patient has a fatty breast, obviously, uh,

4:17

we use the birads vernacular

4:19

and the language we use is the breasts are almost entirely

4:22

fatty, and mammography is highly sensitive in the setting

4:25

of a fatty breast, so about 88%.

4:28

So we know that on mammography, the dense,

4:32

the breast density or the dense breast tissue looks more

4:35

white on the mammogram and fat is more gray.

4:37

So you can see here that, you know,

4:40

we have a lot of gray here.

4:41

So if there is a cancer that is going to be, uh, you know,

4:44

popping up here, we're more likely to see it

4:46

because there's less of that dense tissue

4:48

or that white on the mammogram.

4:50

Uh, fatty breast density comprises about 10%

4:54

of the general screening population of United States women.

4:58

Then scattered, uh, is where we report.

5:00

There are scattered areas of fibro glandular tissue.

5:02

So now we're starting to get more wisps of the dense tissue

5:05

or the white on the mammogram.

5:07

This comprises about 40% of women

5:10

of the general screening population of United States women.

5:13

There are heterogeneously dense breast tissues

5:15

where now we're starting to see

5:17

that more white on the mammogram,

5:18

more fibro glandular tissue.

5:20

And the language we report are the breasts are

5:22

heterogeneously dense, which may obscure small masses.

5:24

This comprises about 40% of the general screening population

5:28

of United States women.

5:30

And then we have extremely dense,

5:32

where the breasts are extremely dense,

5:34

which lowers the sensitivity of mammography.

5:36

So you can imagine if you're looking at a mammogram

5:39

and you see this very dense breast, you see all

5:41

of this white, it can be really hard to see a cancer.

5:44

And whether it's a 2D mammogram

5:46

or digital breast tomosynthesis

5:48

or a 3D mammogram, it still could be hard

5:50

to detect a cancer in the sea of dense tissue.

5:53

This is the sensitivity.

5:54

Uh, the sensitivity

5:56

of mammography in this category is the lowest, about 62%.

6:00

This comprises about 10%

6:02

of the general screening population.

6:05

So this kind of shows the four categories, fatty, scattered,

6:08

heterogeneously dense, and extremely dense.

6:11

Now, about 50%

6:12

of the female population in the United States over the age

6:16

of 40 have dense breasts.

6:17

So a significant number do most patients in the

6:20

United States fall between these two categories in the

6:22

middle, scattered and hetero.

6:24

But about 50% of women do have dense breasts.

6:27

So it is very prevalent.

6:30

So we've already, uh, talked about this,

6:32

but as the sensitivity of mammography, um,

6:35

it essentially decreases as the density

6:37

of the breast increases.

6:39

So that's why your sensitivity is lowest in an

6:42

extremely dense breast tissue.

6:43

And it's important to note too,

6:45

and we'll get into the weeds about breast density

6:47

and being a risk factor for breast cancer.

6:50

But if you are a woman who has a fatty breast on this, uh,

6:53

end of the spectrum versus a woman with a, uh,

6:56

extremely dense breast on the opposite end of the spectrum,

6:59

your risk of breast cancer is four

7:00

to six times higher than the patient with a fatty breast.

7:03

So, like I like to say, breast density matters.

7:07

So after a certain, uh, age

7:09

and genetic mutation carriers, uh,

7:12

or certain genetic mutations such

7:14

as BRCA breast density is the biggest risk

7:17

factor for breast cancer.

7:19

So breast density matters.

7:21

So we feel that this, uh, you know, the science

7:24

of this is cumulative exposure to growth factors

7:27

and hormones in areas of high mammographic density.

7:30

Uh, they may stimulate increased cell division

7:32

and epithelial and non epithelial cells,

7:35

which may explain the increased risk, uh, of breast cancer

7:38

that we see in these women with higher ratio

7:40

of fibro glandular tissue, uh, comparative, uh, comparing,

7:44

uh, or comparatively speaking

7:46

to fatty breast tissue on mammography, we know

7:49

that high breast density is associated

7:51

with a larger tumor size, high histologic grade,

7:54

lymphovascular invasion, more advanced stage

7:57

and positive lymph nodes.

7:59

There's also the masking effect of breast cancers

8:01

that also contributes to increased risk,

8:03

where we see dense tissue, the cancer is hiding,

8:05

we're not able to identify it.

8:07

And then there's a lot of great research on breast density

8:10

actually happening around the country,

8:12

but particularly at Washington University in St.

8:14

Louis. And, um, they have recent research, uh, revealing

8:18

that younger women with a family history

8:20

of breast cancer are at higher risk of developing breast,

8:23

uh, dense breast tissue and mammography meaning higher risk

8:26

of developing breast cancer.

8:29

We also are finding, finding that twin studies support

8:32

that mammographic density is heritable.

8:36

Um, and there was an, uh, article from Boyd

8:38

and colleagues that showed that correlation

8:40

between monozygotic twins was approximately twice

8:43

as strong compared to that between dizygotic twins.

8:47

Uh, genetic factors explain the majority

8:49

of variation in breast density in their study

8:51

with heritability estimated to be as high as 75%.

8:56

Brand colleagues also demonstrated that at least 25%

8:59

of the variants of mammographic vol, uh,

9:01

volumetric mammographic density is explained

9:04

by common genetic variants.

9:06

So we are seeing a genetic predisposition to breast density.

9:10

So this leads me to supplemental screening and modalities.

9:14

So why, you know, are we, uh, in the field

9:17

of breast cancer talking about trying

9:19

to improve supplemental screening and, you know, suggesting

9:22

or encouraging patients to do it?

9:24

Why? Well, we've already talked about it

9:26

as the breast density increases,

9:28

particularly on mammography, the sensitivity decreases.

9:33

And so dense breast is a major limitation of mammography,

9:36

whether you have fulfilled digital mammography

9:38

or 2D mammography or digital breast tomosynthesis and

9:40

or 3D mammography.

9:42

And we've talked about the mammographic density

9:45

is a independent risk factor for breast cancer.

9:48

So there's supplemental screening tools out there,

9:49

which we'll talk about.

9:51

Uh, the first one is digital breast tomosynthesis,

9:53

or 3D mammography, which isn't really considered

9:55

supplemental now, uh,

9:57

but nevertheless, uh, ultrasound MRI, but full

10:01

and abbreviated protocols, molecular breast imaging

10:03

and contrast enhanced mammography.

10:06

So currently many of us know

10:08

that there's robust research out there that demonstrates

10:11

that digital breast chemosynthesis improves cancer detection

10:14

rates while reducing false positive and recall rates.

10:17

The American College of Radiology has also deemed DBT

10:20

as no longer investigational.

10:22

Uh, we know the advantages, many of us who, uh,

10:24

are breast radiologists who are interested in the field

10:27

of breast imaging, where on digital breast tomosynthesis,

10:31

we do have better delineation of margin, lesions

10:34

of a lesion margins, rather, uh,

10:36

there is a reduction in the recall rate.

10:38

We're seeing a higher positive predictive value,

10:41

a lower number of unnecessary biopsies,

10:43

and then also less breast compression than 2D mammography,

10:47

which patients really like in terms of the comfort factor.

10:51

Um, and you know, we know that, uh, particularly, um,

10:56

the recall rate reduction has been wonderful so

10:59

that women don't have to come back for additional imaging,

11:01

uh, due to a finding that, you know, initially was likely,

11:05

you know, superimposed overlapping breast tissue

11:07

that we would, you know, see a lot, particularly in the era

11:11

of fulfilled digital mammography or 2D mammography.

11:14

The disadvantages have really improved

11:16

with the new iterations of digital breast.

11:18

Tomosynthesis artifacts used to be, uh,

11:21

an issue which have really improved, uh, particularly with,

11:25

um, what were called pseudo calcifications,

11:28

where we would see, uh, the

11:30

what could be calcifications on the screening mammogram.

11:32

The patient comes back for additional views,

11:34

the calcifications aren't there

11:36

'cause they were not real in the first place.

11:37

That's really improved with the new iterations of DDBT.

11:41

The scan time has also significantly been reduced

11:45

to be comparable to a 2D mammogram.

11:48

Um, so, you know,

11:49

the disadvantages have definitely improved, uh,

11:51

from a patient standpoint.

11:53

Um, longer interpretation time for radiologists, yes,

11:56

they typically do take longer,

11:58

but now there are systems out there where instead

12:00

of one millimeter slices, there's now six millimeter slices

12:04

with two to three millimeter, uh, overlap without loss

12:07

of image integrity, which can also help

12:09

with the interpretation time.

12:11

So how is DBT covered?

12:13

Uh, screening, uh, covered by insurance?

12:15

So all states cover DBT through Medicare currently.

12:19

Medicaid covers DBT in most states.

12:22

And then private insurance coverage is now covering,

12:24

uh, in many, many states.

12:27

And we were fortunate in Missouri to pass, uh,

12:29

DBT legislation for screening back in 2018.

12:35

So switching gears to whole breast ultrasound

12:37

or automated, uh, breast ultrasound.

12:41

So, um, you know, this modality of ultrasound has been shown

12:45

to catch slightly more cancers, but also has a higher recall

12:48

and false positive rate,

12:50

and there really needs to be more randomized controlled

12:52

trials to prove the efficacy of screening Ultrasound Akron.

12:56

6 6 6 6. A study showed incremental cancer detection rate

13:00

of about two to three per 1000,

13:02

but twice as high recall rate as mammography

13:05

and a lower positive predictive value than mammography.

13:09

And then adjunct ultrasound resulted in biopsy in 5%

13:12

of women compared with 2% referred for biopsy

13:15

based on mammography alone.

13:17

And then only 7.4%

13:19

who actually underwent a biopsy were found to have cancer.

13:22

3.2 occult cancers were found in a study, uh,

13:26

per 1000 screens after Connecticut 9 41 passed.

13:30

Uh, however, that was a bit, uh, skewed in those results

13:34

because they used a mixed population, uh,

13:36

with both screening and diagnostic.

13:38

And so you're gonna have a higher probability malignancy if

13:41

you have a mixed population than just screening alone.

13:44

So wider gerden colleagues revealed whole breast ultrasound

13:47

for women with mammographically normal,

13:49

but dense breast yielded about 3.8 cancers per 1000 screens

13:54

a PPV of 9% and a specificity of 96%.

13:59

So ultrasound is less costly than mammography.

14:02

There's no involvement of radiation.

14:04

Uh, however, it, it can be very time consuming,

14:06

particularly if you are, uh, a facility

14:09

that offers whole breast screening ultrasound

14:11

that's handheld that the technologist does, uh, can,

14:15

you know, obviously take more time to perform the exam.

14:17

There's additional cost associated with that, uh,

14:20

and high frequency of short-term followup recommendations.

14:24

So this is a case of a 58-year-old, uh,

14:27

with a palpable on the left breast.

14:29

You can see here the ma the patient has heterogeneously

14:32

or may, some may say extremely dense breast tissue.

14:35

You can't see, um, really, you know,

14:37

nothing's really glaring at me in terms of a malignancy.

14:40

And then the patient ended up having

14:42

a diagnostic ultrasound.

14:43

And you can see here that there's a conglomerate masses

14:46

here, a regular hypo coke masses greater than five

14:49

centimeters in size at 12 o'clock of the left breast,

14:52

three centimeters from the nipple,

14:54

a patient underwent ultrasound, core biopsy

14:56

and pathology yielded invasive mammary carcinoma and DCIS.

15:02

So switching gears now to full breast MRI.

15:05

So full breast MRI has a length theater protocol.

15:08

It does vary per institution.

15:10

A patient may not be covered

15:12

by insurance even if they're above average risk.

15:15

So there's many states now

15:16

that have passed high risk breast imaging legislation,

15:19

and with that supplemental screening is covered such

15:22

as those patients who want full breast MRI or ultrasound,

15:25

but not all states are covered.

15:27

Um, so it does vary significantly even per institution

15:31

and geographically in terms of what's available

15:34

to the patient as well.

15:36

So breast MRI, however,

15:37

has the highest cancer detection rate

15:39

of all breast imaging exams across all

15:41

breast density categories.

15:42

It's very sensitive. Uh, breast MRI can really see past

15:46

that dense breast tissue that we aren't able

15:49

to see past at times on mammography and on ultrasound.

15:52

Although most evidence demonstrates using breast MRI

15:55

for screening the highest risk patients,

15:57

there is increasing evidence

15:58

that MRI is useful in screening women who are average

16:02

or intermediate risk.

16:03

And so this hence the advent of abbreviated breast MRI,

16:07

which I'll talk about in subsequent slides.

16:10

So abbreviated breast MRI was introduced

16:12

to reduce complexity

16:14

and cost of the full MRI equating to access.

16:17

Uh, so multiple studies have confirmed equivalent diagnostic

16:21

accuracy of abbreviated to full, uh, MRI protocols.

16:25

And so this has really led

16:26

to abbreviated breast MRI being utilized for those

16:29

with dense breasts, particularly of average

16:32

or intermediate risk for breast cancer.

16:34

So abbreviated breast MRI is a brief screening examination

16:38

that can be used to supplement annual screening mammography,

16:40

particularly for those with dense breast tissue.

16:44

And it's important to remember

16:46

that abbreviated breast MRI is a supplemental screening tool

16:49

and it compliments, it does not replace a mammogram.

16:52

And we know this, why,

16:54

because, you know, on mammogram we might see findings

16:58

that we might not be able to catch on MRI, for example,

17:01

subtle microcalcifications

17:02

and an early grade DCIS that may not be seen on MRI.

17:06

Alternatively, on MRI, we might say, see a little focus

17:10

of enhancement that ends up being an invasive cancer

17:13

that we would not have seen on mammography

17:15

until it was much larger.

17:16

But in the end, abbreviated breast MRI is a supplemental

17:19

screening exam that compliments mammography.

17:21

Mammography is the only screening tool that

17:27

to lower breath breast cancer death rates.

17:32

So with the basics with a brev of breast MRI,

17:34

it relies solely on, on one pre

17:36

and one post contrast sequence.

17:38

So we have, you know, less information than a full MRI,

17:40

but we still have pre and post contrast sequences.

17:44

So we can create a subtraction sequence,

17:46

which can really help us aid in seeing, you know,

17:49

if there is something suspicious on MRI.

17:52

Uh, it has been developed, uh, to reduce scan time,

17:54

interpretation time,

17:55

and make breast screening more accessible and affordable.

17:58

Like we talked about. Um, there is a lack

18:01

of delayed post contrast series

18:03

that limits conventional kinetic analysis,

18:05

but there are, uh, certain things that you can work on

18:08

with your vendor to create a kinetic component, uh, so

18:11

that you have some sort of kinetic analysis

18:13

to help you aid in your, uh, diagnosis.

18:18

So looking at abbreviated breast MRI

18:21

and ECOG Akron 1141, uh, looking at eight studies,

18:24

the abbreviated breast MRI sensitivity was 95% versus full

18:29

MRI sensitivity of 98%.

18:30

So very, very commensurate.

18:33

And then the dense trials,

18:34

which are randomized controlled trials

18:36

that study the effects

18:37

of supplemental breast MRI on the incidents

18:40

of interval cancers in women

18:41

with extremely dense breast tissue.

18:43

Uh, looking at trial one supplemental MRI screening in women

18:47

with extremely dense breasts,

18:49

not only yielded 16.5 cancers not detected at mammography

18:53

per a thousand exams,

18:54

but significantly lowered the interval cancer rate trial.

18:58

Two, incremental cancer detection rate

19:00

of MRI over mammography in the second round

19:02

or the incidence round was lower than

19:05

that in the first round or the prevalence round.

19:07

And the false positive results were also lower.

19:10

Uh, and trial three is currently underway.

19:14

So the abbreviated breast MRI protocol, it ranges, uh,

19:18

time-wise depending on your institution.

19:20

At our institution,

19:21

our abbreviated breast MRI protocol is approximately

19:24

11 uh, minutes.

19:26

And patients who benefit are the ones who are average

19:29

or intermediate risk with dense breast tissue,

19:32

as I talked about before.

19:33

However, we do have some patients that, you know, still,

19:36

even though we didn't pass

19:37

above average risk breast imaging legislation in Missouri in

19:40

2020, they may not have insurance through Missouri.

19:44

And so those patients may still be denied

19:46

by their insurance carrier if they don't cover breast MRI

19:50

in patients who are high risk.

19:51

So sometimes we'll have patients call

19:53

and say, you know, I'm a high risk, I want the MRI,

19:55

my insurance is denying it.

19:56

And then in those situations we may say, you know, you know,

20:00

we'd rather you have MRI than not have it.

20:02

So we can, you know, make concessions

20:04

and have you do the abbreviated breast MRI, uh, you know,

20:07

so you have that access to some sort of, of MRI.

20:11

However, we still strive for those patients who are

20:13

above average risk to receive the full MRI alternating

20:16

with mammography every six months per a CR

20:19

and NCCN screening guidelines.

20:21

However, abbreviated breast MRI, uh, you know,

20:24

like I mentioned, it can be really cost

20:26

effective for access.

20:28

Um, and you know, currently,

20:29

unfortunately in the United States,

20:30

abbreviated breast MRI does not have a billable code.

20:33

So if you do try to, uh, push this through insurance, uh,

20:38

usually, uh, people will submit the claim

20:41

with a g modifier code attached.

20:43

So there's sort of like a, a discounted, uh, uh, you know,

20:47

aspect to this given that it's not a full MRI,

20:49

but it's very hit or miss for reimbursement.

20:52

So most institutions right now offer abbreviated breast

20:56

MRI as a cash pay,

20:58

and many institutions offer it as at a lower cost just

21:01

to cover the cost of the contrast

21:03

and the labor adjust so that patients,

21:05

you know, have access.

21:07

So abbreviated breast MRI ranges from $250 the United States

21:11

to, uh, we, uh, we, um,

21:14

at our institution charge 325.

21:16

There are other institutions that charge 400 500.

21:19

So that's huge, you know, kind of the range about, you know,

21:22

th 250 to $500 typically.

21:27

So, like I mentioned previously,

21:29

multiple studies have now demonstrated similar cancer

21:32

detection rates to full breast MRI of approximately 15.5

21:36

to 18.1, uh, per 1000 exams opposed to 3D mammography alone,

21:40

which is about four to six per 1000 exams.

21:44

Um, a recent article from Weinstein

21:46

and colleagues reported a cancer detection rate

21:48

of 27.4 per 1000 in women with dense breasts

21:52

and a negative DBT exam.

21:54

So that's very, very high in showing the power

21:56

of the sensitivity of this examination.

22:00

So some institutions have developed robust MRI high-risk

22:04

screening programs with the use of abbreviated breast MRI.

22:07

However, you know, as the field implements wider use

22:10

of this tool, a standardized abbreviated breast

22:13

MRI protocol truly is needed.

22:15

So future steps will likely include development

22:17

of universal abbreviated breast MRI protocols, as well

22:21

as quality measures and guidelines.

22:24

So when we look at pros

22:25

and cons of MRI, you know,

22:26

MRI is more sensitive in detecting cancers than mammography

22:30

and mammography and ultrasound.

22:32

It is not limited by breast density, which is huge.

22:34

There is no involvement of radiation.

22:37

It preferentially detects higher grade lesions.

22:39

However, with MRI, there is a higher recall rate.

22:43

Um, so Akron six, six, six six study.

22:45

It showed, uh, 14.7, uh, per 1000 cancers found.

22:50

However, a high false positive rate, 7%

22:53

of women in the study had a biopsy based in MRI alone

22:55

with a cancer detection rate of about 18.6%.

22:59

There's a need for IV contrast material,

23:02

and of course, um, it is less tolerated, particularly if,

23:06

uh, the patient has a full breast MRI,

23:08

it can be quite challenging for a patient

23:10

to lay on their stomach depending on how long

23:12

that full MRI protocol is at the institution,

23:14

they might be claustrophobic.

23:16

It's just, you know, an uncomfortable position to be in.

23:21

So this essentially, uh, compares the full protocol MRI

23:25

to abbreviated breast MRI

23:27

and just particularly demonstrating

23:29

that the sensitivity is very commensurate across multiple

23:32

studies in the literature.

23:35

So this is a 30 5-year-old high risk female.

23:38

She presented for screening MRI.

23:39

She had a neg negative mammogram,

23:41

and here you see in her left breast,

23:43

she has a conglomerative masses, uh,

23:45

and the patient underwent second look Ultrasound,

23:48

we found the masses ultrasound guided cornal biopsy was

23:51

performed and pathology yielded IDC and DCIS,

23:54

but not seen on the mammogram.

23:58

So switching gears now to MBI or molecular breast imaging.

24:02

So MBI uses small gamma cameras in a mammographic

24:05

orientation to provide high

24:07

resolution functional images of the breast.

24:10

So TECHNIUM 99 M system maybe is currently being utilized,

24:13

um, as it's an approved agent for breast imaging.

24:16

So the advantages are high

24:18

or increased sensitivity when combined

24:20

with screening mammography versus mammography alone,

24:24

and a higher sensitivity for detecting small breast lesions,

24:27

about 82% for lesions less than 10 millimeters in size.

24:31

The disadvantages are a high radiation dose

24:33

with the injection of TECHNIUM 99 M

24:36

tibby compared to mammography.

24:38

So when you look at a, the effective dose

24:40

from 20 millicuries of TECHNETIUM 99 m,

24:43

it's about 6.5 milli seavers.

24:46

But by comparison, screening mammography is about 0.721,

24:50

uh, milli seavert.

24:51

So the whole body dose in one visit,

24:55

having MBI is non negligible, whereas

24:58

with mammography, it is negligible.

25:00

It is a long, um, there is a long imaging time.

25:03

So the patient is, four views are obtained just like a

25:06

mammogram, but each view, the patient is in compression,

25:09

uh, for 10 minutes.

25:10

So it is a bit longer, uh, much longer than the seconds for

25:14

that you undergo when you undergo a mammogram.

25:17

And it ispor poorly covered by insurance currently.

25:22

So this is a case of a fi 43-year-old high-risk female.

25:25

She had a negative mammogram

25:26

and you know, you can see here

25:27

she's pretty scattered density.

25:29

She's not particularly dense, but it was called negative.

25:32

And the patient had a subsequent MBI exam

25:35

and there was a focus of increased uptake here in the

25:38

central left breast.

25:39

So the patient had a second look ultrasound,

25:41

you can see here, a one by 0.7

25:43

by one centimeter irregular hypo coke mass

25:45

with mi micro lobulated margins.

25:47

It has an anti-parallel orientation.

25:50

The patient underwent an ultrasound guided of corneal biopsy

25:52

and pathology, demonstrated invasive mammary carcinoma

25:55

with mixed ductal and lobular features grade two of three.

26:00

This is another case of a patient, uh, who underwent,

26:03

uh, a mammogram.

26:05

Um, and you can see here that there's nothing, uh,

26:08

that you really pops out at you.

26:10

Patient ended up having MBI,

26:12

and you can see here

26:13

that there's increased radiotracer accumulation.

26:17

The patient ended up having 11 centimeters of disease

26:20

and biopsy was performed.

26:22

Uh, after a second look, ultrasound revealed the masses

26:27

and this came back invasive lobular carcinoma.

26:31

So switching gears now to contrast enhanced mammography.

26:34

It's an additional vascular based imaging modality

26:37

that improves cancer detection

26:39

by identifying the angiogenic effects

26:41

associated with tumor growth.

26:43

So there's a, you know, there's more mounting evidence

26:45

that CEM demonstrates improved diagnostic performance

26:48

characteristics compared to digital mammography alone

26:51

with better lesion detection

26:52

and improved sensitivity and specificity.

26:55

So the pooled sensitivity and specificity estimates for CEM

26:58

and the diagnosis of breast cancer are 0.89

27:01

and 0.84 respectively.

27:03

Um, some and colleagues demonstrated improvements in

27:07

sensitivity specificity,

27:08

and a negative predictive value in the screening setting.

27:11

In 858, women with at least one year of follow-up

27:14

and six of 14 cancers were detected only due

27:17

to contrast enhancement.

27:20

So the availability also

27:22

of contrast enhanced mammography provides an alternative

27:25

screening method for women who may meet guidelines

27:27

to receive breast MRI, uh, particularly like,

27:30

let's say from high risk groups,

27:32

but might have a contraindication to having an MRI.

27:35

So maybe they have a metallic implant,

27:36

they have weight limitations, they're just claustrophobic.

27:39

Uh, CEM can also be useful for, uh,

27:42

just any diagnostic dilemmas you might have.

27:45

Let's say there's a patient also that has a history

27:48

of breast breast cancer.

27:49

You've just diagnosed them. She really needs a breast.

27:51

MRI for extent of disease.

27:53

She can't, um, handle the, uh, exam.

27:55

We need to know if there's any other disease

27:58

in the affected breast, the contralateral breast.

28:00

So CEM can be a great alternative in that situation as well.

28:04

Current generation mammography systems are often, uh,

28:07

delivered with, uh,

28:08

contrast enhanced mammography capabilities as well

28:10

as biopsy capabilities.

28:12

And that really alleviates equipment acquisition costs

28:15

and space allocation needs.

28:17

Uh, but the primary issue related

28:19

to implementation includes creating efficient systems

28:22

and operational workflow, uh, to administer

28:25

IV iodinated contrast safely.

28:29

So this is just a summary of all

28:32

of the supplemental tools from ultrasound

28:34

and MBI, uh, contrast enhance mammography and full MRI

28:39

and abbreviated breast MRI, uh, really looking at, uh,

28:43

you know, the cancer detection rates, uh, in, in these,

28:46

and just comparing them

28:47

and the false positive recalls as well.

28:53

So when we look at supplemental screening tools, you know,

28:56

we have to look at potential adverse outcomes.

28:59

Um, now, you know, there's always that debate

29:01

of overdiagnosis and overtreatment.

29:03

You know, are we finding cancers

29:05

that if we didn't find they would remain, you know,

29:08

dormant in the breast, they wouldn't grow and

29:11

otherwise the patient would never know they had a breast

29:13

cancer and they wouldn't have died from that breast cancer.

29:16

Well, the argument that many

29:17

of us have is if there is a breast cancer in the breast,

29:21

we don't know which cancers are going

29:23

to be more biologically aggressive than others.

29:25

So it's hard to say, you know, just leave

29:28

that cancer alone that's in the breast.

29:30

You really need a tissue diagnosis.

29:31

There needs to be intervention to know

29:34

what you're dealing with with the cancer.

29:35

So, you know, the overdiagnosis

29:37

and overtreatment has kind of been, um, you know,

29:40

in our field sort of debunked over the years.

29:43

Uh, although we still, uh, is a hot it, it's a hot debate,

29:47

you know, in the field of medicine in general,

29:49

false positives, I think we've improved that.

29:52

You know, we still see false positives with MRI

29:54

and with ultrasound, but I think that that's significantly

29:57

improved just with the quality of imaging we now have today.

30:01

Uh, patient anxiety, um, is also something

30:04

that we always consider,

30:06

but we know that, you know,

30:07

of what's published in the literature that usually

30:09

that patient anxiety is short-lived just the cost

30:13

of additional screening, though.

30:14

I mean, that is something

30:15

to consider both monetary and labor costs.

30:18

We know there's a shortage of radiologists in this country,

30:21

uh, technologists in this country, uh, who are available

30:24

for supplemental screening for every woman

30:26

with dense breasts.

30:28

And for example, after the New Jersey dense breast

30:30

legislation was passed, there was 176

30:33

to 335% relative increase in screening breast ultrasound.

30:37

And the increased direct costs

30:38

for insurers increased from 4.9 million

30:41

to 9.8 million, um, uh, per month.

30:44

And that was as reported back in 2015.

30:48

So switching gears now to breast density legislation.

30:53

So, breast, uh,

30:54

density legislation began with Nancy Capello.

30:57

Uh, she was the former chief

30:59

of special education in Connecticut.

31:02

She was informed she had stage three breast cancer

31:04

after normal mammogram.

31:06

She was told she, she was not told

31:08

that she had dense breasts.

31:09

So the den movement was established by her in 2008

31:13

and her husband as well as a grassroots advocacy effort.

31:16

And in October, 2009, Connecticut passed public nine, uh,

31:21

public Act 9 41, which required radiologists

31:23

to communicate breast density information to patients

31:26

for both screening and diagnostic examinations.

31:29

And then from 2005 to September 9th of this year,

31:32

39 states in the District of Columbia enacted some form

31:36

of breast density legislation

31:38

or breast imaging that included, uh,

31:41

breast density language in various forms.

31:43

So it varied all across the country, um,

31:46

anywhere from discussing the percentage of women

31:48

that have dense breasts explaining how dense breasts can,

31:50

obscure masses, encouraging dialogue between the patient,

31:54

um, and her primary care provider

31:56

regarding supplemental screening

31:57

and speaking directly with the radiologist

31:59

who interpreted the mammogram.

32:01

But this legislation did not require states

32:05

to notify a patient of whether they did have dense breast

32:08

tissue or didn't have des dense breast tissue.

32:11

So we passed breast density legislation in 2015.

32:15

Um, this was, you know,

32:16

before my, uh, clinical practice time, like right

32:18

before, um, I don't know the origins of how this came to be,

32:22

but I do know that there was breast

32:24

density legislation passed.

32:26

The problem with Missouri's, uh,

32:28

dense breast legislation was

32:29

that obviously did not tell the patient whether they

32:31

had dense breasts or not.

32:33

Um, this, uh, blurb got, you know, included in the, uh,

32:37

patient lay letter, um,

32:39

and, you know, created a lot of confusion

32:41

with referring providers of what to recommend to patients.

32:44

And I think that we, in the field

32:45

of breast imaging didn't have a lot of GUI guidance

32:47

and clarity on that either back in 2015.

32:52

So over the years, you know,

32:54

there has been legislation introduced to, uh,

32:58

at the federal level, uh, when it comes to breast density

33:01

and making sure that, um, making sure

33:05

that patients were notified

33:07

of their breast density across the country,

33:09

because of course, there were some states

33:10

that still didn't have, uh, breast density legislation,

33:14

and it just kept failing at the federal level.

33:18

And then, um, you know, switching gears a little bit

33:21

to the FDA and MQSA, so,

33:23

and how did they come into the scene

33:25

regarding breast density?

33:27

Well, the FDA with input from leading organizations such

33:30

as the A CR established MQSA in 92, and this was established

33:35

because there really was a lot of, um, issues when it came

33:40

to mammography quality, um, up until that point.

33:43

So this was developed

33:44

to ensure standard mammography quality across the country

33:47

through enforcing strict accreditation certification

33:50

and inspection of equipment and personnel

33:53

and mammography facilities.

33:55

And breast density notification was not in the first

33:58

iteration, um, as we know.

34:00

So, you know, mammography in this country is highly

34:03

regulated now leading up to 92, it was not.

34:06

And so the quality has really, really improved over time,

34:09

and really with the impetus of the passage of MQSA.

34:14

So, um, you know, in recent years,

34:18

Congress was really not trying

34:19

to pass any legislation on breast density

34:21

because they knew that the FDA was had something brewing

34:25

with, um, amending the final rule of MQSA, uh,

34:28

that was going to include breast density reporting.

34:31

So that was issued, uh,

34:33

the announcement on March 10th, 2023, with the rule

34:36

to go into effect on September 10th of this year,

34:39

where we needed to also notify our patients, uh,

34:42

whether they were dense or not dense, include the language

34:44

that they, uh, had for us to put in the patient lay letters.

34:49

So now we're dealing with some issues in states

34:52

where we have existing breast density legislation

34:56

and the language that we are required

34:59

to put in the patient lay letter, uh, is incongruent

35:03

or confusing when you compare it to the FDA language.

35:06

But we are still required to put

35:10

the state language in the lay letter

35:12

because it hasn't been rescinded yet.

35:13

So now we're dealing with that in many states,

35:16

and we're dealing with that in Missouri.

35:18

So we have to include this language here, um, in,

35:23

uh, particularly the FDA has this language that's,

35:27

that is here in blue that we have

35:29

to put into the patient lay letters now, which is great.

35:31

You know, it says whether you're dense or not dense,

35:34

and if you know, and if you, you need to talk

35:36

to your provider about supplemental screening, um,

35:38

if you know that's right for you.

35:41

So this leg, this last legislative session in Missouri,

35:44

we tried to get the Missouri language rescinded

35:46

because again, it's very incongruent, uh, in comparison

35:49

to the FDA language.

35:51

And the bill died

35:52

because unfortunately it was, um, kind of clumped

35:55

with a women's health bill that was very, very contentious

35:58

with very, um, contentious issues in that bill.

36:01

So the whole thing died.

36:02

So now we are introducing it again this legislative session

36:05

to try to get our Missouri language rescinded.

36:08

So we only have to put the FDA

36:09

language in the patient lay letter.

36:11

So for this year, we have to include both the FDA language

36:14

and the state language,

36:15

which other states are unfortunately

36:17

still having to do as well.

36:20

So this is an example of a,

36:22

the actual dictated patient report.

36:24

So we're all required,

36:26

and many of us have already been doing this,

36:27

but to include the tissue density.

36:29

But there were some, you know, uh, practices in institution

36:33

that still weren't including the tissue

36:35

density, but now they have to.

36:36

So this is an example of a dense, uh,

36:39

a patient who's heterogeneously dense.

36:41

Now, when it comes to supplemental screening,

36:43

that really varies per institution about whether

36:45

they suggested or not.

36:47

They don't say anything in their, uh, the dictator report.

36:50

They just put the FDA blurb, uh,

36:53

or whatever they're required to in the patient lay letter

36:55

and just, you know, leave it in the hands

36:57

of their primary care providers.

36:59

Um, we actually put this blurb under impression number two

37:03

in the report

37:04

because we've worked with our primary care providers

37:07

and OB GYNs who want this in there.

37:09

Also, when a patient is dense, we give them a pamphlet, uh,

37:13

that we, I have put together, um, in our breast center so

37:16

that the patient has the information about breast density,

37:20

uh, why it's important,

37:21

and if they want supplemental screening, how, you know,

37:23

how do you get that schedule.

37:25

So we worked really closely

37:26

with our referring providers on this,

37:28

and I think that that was really, um, imperative

37:32

and also to help educate them.

37:34

I think they really appreciated it.

37:36

So I encourage you, if you go, you are going

37:38

through some growing pains with this at your institutions,

37:41

talk to your, uh, primary providers, you know,

37:43

they're the first frontline, uh, physicians

37:45

that are meeting with these patients.

37:47

Work with them to see what works for your institution

37:49

to make sure the patients are getting educated,

37:52

and if they do desire supplemental screening,

37:53

they know the proper channels to go about it

37:55

to have that exam done.

37:58

So this is an example of a dictator report

38:00

where the patient's not dense.

38:02

Um, and of course for this one, we don't, uh, you know,

38:05

suggest anything in terms of supplemental screening.

38:08

So this is the pamphlet that we,

38:10

I've put together at our breast center.

38:12

Um, and you know, this is something that we give to patients

38:15

who are dense, so they'll take it home

38:17

and then if they want to, um, you know,

38:20

schedule it has the information for scheduling,

38:22

but it's been really great.

38:24

And then we have additional resources if

38:26

they wanna learn more.

38:28

Um, but, you know,

38:29

our technologists have been really helpful in being a part

38:32

of the team to really educate patients on breast density

38:35

and giving them this information

38:37

as well that they can take home.

38:39

So this is an example of our patient lay letter.

38:41

So what we decided, since we have to include, you know,

38:45

obviously the FDA language,

38:46

and we still have to include the Missouri language,

38:48

we're basically putting the FDA language at the top,

38:50

so hoping patients read that.

38:52

And we're bearing the Missouri language at the bottom, uh,

38:55

because again, I, we feel this is, you know, incongruent

38:58

and hopefully next, uh, this upcoming legislative session,

39:02

we will be able to rescind Missouri language

39:03

and this whole big blurb at the bottom we can get rid of.

39:08

So what's currently happening in the states?

39:09

So it's, you know, you know, it's happening in Missouri.

39:13

We're trying to rescind our existing breast

39:15

density legislation.

39:17

Um, but there are some states

39:18

that already were successfully able to sunset ex

39:22

existing stipulated language, which is awesome.

39:25

But there's so many states that are at different, um,

39:28

phases of this right now.

39:29

So just because September 10th has passed, uh, us,

39:33

there's still states that are trying

39:34

to get their language sunsetted.

39:37

There are some states where their

39:38

language sunsets in January.

39:40

Um, but then, you know, at the bottom here,

39:42

there's many states where they prior, um, to this, uh,

39:45

final rule had no breast density

39:48

legislation passed in their state.

39:49

So they're kind of, um, you know,

39:52

more fortunate in the sense

39:53

that they are basically starting from scratch,

39:55

and they just have to include the F-D-A-M-Q-S-A language in

39:59

their patient lay letters, and they don't have to go

40:00

through all this, uh, that we have to in states

40:03

who previously had breast density legislation.

40:06

So as you can see, there's a lot

40:08

of variability in what's happening

40:10

with the states when it comes to this.

40:14

So how have physicians responded?

40:16

Well, primary care physicians, you know,

40:19

they still may be unsure how to explain the risks

40:21

and benefits of supplemental screening

40:22

and the concept of dense breast.

40:24

So, you know, I really, you know, am a fervent believer

40:27

that you really need to talk to, uh, your providers

40:30

to make sure that they understand what this is,

40:33

and so they can appropriately educate patients.

40:35

I also feel that we should be taking a greater role,

40:38

even though, you know, we're busy as well,

40:40

but talking to patients about breast if they have questions,

40:43

and our technologists as well.

40:46

So, you know, I think that, you know,

40:48

previously it had been reported

40:50

that many women were still unaware of

40:52

what breast density is.

40:53

I think now that all states are required

40:55

to include this in the patient lay letter,

40:57

and there are breast centers that are going more above

40:59

and beyond in educating patients on breast density, I think

41:02

that that will really change, um, in the years to come.

41:07

Um, you know, it's important

41:08

to remember there's varying levels

41:10

of state insurance coverage for additional screening.

41:12

So like in Missouri, you know, patients who are

41:15

above average risk supplemental screening should be covered,

41:18

but that's only if you have insurance

41:19

under the state of Missouri.

41:20

If you don't, you may not be covered.

41:22

And then if you're a woman with who are, who is average

41:25

or intermediate risk with dense breast, you know,

41:27

there's nothing in the Missouri legislature right now

41:29

that says, or the legislation that says that insurance has

41:33

to cover these patients.

41:34

So we still need have a ways to go, you know,

41:37

we're making these recommendations.

41:38

You, the MQA say, final rule comes out,

41:40

but yet we don't have coverage for all women.

41:43

So that's something that we are working about,

41:46

uh, working, uh, towards.

41:47

And then women may not have access to different types

41:50

of supplemental screening techniques based on factors such

41:53

as geographic location.

41:56

So where can we, uh, potentially improve education?

42:00

So, you know, research in the past has shown

42:03

that many PCPs are really uncomfortable talking about breast

42:06

density and it's implications.

42:07

So I think it's important for us

42:09

to get them comfortable, right?

42:10

So we can, you know, we can only reach as many patients

42:13

as we can reach, but it really takes a village

42:15

to educate these patients.

42:16

So going and talking to your providers, talking

42:19

to your OB GYNs, your primary care docs

42:21

or internists about this is important.

42:24

So they, you know, knowledge is power, um,

42:26

stressing the importance of physician education.

42:28

Uh, particularly PCPs who are more, most likely

42:31

to address patient concerns of screening,

42:33

like we talked about, a lot of times they're the, the first,

42:35

the frontline, uh, for us.

42:38

Um, and you know, I, again, I'm a huge believer

42:41

that radiologists and radi and tech

42:43

and technologists are technologists really need

42:45

to take a greater role in discussing breast density

42:48

with patients so they can make an informed decision when

42:50

they decide on supplemental screening.

42:54

And it's also important for us, uh, for us,

42:57

our technologists, our primary care providers, to convey

43:00

to patients and also PCPs when we're educating them on the

43:03

subject that breast density is not fixed

43:05

and it can change over time due to interpreter variability.

43:09

For example, if you're not using, um, an, uh,

43:11

objective software that calculates your breast density, uh,

43:14

physiologic changes to the breast over time

43:17

and differences in positioning.

43:20

So, Crescent's been doing a lot

43:21

of research about patient understanding

43:23

about breast density.

43:25

Um, so this was an article in 2016 where, uh, they,

43:30

they found a wide variation of understandability

43:33

by patients in 23 states, um, analyzed, um,

43:37

most having readability at the high school level

43:40

or above poor understandability

43:41

and discontinuity with states average average literacy.

43:46

Uh, Crescent published another article in 2022, um,

43:50

where they conducted a national telephone survey with 20,

43:55

a little over, uh, 2300 racially and ethnically

43:58

and literacy diverse women, 61 of whom participated in,

44:02

in-depth, quality, uh, qualitative interviews.

44:05

Most women preferred learning about their breast density

44:08

and the risks from their providers rather than letters.

44:11

And these findings were prevalent, uh, more prevalent

44:14

among non-Hispanic black women compared

44:16

to non-Hispanic, white and Asian women.

44:18

The opposite was true for women with low literacy

44:21

who prefer written notification over personal,

44:24

which I thought was interesting.

44:25

And then women with really high literacy most often favored

44:28

learning of the results via an online portal.

44:31

And then re the researchers also noted that women

44:33

with low literacy are those

44:35

who do not speak English as a first language.

44:38

They might prefer having a handwritten notification

44:40

as backup if they're unable

44:42

to process verbal communications confidently.

44:44

So right now we're working on with, uh,

44:46

particularly our supplemental screening pamphlets,

44:48

having them in different languages for patients so

44:51

that if they don't truly understand English well, they have

44:54

that in their own native language.

44:57

So, very quickly, you know, as we, you know, um,

45:00

are suggesting

45:02

and more supplemental screening is happening, um,

45:04

quality definitely matters, and especially for ultrasound.

45:08

So, you know, these were ultrasound images from an

45:12

outside facility where, you know, you just see a lot

45:15

of shadowing, you're not really sure, you know,

45:17

is could there be a mass there?

45:19

It's not, I'm not quite sure, particularly on this image.

45:21

There's just a lot of shadowing going on.

45:24

Um, and then this, uh, was also, you know, measured,

45:28

but then it's like, well, what's the shadowing next to it?

45:30

You know, to the left of it, it's just hard

45:32

to really, uh, tell.

45:34

Uh, but then looking at these ultrasound images, uh,

45:37

from our facility, um, you know, clearly I see

45:41

that there is a malignancy here.

45:43

Uh, so, you know, I always, you know,

45:45

especially if we're gonna be offering supplemental screening

45:48

at facilities, uh, when it comes to an ultrasound modality,

45:51

the quality of the technique,

45:53

it most certainly matters for these patients.

45:56

We wanna try to find these cancers when they're really,

45:58

really, uh, small to ensure

46:00

that they have an excellent prognosis.

46:04

So where are we going with the future of breast density?

46:07

So, um, some of you might have heard, you know,

46:09

the Find It Early Act is federal legislation.

46:12

That's a bipartisan effort from Representative Rosa Del Laro

46:16

and Brian Fitzpatrick.

46:17

And that would ensure all health insurance plans,

46:20

cover screening and diagnostic breast imaging

46:22

with no out-of-pocket costs for women with dense breasts

46:25

or at higher risk for breast cancer.

46:27

So that is, uh, currently, um, reintroduced,

46:31

uh, in the house.

46:32

Uh, there will be, uh,

46:34

and you might've seen there's a, there's been a call

46:37

to action that has gone out, uh,

46:39

to support this legislation.

46:41

The American College of Radiology will be sending out a call

46:44

to action on this soon.

46:45

So if you do receive that, uh, email to respond to your, uh,

46:49

federal elected officials, please do on this as we're trying

46:53

to fi fight coverage for all women across the country.

46:57

However, this bill is seen as costly when trying

47:00

to achieve budget neutrality.

47:02

But we will continue to push for,

47:04

uh, coverage across the country.

47:05

And, you know, just like breast density, you know,

47:07

we saw all these states that passed legislation

47:10

and then finally we had federal sweeping

47:12

legislation through the FDA.

47:13

Well, the same happen here with, um, you know, with coverage

47:18

for these patients.

47:19

And we're hoping so, 'cause we're seeing more

47:20

and more states passing their own coverage for

47:23

above average risk women diagnostic breast imaging

47:26

legislation without copay

47:27

or deductible

47:31

states are doing this.

47:32

Hopefully we'll finally have federal sweeping legislation,

47:36

so no, uh, woman is left behind.

47:40

So with that, I wanna say thank you for your time.

47:42

Um, I am happy to answer some questions.

47:45

I see some, uh, things popping up in the chat.

47:48

I can, uh, look at that as well. But thank you so much.

47:53

Yes, thank you so much for sharing your lecture

47:54

with us today, Dr. Patel.

47:56

At this time, we will open the floor

47:58

for any questions from our audience.

48:00

You may submit your questions through the q and a feature.

48:03

Um, and yes, we've got a few questions in the q and a.

48:08

Okay, I'll take a look here.

48:12

Okay, this is a good question.

48:13

Um, if we are a small breast imaging center,

48:17

what is the one supplemental tool that we can add

48:19

that will use our resources the best

48:22

and not strain our schedule and staff?

48:24

Mainly question is if we should offer handheld ultrasound

48:27

or MRI, we probably would not buy abus.

48:31

We already have DBT.

48:32

That's a really great question

48:33

because as a medical director, I feel the strain

48:37

and whether it's a small center, a large center,

48:40

a medium sized center, um,

48:41

and this is something we are constantly having issues with,

48:45

uh, with staffing, uh, with scheduling patients, you know,

48:49

we have issues with scheduling.

48:51

Um, it's kind of a nightmare.

48:52

So my answer to you would be, I would sit down

48:55

with your team and see where you have the best bandwidth.

48:59

Um, for us, you know,

49:01

and looking at the literature, you know, we have pushed

49:04

for abbreviated breast.

49:05

MI is the first line

49:07

because of what we're seeing in the literature,

49:09

and particularly with the sensitivity using ultrasound

49:12

as a backup, we also do not, uh, utilize abus.

49:16

Um, but as a result, you know,

49:18

our MRI volumes have exponentially increased since we have

49:22

offered, um, abbreviated breast MRIA little about two years

49:26

ago is when we started.

49:28

So making sure we had the staff bandwidth, uh, to do

49:32

that was important and making sure we had, um, you know,

49:36

the appointment slot times that, uh,

49:39

we could get these patients in in a timely

49:41

fashion was important as well.

49:42

So I think it really is institutionally dependent.

49:45

Um, where do you see on your schedule, where do you see

49:48

with staffing where you, uh, can offer this, um, uh,

49:53

you know, more readily than others?

49:55

But no doubt, I mean, this is a,

49:57

causing a crunch on workflows, whether it's an MRI,

50:00

whether it's an ultrasound.

50:02

Um, I really wish it wasn't as murky as it is,

50:05

but it really, I think is institutionally dependent on what,

50:08

where you see your bandwidth.

50:11

Um, and, and then also other things too,

50:13

like some institutions wanna have abbreviated breast MRI

50:16

and offer to cash pay,

50:17

but then they, it might be taking forever to get to

50:21

that agreement with the health system of offering cash pay.

50:24

I mean, there's just so many layers to this.

50:26

So I think just working with your team, seeing

50:28

where you see the, uh, potential bandwidth, say working

50:31

with your finance team at your health system to make sure

50:34

that they're okay with this, moving forward

50:36

with whatever modalities you offer, I think is important.

50:40

'cause that's what we did, uh, when we embarked on this.

50:44

Ugh, what a question.

50:45

If I had a, you know, you know,

50:47

this is like a million dollar question.

50:49

One of the questions is, uh, can you tell me

50:51

how we can accurately diagnose suspicious lesions in case

50:55

of marked background parenchymal enhancement in breast MRI,

50:59

woo, I, you know, breast MRI is can be

51:02

so challenging to interpret.

51:05

Um, and then you get hit

51:08

with marked background pral enhancement,

51:10

and it's so hard to know what do we go after, right?

51:13

So, you know, for me, you know, I really try to, uh,

51:18

you know, and I'm a breast specialist.

51:19

I don't read anything else but breast, um,

51:21

and I've been that way since I came out of training.

51:24

For me, the things that I remember

51:26

and try to think about is, you know, is there a morphology

51:30

of one of these areas that are enhancing

51:32

that look differently from the rest of the BPE?

51:35

You know, we, we learn that morphology co trumps kinetic,

51:38

so using that kinetic mapping can help.

51:41

Um, but I rest my, you know,

51:43

I don't hang my hat on kinetics,

51:45

although it can help particularly in the setting

51:47

of marked BPE, uh,

51:49

but really looking at the morphology of that area

51:51

of enhancement, you know, does it look different

51:54

for relief from the rest?

51:55

Uh, and sometimes it's just hard to make the call.

51:58

You might over call, you might do the biopsy

52:00

and to being benign,

52:01

or you might, you know, under call,

52:03

you might just give it a birad three,

52:05

but it ended up being a malignancy.

52:07

Uh, so it can be a very, very challenging, uh,

52:10

but those are sort of the things that I try to do, you know,

52:13

is this one area of enhancement?

52:15

Maybe it's more avidly enhancement, you know, again,

52:17

is the morphology looking more suspicious than other

52:20

areas in that breast tissue?

52:21

And then of course, I try to use a kinetics as sort of as a,

52:24

as, as a, you know, a backup, uh, sort of, uh, you know,

52:28

tool in my diagnostic, um, you know, in my diagnosis

52:32

of what I think something is.

52:33

So, um, okay.

52:41

All right. I think we're good.

52:45

All right. Thank you so much Dr. Patel,

52:47

for taking the time to share your lecture

52:49

and expertise with us

52:50

and to answer, um,

52:51

everyone's questions. So thank you so much.

52:54

Thank you. I appreciate it.

52:55

Alright, and be sure to join us next week on Thursday,

52:59

October 24th at 12:00 PM Eastern, where Dr.

53:02

Steven Pomerantz will deliver a lecture

53:04

entitled MRI of the hip.

53:06

You can register for it@mrionline.com

53:09

and follow us on social media

53:10

for updates on future noon conferences.

53:13

Thanks again and have a great day.