With the introduction of the first FDA-approved, full-field digital mammography systems, clinicians and their patients can now take advantage of the most sophisticated technology available for the detection of breast cancer. Digital mammography has been shown to offer a variety of advantages over conventional analog-based film mammography: superb image quality, increased patient throughput, fewer recalls and retakes, and, in many cases, increased reimbursement from Medicare and third-party payers. It also eliminates the problem of lost films and allows both clinicians and patients to be assured that the machines being used to detect even the smallest breast cancers are built on the most advanced technology available.

As digital mammography systems have become commercially available, many practices across the country have begun switching from analog to digital systems for their mammography studies. One such practice is the Sitron-Hammel Radiology Group of Bethpage, NY, which performs approximately 12,000 digital mammograms a year.

"We have always tried to be cutting edge in technology at our facility," said Jay D. Hammel, MD, Managing Partner for Sitron-Hammel. "The preliminary data suggested that digital has some improvement over analog mammography for the detection of breast cancer. We also liked the idea that it cut back on the need for some additional views, especially spot magnification views. We now clearly see calcifications and, in particular, microcalcifications, better. The ability to manipulate the data in the same fashion as any other digital modality is also important; we believe that that improved cancer detection in digital mammography."

Debra S. Mitchell, MD is Managing Partner at Breast Imaging of Oklahoma (Edmond, OK), an all-digital mammography program. "As we look toward the future," noted Dr. Mitchell, "I think that we will see a continued increase in the use of digital mammography. We didn't see any reason to go back to analog; we decided to go digital and have had no second thoughts."

Image quality

As with any imaging modality, image quality is of paramount importance, and digital mammography has repeatedly been shown to be as good as, if not better than, analog imaging.

"There's a learning curve if you're used to analog. I personally believe that the image quality is equivalent, if not better," Mitchell said. "As an example, the U.S. Food and Drug Administration and the American College of Radiology require that we image phantoms to maintain consistent image quality. On the phantoms, you look for little tiny dots and specks. With analog, you don't always see all the imperfections on the phantom. With digital, we always see every single imperfection every time."

"I think people are beginning to realize that image quality is clearly better with digital mammography as opposed to analog mammograms, which, in turn, allows us to feel more confident of our diagnosis," agreed Hammel.

Patient throughput

Digital mammography has also been shown to increase the number of patients who can be imaged in a given time, thereby increasing the volume of patients that an imaging center can serve.

"There is no question," noted Hammel. "We are quicker doing digital mammography than we were with analog. Once our technicians got over the short learning curve, they clearly are happier doing digital mammograms. We can easily do 6 patients in an hour, where previously that was a stretch for us."

"I have absolutely no doubt that one digital machine can do the equivalent of two to two-and-a-half analog machines," agreed Mitchell. "Digital mammography is quicker for the patient and quicker for the technologist. I think it's improving for the radiologist, but throughput is
certainly increased."

In light of the manpower shortage in radiology in general and in mammography in particular, this increase in efficiency takes on added importance. "Digital mammography provides the option for more people to have access to the expertise," explained Mitchell. "Because you can transmit the images with no degradation in image quality, the system becomes 'virtual.' You can concentrate all of your most expensive equipment and your expertise at one location. Yet, patients can go some place convenient to have their screening, with all images interpreted at the same high level of expertise. It doesn't matter anymore whether your mammography machine is 10 feet away, 10 miles away, or clear around the Earth."

Improving the bottom line

Breast imaging centers also face the challenge of extremely low levels of reimbursement for screening mammography. In 2003, the Medicare reimbursement for screening mammography with plain film at free-standing clinics was $82.77. When performed with digital equipment, the reimbursement jumps to $132.06.

"Although the cost for the machine is significantly more expensive than the analog machine," explained Hammel, "most insurance companies are reimbursing more money for digital mammography. We are surely doing as good as, or maybe a little better, financially with the digital mammography than we were with the analog."

Mitchell called the financial impact a mixed bag. "It costs more," she said. "The equipment, the storage, the PACS, the workstation, the gantry, the mammographic machine itself all cost more, but you can see more patients on it. So there is a trade-off. There are also some payers who pay more for digital mammography. So for each practice, it's a unique combination of their payer mix and their volume."

Making the move to digital

Once a radiology practice determines that the benefits of digital mammog-raphy are right for them, the question becomes which system to chose. For both the Sitron-Hammel Radiology Group and Breast Imaging of Oklahoma the answer was the GE Senographe (GE Medical Systems, Waukesha, WI).

"We felt that there were features of the GE machine that we liked better than others," said Hammel. "It was important to us that they have a service track record. In our industry, as important as the quality of the machine when you get it is how fast
do you get back up once your machine has been down. GE has always been superb to our office in that respect."

For Mitchell, the advanced applications of the GE system were key. "All the other digital mammography vendors are newer," she explained. "GE is obviously further along in their advanced applications, including Premium View. I think their mammography machine itself is more user friendly for the technologist, it's more automated. I think their radiologist workstation is also more user friendly."

The GE Senographe 2000D

Since its introduction more than 3 years ago, more than a million women in more than 32 countries have undergone digital mammography with the GE Senographe.

This digital system features the company's Revolution flat-panel digital detector. The intuitive operator console automates many steps, increasing user productivity. In addition, the digital detector's small pixels automatically identify the densest part of the breast for phototiming. The system then identifies and automatically marks all other parameters.

The included Review Workstation consists of two dedicated high-resolution monitors and an operator keypad. Archiving and networking capabilities allow the radiologist to review virtually any stored image.

Advanced applications

The GE Review Workstation also has available a new tool designed to increase diagnostic confidence by optimizing contrast and providing more detailed information. Premium View, as the "one-click" feature is called, increases productivity by allowing the user to optimize the image contrast in a single window, thereby deleting the need for additional steps such as windowing. In addition, this optional feature automatically improves visualization in dense areas of the breast while maintaining peripheral contrast at the chest wall and skin line.

CAD capabilities

The addition of the computer-aided detection (CAD) module provides an added layer of diagnostic confidence for women undergoing screening mammography and for the radiologist reading the exams.

The Senographe 2000D includes a seamlessly integrated all-digital CAD module. With the push of one button, the system reviews the image and displays the image with regions of interest highlighted, serving as a second set of eyes to support and enhance the radiologist's clinical judgment.

"The literature reports a 10% to 20% increase in breast cancer detection rate linked to having a mammographer read a mammogram with a CAD module," noted Hammel. "The combination of doing a digital mammography with a CAD has really helped us in terms of recruiting patients. As well, we feel that we are giving our patients the best possible mammographic care."

"As for the GE digital mammography with the Premium View and CAD," agreed Mitchell, "I think there's nothing superior in mammography right now. I think we all sleep well at night thinking that we are providing our patients with the absolute best technology for mammography."