No matter how we look at it—from the organ, to the cell, to the gene—breast cancer detection has been and remains as challenging as looking for a needle in a haystack, and even goes beyond by looking for needles in an immense field of haystacks. About one in eight American women will develop invasive breast cancer over the course of her lifetime. In 2017, an estimated 252,710 new cases of invasive breast cancer are expected to be diagnosed in women in the United States, with 63,410 new cases of noninvasive breast cancer. About 40,610 of these women diagnosed are expected to die from breast cancer, even though death rates have been decreasing since the early 1990s . To date, breast cancer, known to mankind since ancient times, continues to be on the top of the list as the most common cancer in women worldwide. The challenge to overcome this disease, and to develop new solutions that would zero out the statistics of breast cancer in all countries, is enormous for research.
Over the past few decades, numerous medical technologies, tests, and treatments have emerged from research efforts, and had been introduced into clinical practices as solutions to prevent, detect, and treat breast cancer . The translation of new technologies, tests, or treatments into improved patient outcomes involves a complex process, but ultimately relies on the adoption by clinicians and health-care providers . In fact, the adoption of a new technology, test, or treatment regime for patients across all clinical facilities can be laborious and may take several years. Leaving out the financial aspect, one of the principal factors that account in the adoption of a particular medical technology, test, or treatment is how it fits to current or older similar technologies, tests, or treatments, and what other technologies, tests, or treatments it displaces, changes, or replaces. In the end, as Steve Jobs said (paraphrase), […] new technology , test, or treatment will not necessarily replace old technology , test, or treatment, but it will date it . By definition. Eventually, it will replace it. But it’s like doctors, who had grandfather medical technologies, tests, or procedures, when brand new technologies, tests, or other came out. They eventually decided whether or not these new technologies, tests, or treatments were worth the investment for improved patient outcomes.
Early detection of breast cancer reduces the burden of the disease by allowing intervention at an earlier stage of cancer progression. The ability to couple monitoring of genetic predisposition based on family history, genetic and phenotypic markers, and environmental exposure with enhanced imaging performed at intervals beneficial to this high-risk group continues to inform risk assessment programs to improve breast cancer detection . Such information could also be used to promote less frequent imaging of women who have low cancer risks, but currently are at risk of being overdiagnosed . Women diagnosed with early-stage breast cancer are less likely to die of the disease than those diagnosed with more advanced stages of breast cancer. Advances in more effective therapies with fewer side effects than traditional treatment would not be possible without accurate detection and diagnosis from radiologists. Notable advances include targeted gene therapies, new drugs less toxic than chemotherapy, genetic tumor testing that can determine whether a cancer patient will respond to chemotherapy and whether the cancer is likely to recur, immunotherapy medication, less invasive surgery, and preventive treatments .
Radiology therefore plays a major role in the fight against breast cancer, and thus in the advancement on all possible fronts for solutions in breast cancer prevention and cure. However, the task of a radiologist for detecting breast cancer on a mammogram has always been known to be challenging. Interpretation of a mammogram is known to be subjective and can be variable among radiologists . Breast parenchyma may mask or appear as a lesion on a mammogram, leading to either a false-negative or a false-positive detection result—in other words, delay in diagnosis or unnecessary recall or workup of a patient, respectively. Detection performance remains limited because of these perception and anatomical factors. Providing high-quality mammograms as well as associated accessory imaging solutions to overcome such limitation is therefore critical.
In this issue of Academic Radiology , a team of physicians and scientists from the Fondazione IRCCS Istituto Nazionale dei Tumori (Milano, Italy) presents a multiple-reader multiple-case reader study focused on the role of the display luminance level on the detectability of breast cancer lesions in digital breast tomosynthesis (DBT) images . Four monitors with different luminance characteristics were evaluated. The study consisted of having three radiologists with different levels of experience performing interpretation of 48 DBT examinations on each monitor. The interpretation included reporting lesion presence or absence and localization statements, confidence level on a five-point scale, and overall quality of the DBT images. Concordance (ie, intra- and interobserver reproducibility) and detection performance derived from the study data led to the conclusion that “the performances achieved with lower luminance monitors (500–600 cd/m 2 ) were significantly lower than those obtained with higher luminance monitors (1000 cd/m 2 ),” and therefore “higher display luminance level can improve the percentage of correct detection for radiologists with different expertise.” As Ferranti and colleagues demonstrate through their clinical investigation , the luminance characteristic of a monitor is a non-negligible component in breast lesion detection in DBT images. The results of the Ferranti et al study confirm findings from a prior perception study and observations, such as that by Smith et al stating “If a monitor has … limited luminance, there is a potential disadvantage for detecting subtle signs of early cancers” .
The study by Ferranti et al augments the importance of not overlooking the display luminance level characteristic, as new breast imaging units, such as DBT, or other imaging modalities are deployed into clinical practices. With respect to DBT, the U.S. Mammography Quality Standards Act and program reports that, in October 2016, approximately 2 years after DBT first came into clinical use, certified breast imaging facilities with DBT units represent ~36% of all 8744 certified US facilities . The rapid deployment of DBT units is likely owing to the fact that almost all clinical facilities (~97% as reported in July 2015) have already transitioned from screen-film mammography to full-field digital mammography (FFDM). Therefore, breast imaging facilities are taking advantage of the significant changes in infrastructure, such as implementation of a picture archiving and communication system, workstation, and display accessories, that were needed while transitioning into the digital era. Such a challenging transition would have not been possible without guidelines and recommendations that resulted from a tremendous collaborative effort among multiple government agencies, industry, and academia . Furthermore, it is clear that clinicians and health-care providers undeniably understand the potential of DBT system for addressing some of the long-standing limitations of conventional mammography. DBT provides the ability to see through overlying areas of dense benign fibroglandular tissues, improves detection of early breast cancer, and provides more accurate characterization of benign and malignant lesions . Yet one may wonder if recommendations and guidelines on monitors for display of FFDM images remain applicable to that for display of DBT images, or should additional guidelines on displays be provided for DBT so that it accounts for the difference in image characteristics between FFDM and DBT.
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