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Posts Tagged ‘smart imaging’


There are 40 million women seeking mammography breast-screening every year in the USA, out of which 15 million are women with heterogeneously dense or extremely dense breasts. USA epidemiology statistics show that 6 out of 7 missed cancers at mammography occur in women with dense breasts. It is also known that the majority of women presenting with mammography-dense breasts are below 45 years old.

The Oct. 22 issue of the American Journal of Roentgenology ( AJR) publishes results of a study showing that ultrasound is superior to mammography in evaluating symptomatic women 30-39 years of age [1].

This study was conducted by researchers at the Seattle Cancer Alliance and University of Washington. Patients were recruited between January 2002 and August 2006.   954 women ranging from 30 to 39 years old who presented for diagnostic breast imaging evaluation were  examined, and it was found that sensitivity (probability for cancer detection) of ultrasound was 95.7 percent compared to 60.9 percent for mammography. A very important result of this study is the calculated Negative Predictive Value (the probability to have negative pathology if the imaging-test is negative) which was similar for both modalities: 99.9% for ultrasound and 99.2% for mammography.

Show case in images (All images courtesy of the American Roentgen Ray Society.):

35-year-old woman who presented with a palpable left breast lump. Whole-breast craniocaudal (above left) and mediolateral oblique (above right) and spot-magnification craniocaudal (below left) and mediolateral (below right) mammographic images show no abnormality at area of clinical concern, marked by BB.

Zoom-in on the region of interest

Targeted ultrasound image above reveals solid mass with irregular shape and indistinct and angular margins. BI-RADS 5 assessment was made. Histopathology from ultrasound-guided core needle biopsy showed invasive ductal carcinoma.

In regards to which imaging modality should be used when screening such a population, the conclusion of the investigators is very clear: “Ultrasound has high sensitivity (95.7%) and high NPV (99.9%) in this setting and should be the primary imaging modality of choice. The added value of adjunct mammography is low.”

When reading this article I noted a gap to overcome if we want to successfully replace mammography with ultrasound. The Positive Predictive Value (the probability of  detecting a cancer) calculated for ultrasound in these study settings was lower than that calculated for mammography: 13.2% for ultrasound and 18.4% for mammography. This is because mammography detected one additional malignancy in an asymptomatic area in a 32-year-old woman who was subsequently found to have a BRCA2 gene mutation. Mammography could do that because it scans the whole breast, whereas the investigators in this study used ultrasound just for scanning the suspicious lumps. A solution is offered in using the recently introduced ultrasound modalities, which are able to perform automatic full breast ultrasound scans [2], preferably enhanced by real-time tissue characterisation capability – a technology I’m working to develop.

References:

  1. Accuracy and Value of Breast Ultrasound for Primary Imaging Evaluation of Symptomatic Women 30-39 Years of Age,Constance D. Lehman1,2Christoph I. Lee1,2Vilert A. Loving1,2, Michael S. Portillo1,2Sue Peacock1,2 and Wendy B. DeMartini1,2, Oct. 22 issue of the American Journal of Roentgenology
1 Department of Radiology, University of Washington School of Medicine, Seattle WA.
2 Seattle Cancer Care Alliance, G2-600, 825 Eastlake Ave E, Seattle, WA 98109.

2. Using Automated Breast Sonography as Part of a Multimodality Approach to Dense Breast Screening, Vincenzo Giuliano, MD, RDMS, RVT1, Concetta Giuliano, DO1, Journal of Diagnostic Medical SonographyJuly/August 2012 28: 159-165,

1Novasoutheastern University, Winter Springs, FL, USA
 
 
Written by: Dror Nir, PhD.
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The Incentive for “Imaging based cancer patient’ management”


Author and Curator: Dror Nir, PhD

It is generally agreed by radiologists and oncologists that in order to provide a comprehensive work-flow that complies with the principles of personalized medicine, future cancer patients’ management will heavily rely on “smart imaging” applications. These could be accompanied by highly sensitive and specific bio-markers, which are expected to be delivered by pharmaceutical companies in the upcoming decade. In the context of this post, smart imaging refers to imaging systems that are enhanced with tissue characterization and computerized image interpretation applications. It is expected that such systems will enable gathering of comprehensive clinical information on cancer tumors, such as location, size and rate of growth.

What is the main incentive for promoting cancer patients’ management based on smart imaging? 

It promises to enable personalized cancer patient management by providing the medical practitioner with a non-invasive and non-destructive tool to detect, stage and follow up cancer tumors in a standardized and reproducible manner. Furthermore, applying smart imaging that provides valuable disease-related information throughout the management pathway of cancer patient will eventually result in reducing the growing burden of health-care costs related to cancer patients’ treatment.

Let’s briefly review the segments that are common to all cancer patients’ pathway: screening, treatment and costs.

 

Screening for cancer: It is well known that one of the important factors in cancer treatment success is the specific disease staging. Often this is dependent on when the patient is diagnosed as a cancer patient. In order to detect cancer as early as possible, i.e. before any symptoms appear, leaders in cancer patients’ management came up with the idea of screening. To date, two screening programs are the most spoken of: the “officially approved and budgeted” breast cancer screening; and the unofficial, but still extremely costly, prostate cancer screening. After 20 years of practice, both are causing serious controversies:

In trend analysis of WHO mortality data base [1], the authors, Autier P, Boniol M, Gavin A and Vatten LJ, argue that breast cancer mortality in neighboring European countries with different levels of screening but similar access to treatment is the same: “The contrast between the time differences in implementation of mammography screening and the similarity in reductions in mortality between the country pairs suggest that screening did not play a direct part in the reductions in breast cancer mortality”.

In prostate cancer mortality at 11 years of follow-up [2],  the authors,Schröder FH et. al. argue regarding prostate cancer patients’ overdiagnosis and overtreatment: “To prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected”.

The lobbying campaign (see picture below)  that AdmeTech (http://www.admetech.org/) is conducting in order to raise the USA administration’s awareness and get funding to improve prostate cancer treatment is a tribute to patients’ and practitioners’ frustration.

 

 

 

Treatment: Current state of the art in oncology is characterized by a shift in  the decision-making process from an evidence-based guidelines approach toward personalized medicine. Information gathered from large clinical trials with regard to individual biological cancer characteristics leads to a more comprehensive understanding of cancer.

Quoting from the National cancer institute (http://www.cancer.gov/) website: “Advances accrued over the past decade of cancer research have fundamentally changed the conversations that Americans can have about cancer. Although many still think of a single disease affecting different parts of the body, research tells us through new tools and technologies, massive computing power, and new insights from other fields that cancer is, in fact, a collection of many diseases whose ultimate number, causes, and treatment represent a challenging biomedical puzzle. Yet cancer’s complexity also provides a range of opportunities to confront its many incarnations”.

Personalized medicine, whether it uses cytostatics, hormones, growth inhibitors, monoclonal antibodies, and loco-regional medical devices, proves more efficient, less toxic, less expensive, and creates new opportunities for cancer patients and health care providers, including the medical industry.

To date, at least 50 types of systemic oncological treatments can be offered with much more quality and efficiency through patient selection and treatment outcome prediction.

Figure taken from presentation given by Prof. Jaak Janssens at the INTERVENTIONAL ONCOLOGY SOCIETY meeting held in Brussels in October 2011

For oncologists, recent technological developments in medical imaging-guided tissue acquisition technology (biopsy) create opportunities to provide representative fresh biological materials in a large enough quantity for all kinds of diagnostic tests.

 

Health-care economics: We are living in an era where life expectancy is increasing while national treasuries are over their limits in supporting health care costs. In the USA, of the nation’s 10 most expensive medical conditions, cancer has the highest cost per person. The total cost of treating cancer in the U.S. rose from about $95.5 billion in 2000 to $124.6 billion in 2010, the National Cancer Institute (www.camcer.gov) estimates. The true sum is probably higher as this estimate is based on average costs from 2001-2006, before many expensive treatments came out; quoting from www.usatoday.com : “new drugs often cost $100,000 or more a year. Patients are being put on them sooner in the course of their illness and for a longer time, sometimes for the rest of their lives.”

With such high costs at stake, solutions to reduce the overall cost of cancer patients’ management should be considered. My experience is that introducing smart imaging applications into routine use could contribute to significant savings in the overall cost of cancer patients’ management, by enabling personalized treatment choice and timely monitoring of tumors’ response to treatment.

 

 References

  1. 1.      BMJ. 2011 Jul 28;343:d4411. doi: 10.1136/bmj.d4411
  2. 2.      (N Engl J Med. 2012 Mar 15;366(11):981-90):

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