Q&A: Marc F. Inciardi on using FFDM and ABUS together in dense-breast screening

A recent American Journal of Roentgenology study found that combining full-field digital mammography (FFDM) with 3D automated breast ultrasound (ABUS) improved radiologists’ performance in detecting breast cancer in women with dense breast tissue compared to just FFDM alone.

Marc F. Inciardi, MD, of the University of Kansas Medical Center in Kansas City, Kan., was one of that study’s authors. Inciardi spoke with Radiology Business about the study’s findings, ABUS, and more.

RadiologyBusiness.com: Were the study’s findings roughly what you expected? Did anything surprise you? 

Marc F. Inciardi, MD: In a reader study, we were able to improve reader performance by 25 percent by supplementing FFDM with ABUS in detection of breast cancer in patients with dense breast tissue, without significantly affecting specificity. We were a little surprised in that we expected at least a small decrease in specificity.

Do you think breast cancer screening guidelines will someday require the use of ABUS technology in addition to mammography for patients with dense breasts? 

It is difficult to think, in today’s cost-sensitive environment, that we could go as far as to require that this to be mandated, and also because there are alternative screening exams such as 3D mammography and molecular breast imaging that also improved breast cancer detection, as compared to FFDM.

Lastly, MRI has shown potential in screening average risk patients, and research trials exploring this are about to begin. Implementation of large scale screening of all patients with dense breast tissue also raises issues of manpower challenges, with regard to either physician or technologist scanning of patients.

In addition, hospitals and breast centers would have to purchase additional ultrasound devices. This would present challenges if large numbers of patients were required to have this study.

How does ABUS compare with handheld ultrasound?

ABUS exams are most commonly scheduled as 20-minute exams, though some prefer to schedule as 30-minute exams. Appointment times for technologist-performed screening with handheld ultrasound have been reported to be as short as 30 minutes, so ABUS has a mild advantage. 

ABUS gives the radiologist a 3D volumetric dataset for interpretation, something akin to a CT or MRI scan, with ability to review in 3 planes, with virtually all of the breast imaged. Technologist-performed screening ultrasound is dependent upon the skill and training of the technologist. If the technologist does not see and image the cancer, then neither will the radiologist.

In general, there is probably less variation in the quality of the scans and better reproducibility with ABUS than with technologist-performed screening exams. Interpretation time for technologist-performed screening ultrasound is typically less than a minute; for ABUS, it is typically between three and four minutes.

In the study, you and your co-authors mention that training is especially important as ABUS is implemented more and more. What kind of training is involved? Is there anything radiologists should be focused on or learning now to help them prepare for such training?

There is workstation “knobology” training—how to use the workstation and various tools—as well as review of multiple cases of benign and malignant breast pathology. The focus, however, is on ways to reduce call backs, or maintaining high specificity. It is a different mindset than diagnostic breast ultrasound, which of course, is the type of training that all radiologists are typically receive in residency as well as what the vast majority of radiologists typically see from day to day.

Radiologists thinking about starting a screening breast ultrasound program should be familiar with the recent published literature on the subject at a minimum.

Is there anything else you’d like to share about this topic or women’s imaging in general? 

This technology is still in its infancy, as is 3D mammography. We anticipate that equipment will continue to improve, along with improvement of physician performance with regard to sensitivity and specificity. 

It is notable that this technology was able to show added benefit in breast cancer detection in patients with dense breast tissue (in conjunction with FFDM) at the time of FDA approval, given that current scanner and beam former technology has improved significantly.

This text was edited for space and clarity.