Going Digital




It's probably safe to say that for most women mammograms are included on the I-know-I-should-do-it-but-I-really-don't want-to healthcare checklist, along with dentist and ob/gyn visits. There's the psychological discomfort of baring oneself to a stranger, the awkward posing to get the angle just right, the handling and arranging, the squeeze as the breast is flattened for the photos, and then the nerve-wracking wait while the images are checked for poor clarity or, worse, something that doesn't look right. But breast cancer is the most common non-skin cancer for women in the United States and the second leading cause of cancer-related death, according to the National Cancer Institute. Much of the unpleasantness of mammograms doesn't appear to be going away any time soon, but technological gains have led to new mammography options and other breast cancer-detection methods that are invaluable diagnostic tools for physicians, making any of the brief discomfort brought on by a check-up well worth the experience. One of the latest advances in mammography that is available at some New Hampshire healthcare facilities presents many benefits to caregivers as well as to patients: digital mammography. Whereas traditional mammography uses low-dose X-ray to capture and display pictures on film, digital mammography creates electronic images that are stored directly in a computer. Radiation is still required to capture that image; so is the dreaded squeeze. And digital mammography is pricey, with digital systems currently costing approximately 1.5 to 4 times more than film systems, so some hospitals have been slow to adopt it. But digital mammography has been shown to be more effective than film mammography at detecting breast cancer in certain populations, namely women under age 50; women of any age who have very dense breasts; and pre- and perimenopausal women. Digital mammography allows for better visualization in these subgroups, hopefully leading to cancer detection at an earlier, more treatable stage. For the general population of women outside of the subgroups, no significant difference in breast cancer detection has been found between digital and standard film mammography. And, like its film cousin, digital mammography is imperfect, allowing some cancers to go undetected, and false positives to be declared. But digital still offers advantages over analog that benefit many people in a variety of ways. Digital differences A woman undergoing a digital mammogram will probably not notice much difference during the procedure from a film mammogram. "You still have the same kind of compression," says Anna N. A. Tosteson, Sc.D., professor at the Dartmouth Institute for Health Policy and Clinical Practice. "I think the only thing that might be different in terms of the experience is that [patients] don't have to wait around to see if the image is good or not" because a digitally displayed image is available in about 10 seconds, compared to the two minutes required for a conventional film mammogram. Additional new imaging techniques Breast screening technologies that are intended to supplement mammography are also gaining traction in the medical world. For instance, magnetic resonance imaging (MRI) is sometimes used to screen for breast cancer in conjunction with a digital or film mammogram. Although full-body MRIs can be used for breast imaging, newly adopted breast MRI uses an MRI machine specifically developed for breasts. "Open" versions of these systems are less claustrophobia-inducing than a regular MRI and provide excellent pictures, says Edward P. Dalton, M.D., breast surgeon and medical director of the Elliot Breast Health Center at Elliot Hospital in Manchester. The diagnostic information provided by an MRI can provide crucial clues for surgeons working on a breast cancer case, and sometimes leads to altered treatment plans and prognosis. "[MRI] is really a great tool for surgeons," Dalton says, as it helps them better estimate the extent of a tumor in a patient. Further out on the horizon (FDA approval is pending) are digital tomosynthesis and nuclear breast imaging. Digital tomosynthesis results in a 3-D image of the breast that can be viewed from different angles, and nuclear breast imaging is similar in concept to an MRI, but eliminates the need for an MRI tube. "It's very comparable to having a camera take pictures, like a mammogram," Dalton says. "There are a lot of people who are claustrophobic. They can't get into an MRI. About 14 percent of people absolutely refuse, even though these are patients who should be motivated to do it." Modalities such as MRI, tomosynthesis and nuclear breast imaging are not expected to replace film or digital mammography. "They are niche tools or supplemental tools for certain people," Dalton says, and are likely to be used with high-risk patients and those who have dense breasts that can make some cancers tough to see. Many hospitals do not yet offer new breast imaging technology, including digital mammography, probably because of the significant investment the related equipment requires. The important thing for women to remember, experts agree, is to be screened regularly, even if the exam relies on old-fashioned film. Ideally, a younger woman or a woman with dense breasts will get digital mammograms, Tosteson says. "But if the choice is between no mammogram or a film mammogram, have a film mammogram." NH The list of digital mammography advantages over film is quite long, and also includes: Less radiation. A digital mammogram requires about 22 percent less radiation than film mammography. Easy access and transmission. Digital images can quickly be fired off to diagnosticians and surgeons within a healthcare facility or around the world if need be, which is especially valuable to women in rural areas who might desire the opinion of a specialist located many miles away. Convenient, less expensive storage and comparison. Digital files do not take up valuable hospital real estate the way film images do and are less likely to be misplaced. And, with a digital system, comparing last year's image to this year's is a snap. Enhanced viewing capability. An expert reviewing a digital mammogram can enlarge the image, zoom in, adjust the contrast and change black to white or white to black to create a clearer picture. Fewer callbacks. A digital mammogram is less likely to need to be retaken, a definite plus to anyone who has experienced the sobering feeling of being called back for more photos because the radiologist wants to get a closer look at something.

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