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Mammography and Breast Imaging Workflows

Enterprise imaging has played a pivotal role in modern medicine by supporting the diagnosis and treatment of a disease. Encompassing ultrasonography, x-rays, mammography, computed tomography (CT scans), and nuclear medicine, medical imaging is crucial in a variety of medical settings and at all major levels of health care. The use of diagnostic imaging services is essential in confirming, assessing, and documenting the course of many diseases and response to treatment

Mammography is a specialized type of medical imaging that helps detect breast cancer and other abnormalities in breast tissue. It is a low-dose x-ray examination that creates detailed images of the breast. It is a non-invasive procedure that is typically performed at an outpatient facility.

What is a Mammography Procedure?

A mammography procedure takes place using a low-dose x-ray machine, full-field digital mammography (FFDM) machine, film-screen mammography machine, or 3D mammography (tomosynthesis) machine. During the procedure, a radiologic technologist or a breast imaging specialist (mammographer) places the breast on a plate near the x-ray machine while the machine lowers another plate that firmly presses the patient’s breast from above. The breast is compressed between two plates in order to spread out the breast tissue and reduce the amount of radiation needed to produce a clear image. The compression can cause some discomfort, but it is usually minimal and only lasts for a few seconds. This is repeated again to obtain a side view of the breast.

The recommended age for a woman to start getting routine mammograms varies depending on various factors such as personal and family medical history, breast density, and other risk factors.

The following guidance has been established by the American Cancer Society for women at average breast cancer risk.

These guidelines are for women at average risk for breast cancer. For screening purposes, a woman is considered to be at average risk if she doesn’t have a personal history of breast cancer, a strong family history of breast cancer, or a genetic mutation known to increase the risk of breast cancer (such as in a BRCA gene), and has not had chest radiation therapy before the age of 30.

  • Women between 40 and 44 have the option to start screening with a mammogram every year.
  • Women 45 to 54 should get mammograms every year.
  • Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
  • All women should understand what to expect when getting a mammogram for breast cancer screening – what the test can and cannot do.
Clinical breast exams are not recommended for breast cancer screening among average-risk women at any age.

What are the types of mammogram procedures?

The different types of mammography exams include
  • Diagnostic mammogram: This exam is used to evaluate a specific breast change or symptom, such as a lump or nipple discharge.
  • Screening mammogram: This is a routine exam used to detect breast cancer in women who have no symptoms.
  • 3D mammography (Tomosynthesis): This is a newer type of mammogram that creates a three-dimensional image of the breast to help detect breast cancer.
  • Ultrasound or Magnetic Resonance Imaging (MRI): If an abnormal area is found and additional imaging tests are needed to further evaluate the area. In some cases, a biopsy may be recommended to remove a sample of the tissue for further analysis.

3D tomosynthesis has better lesion detection than 2D mammography as it prevents the masking effect of the overlying normal breast tissue and therefore allows the detection of your cancer. Source: radiology.co.nz

According to statistics from the FDA from June 1, 2022, about 83% of U.S. screening facilities now offer 3D mammograms in at least one of their mammography units, but fewer than half of all accredited units are actually 3D-capable.

Where are Mammograms performed?

In most cases, mammogram procedures occur at medical imaging centers, such as radiology practices, imaging centers, and hospital-based departments. Mammography centers can also be standalone facilities, while others are part of larger medical centers or hospital IDNs and are included in the women’s health clinics or breast center facilities.
For more remote locations or frontier health regions, mammograms may also be performed in mobile units or at off-site locations and depend on several factors, such as convenience, availability, cost, insurance coverage, and patient preference. These units are equipped with mammography equipment and staffed by radiologic technologists or breast imaging specialists, who perform the mammograms and send the images to the radiologist for reading, diagnosis, and interpretation.

According to the American College of Radiology (ACR), as of 2021, there were over 17,000 accredited mammography facilities in the United States. The ACR is one of the most recognized accreditation organizations for mammography centers. It is important to note that not all mammography centers are accredited, and a significant number of mammography procedures are also performed in hospital-based and clinic-based facilities.

What is the continuum of care and process for the patient?

There are several stages of the care continuum that are related to mammography and breast imaging including
  1. Patient Scheduling and Registration includes appointment setting for mammograms, registering patients, and providing education about the procedure.
  2. Image Acquisition captures mammographic images and sends them to the PACS/MIMPS system for storage and retrieval.
  3. Image Interpretation involves interpreting mammographic images by radiologists or other specialists for diagnosis.
  4. Reporting and Communication summarize the findings of the mammographic examination by creating reports and sending them to the referring physician and other members of the patient’s healthcare team.
  5. Quality Control consists of monitoring the performance of the mammography equipment and ensuring that the images are of high quality and accuracy. Clinical image quality can affect the accuracy of radiological diagnosis.
  6. Data Management requires managing the data associated with mammography examinations, such as patient demographics, medical history, and imaging data.
  7. Breast Density Management: incorporates assessing and classifying breast tissue density using automated or semi-automated techniques, and providing additional imaging or clinical recommendations as needed. As of 2019, all mammography reports and the lay summaries provided to patients must include information about women’s breast density.
  8. Data Analytics includes analyzing data from mammography examinations to identify trends and patterns and using the information to improve patient outcomes and the overall quality of care.
  9. Archiving and Retrieval entail archiving mammographic images and associated Dicom and non-Dicom data in a long-term storage system and providing fast and secure access to the images for authorized users.
  10. Patient Follow-up includes scheduling follow-up appointments and exams and communicating with patients and providers to ensure continuity of care.

What are the types of mammography images?

There are two main types of mammography images:
  • Digital mammography: uses produces Full-Field Digital Mammography (FFDM) to create digital images of the breast. A digital mammography machine captures X-ray images of the breast and converts them into digital data that can be stored and manipulated electronically. This method is commonly used for breast cancer screening and diagnostic evaluation. Two types of mammograms are available in the United States: 3D mammograms — also called digital breast tomosynthesis, digital tomosynthesis, or just tomosynthesis — and 2D digital mammograms.
  • Film mammography: uses X-rays to produce an image of the breast on traditional X-ray film. Film mammography has been the standard method for breast cancer screening and diagnostic evaluation for many years. However, it has largely been replaced by digital mammography, which provides several advantages over film mammography, such as the ability to easily store and manipulate images electronically, improved image quality, and better visualization of dense breast tissue.

Digital mammography image

History of Mammography

The history of radiology dates back to the early 20th century in 1895 when Wilhelm Conrad Röntgen captured the first x-ray of his wife’s hand. This breakthrough advancement became the standard worldwide for clinical discovery and treatments.

Wilhelm Conrad Röntgen takes the first X-ray of his wife Anna Bertha Röntgen’s hand, with her rings. 1895. Source: Sensaweb

The first study of mastectomies was considered the beginning of mammography and was performed in
1913 by Jewish-German surgeon Albert Salomon. In his study, Salomon conducted 3,000 mastectomies, and compared X-rays of the breasts to the actually removed tissue, observing microcalcifications. His research was able to establish the difference as seen on an X-ray image between cancerous and non-cancerous tumors in the breast.

In 1930, American physician, radiologist, and pioneer in the field of nuclear medicine Stafford L. Warren used radiology to identify changes in breast tissue, He developed a stereoscopic technique where the patient would lie on the side with one arm raised while being x-rayed. This subtle change in the positioning of the patient was a huge breakthrough for breast cancer detection, as it allowed diagnosis of breast cancer to be possible without invasive surgery. Warren subsequently published “A Roentgenologic Study of the Breast” in 1930. Warren is cited as the inventor of the mammogram for his breast imaging technique.

It took almost 50 years from 1930 to the 1960s-1970s for mammography to become widely used as a screening tool for breast cancer. In the 1980s and 1990s, digital mammography became more widely adopted. This new technology allowed images to be captured and stored electronically, which made it easier to store, transmit, and manipulate images. In addition, digital mammography also improved image quality and provided better visualization of dense breast tissue.

Digital breast tomosynthesis (DBT) was approved by the FDA for breast cancer screening in 2011, subsequently becoming a standard of care. This technique acquires a series of low-dose breast tissue images and then reconstructs them into thin parallel planes through a computer algorithm. DBT is particularly useful for women with denser breast tissue, as cancer is harder to detect in such cases. According to retrospective studies in the U.S. and prospective studies in Europe, combining DBT with conventional 2D mammography leads to decreased recall rates and improved breast cancer detection. False positives also decreased, which reduces the need for additional imaging, office visits, and other downstream costs.

What types of enterprise imaging workflows are related to mammography?
Digital Imaging and Communications in Medicine (DICOM) is the standard for the communicating and managing of medical imaging information and related data. DICOM is most commonly used for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and PACS (picture archiving and communication systems) from multiple manufacturers. In mammography and breast imaging, DICOM is critical in streamlining workflows, improving the accuracy and efficiency of diagnoses, and enabling better patient care. DICOM systems support mammography and breast imaging workflows including

  1. Image storage: DICOM allows for the secure storage and retrieval of mammogram images and other related information, such as patient demographic data, radiology reports, and relevant priors.
  2. Image transmission: DICOM facilitates the secure and efficient transmission of mammogram images between different healthcare providers, such as radiologists, referring physicians, and patients.
  3. Image visualization: DICOM provides tools for visualizing and manipulating mammogram images, including image enhancement, zooming, and panning. This can aid in the interpretation of the images and help to improve the accuracy of diagnoses.
  4. Image analysis: DICOM supports advanced image analysis and processing techniques, such as computer-aided detection (CAD), which can help to identify potential breast cancer lesions and reduce the number of false positive results.
These workflows can be integrated into an enterprise imaging platform to provide a seamless experience for the patients and the healthcare providers and ensure the best outcomes.

Workflow Challenges in Mammography and Breast Imaging

In breast imaging, decision-making, and patient management pose unique challenges. The goal of detecting nonpalpable cancers while minimizing false positives requires a delicate balance, resulting in distinct practice patterns and challenges. Breast imaging also presents other challenges, including inappropriate indications for mammography breast intervention, dense breasts, double reads, clinical breast exams during screening, imaging the male breast, and overdiagnosis of breast cancer through screening mammography. In addition, many breast imaging centers struggle specifically with workflow challenges that impact efficiency, productivity, and patient care.

  1. Disparate systems: radiologists are often required to utilize multiple imaging systems to interpret a patient’s medical images and formulate a comprehensive report. These disparate systems can often result in inefficiencies in the reading process due to various interfaces needed to access the images.
  2. Communication: the need for efficient communication between breast center staff and radiologists is paramount. However, in some cases, the only option for technicians to discuss an issue with the reading radiologist is to physically stand in line outside the physician’s door. This can lead to significant time wastage, taking staff away from patient care and disrupting the smooth flow of operations. Finding alternative communication methods could mitigate these challenges and facilitate better staff collaboration to deliver quality care.
  3. Study Prioritization: A critical aspect of the mammography workflow is the prioritization of studies. Within the extensive list of studies awaiting interpretation, there may be time-sensitive cases that require urgent follow-up or intervention. Failure to accurately identify, prioritize and read these studies can lead to delays for patients who might need immediate care.
  4. Information from multiple screens. Another challenge for radiologists is retrieving necessary information from disparate locations across multiple screens, even when a single system is available to evaluate patient studies. The need to toggle between different screens to locate relevant data can result in decreased efficiency and longer reading times.
  5. Inadequate clarity of workflow lists: may impede a reading radiologist’s productivity, resulting in an ineffective task prioritization approach. Clear “to-do” lists can assist radiologists in maximizing their time by completing important tasks first, rather than wasting time attempting to sort through their duties.
  6. Balancing the load evenly. Achieving workload balance in a bustling breast center can be a daunting task as it can be difficult to discern which radiologists have a heavy reading load and which ones have the capacity to appraise additional studies. However, an evenly distributed workload is indispensable for ensuring the optimal efficiency of the center.
  7. Mammography study normalization: this is essential and relies heavily on proper mammography study normalization by the radiologist/diagnostician. Failure to correctly classify the SOP, UID, and modality type may lead to incorrect study classification and misinterpretation.
  8. Proprietary file conversion. Certain vendors store and display mammography exams in proprietary formats Chronic total occlusion (CTO) and Secondary Capture Object (SCO), and cannot be viewed by other viewers which can present workflow challenges. These file formats need to be converted into standard Breast Tomosynthesis Objects (BTO) to pull relevant prior studies for the proper diagnosis. It is important to recognize which proprietary files are included in the workflow and obtain the proper tools for conversion.
  9. Obtaining Relevant Priors: The importance of pulling relevant priors cannot be overstated. False positives cause unnecessary anxiety to patients and put increased financial, time, and energy demands on all involved—patients, practice staff, and the greater healthcare system. Mammography priors provide essential information for comparison with current studies. It may be necessary to pull all relevant studies based on the region and body part, not just the mammography modality type.
From a workflow perspective, the timing of relevant mammography prior to study retrievals may also present a challenge. Mammograms are often scheduled long in advance, long before they need to appear on a technologist’s modality work list, and long before the images need to be reviewed by the radiologist. Not only is it important to create a worklist entry in time for the patient’s scheduled procedure, but it is also crucial to time the retrieval of relevant priors in line with the needs of the reading physician. Suppose the prior images need to be prefetched from a long-term archive. In that case, the prefetching rules may trigger a retrieval at the wrong time, thereby unnecessarily populating the PACS and the reading worklist with exams that won’t be needed for weeks or months down the line.
  1. Image Size and transfer speed: Mammography studies can range from 450 MB to 3 GB in size. This increase in file size may slow digital image transmission and the use of storage media. Queue prioritization and bandwidth optimization are crucial to improving turnaround times.

The importance of relevant priors for mammography and breast imaging

Relevant priors, such as previous mammograms, biopsies, or imaging studies, is crucial in interpreting current mammogram images, providing additional context and differentiating between new changes and longstanding findings. Diagnostic mammograms require prior images for comparison to determine a personalized plan based on medical history and unique needs, particularly for women with breast abnormalities or symptoms.

For example, if a woman has a history of benign cysts in one area of her breast, a radiologist may be able to identify a similar appearing cyst on a current mammogram and not interpret it as a new finding requiring further evaluation.
By incorporating relevant priors into the interpretation, radiologists can more accurately distinguish between benign and suspicious findings, reducing false positives and unnecessary biopsies. This ultimately improves the accuracy and specificity of the mammogram, benefiting patient care. Gaining access to these studies can sometimes be problematic. Patients who had prior imaging done at a different facility need to bring CDs or DVDs of these prior studies and the existing PACS needs a foolproof methodology for uploading these studies for comparison. Patients should maintain records of previous mammograms and communicate past breast health concerns or biopsy results to their healthcare provider.

Digital Imaging and Communications in Medicine (DICOM) for mammography and breast imaging

Digital Imaging and Communications in Medicine (DICOM) is the standard for the communication and management of medical imaging information and related data. DICOM is most commonly used for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and PACS (picture archiving and communication systems) from multiple manufacturers. In mammography and breast imaging, DICOM is critical in streamlining workflows, improving the accuracy and efficiency of diagnoses, and enabling better patient care. DICOM systems support mammography and breast imaging workflows including:

  1. Image storage: DICOM allows for the secure storage and retrieval of mammogram images and other related information, such as patient demographic data, radiology reports, and relevant priors.
  2. Image transmission: DICOM facilitates the secure and efficient transmission of mammogram images between different healthcare providers, such as radiologists, referring physicians, and patients.
  3. Image visualization: DICOM provides tools for visualizing and manipulating mammogram images, including image enhancement, zooming, and panning. This can aid in the interpretation of the images and help to improve the accuracy of diagnoses.
  4. Image analysis: DICOM supports advanced image analysis and processing techniques, such as computer-aided detection (CAD), which can help to identify potential breast cancer lesions and reduce the number of false positive results.

Dicom Systems Mammography and Breast Imaging Workflows

Managing the imaging workflows at mammography and breast imaging centers presents a unique set of challenges. The Unifier platform from Dicom Systems provides a comprehensive solution for managing mammography images leveraging specialized workflows, that allow users to interoperate between systems, retrieve prior images, modify modality worklists, query-retrieve proxy, balance load, convert files, prioritize studies, and integrate third-party apps.

One of the biggest challenges in mammography imaging is managing the large file sizes of tomosynthesis (3D mammography) studies, which can range from 450 MB to 3 GB. On-the-fly compression and network transfer optimization, and study prioritization with an enhanced routing queue, are some of the features Unifier offers to help optimize transfer speed and turnaround time. Read more about imaging data transmission speed in our whitepaper.

It is imperative to pull relevant prior studies stored in proprietary formats such as CTO and SCO when the mammography equipment is aging and being upgraded. The ability to manage proprietary file formats and convert them to a standard (BTO) is very important for complying with standard mammography viewing protocols. By converting proprietary files into BTO, Unifier streamlines workflows and reduces IT and clinical challenges.

Proper timing is also critical in mammography imaging, with mammograms often scheduled long before the patient’s procedure and reviewed by the radiologist. The Unifier platform’s DICOM modality worklist can be configured up to a year in advance, allowing for scheduling HL7 messages and orders to ensure relevant priors are retrieved at the right time.

In addition to these features, Unifier also allows for easy integration of third-party apps and serves as a backup and disaster recovery archive. It can be used as the primary archive for a vendor-neutral archive or as a backup, disaster recovery, or business continuance service using on-prem or cloud infrastructure.
If you are looking to streamline your mammography and breast imaging workflow and overcome these challenges, consider the Unifier platform by Dicom Systems. Contact an enterprise imaging workflow expert to learn more about how Unifier can help you achieve greater efficiency and productivity in your imaging operations.
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