Digital breast tomosynthesis: my adoption journey

July 30, 2018
By Dr. Regina Hooley

There are often questions among radiologists surrounding the topic of adopting digital breast tomosynthesis (DBT) and how to best implement this exam for clinicians and patients. As a breast imager and an associate professor and vice chair for clinical affairs in the Department of Radiology and Biomedical Imaging at the Yale School of Medicine, I have firsthand experience in the transition from conventional 2D full field digital mammography (FFDM) to DBT. In fact, Yale participated in a very early DBT clinical trial before this form of screening was even FDA approved, and since then, I have witnessed its many benefits for both my peers and patients time and again. As I reflect upon these experiences, from installation to present day, I can confidently say that any healthcare executives who are deciding whether or not their facilities should transition to using DBT should make up their minds with a resounding yes.

Like in any industry, the introduction of new technology and protocols can be intimidating to staff members who are already comfortable with traditional processes. Fortunately, in my experience this was not the case with DBT. Everyone in my group quickly discovered that it was not at all difficult to teach the mammography technologists how to use it, due in large part to the technique being very similar to conventional 2D FFDM. The main key to success is that the technologists need to learn how to best teach the patients to breathe during the exam, since tomosynthesis takes a few seconds longer than the traditional 2D FFDM. As is always the case, it is still important that the patients try not to move while the technologist is taking the 3D "picture" so that the image is not blurry. Mastering the technical usage of this new technology may not seem so different from its predecessor, but its effects are far from the same.

The main benefit of DBT was clear and undeniable to me very early on after initial usage. It’s no secret today that the primary benefit of DBT for both clinicians and patients is that DBT provides more accuracy. Any radiologist knows that, above all else, accuracy is the most important part of a mammogram and biopsy. It’s what enables us to be able to identify more early cancers so that those patients diagnosed with breast cancer will often have the option of less aggressive treatment while still increasing survival. From personal experience, I know accuracy is what also helps lessen false positive recalls, resulting in a reduced need for diagnostic mammograms as well as short interval follow-up recommendations.

The single benefit of accuracy spans far beyond what initially meets the eye. By providing more accurate mammograms and biopsies, clinicians are really offering something on a larger scale – more positive patient experiences. Patients diagnosed with cancer are able to begin treatment sooner to, hopefully, get better, while fewer women are having to experience the anxiety undoubtedly associated with a recall for additional diagnostic workup. In my practice, we have noticed a 50 percent decrease in screening recalls and fewer short interval follow-up mammograms. DBT’s accuracy is improving the overall patient outcome for all, from start to finish. Likewise, facilities as a whole can benefit from the ability to serve more patients in a day, and more positive patient experiences can translate into higher performance scores.

Another advantage I gained by adopting DBT is an improvement in workflow. Due to the reduction of the number of diagnostic mammograms needed as a result of the technology, radiologists are able to offer more screening patients immediate results instead of their having to wait to receive a letter in the mail telling them their mammogram is normal. When patients are recalled for a possible abnormal finding on their screening mammogram, more often than not, they are first worked up with ultrasound. The 3D DBT images show so much detail that a diagnostic mammogram is often not necessary. Furthermore, even if a diagnostic mammogram is needed, often fewer images are required, which saves a lot of time for radiologists and patients. For stereotactic breast biopsies, I have found that with DBT it is much easier to target the lesion and therefore significantly reduce the procedure time, which satisfies the patients, technologists, and radiologists.

The way I see it, I always want to offer my patients the best possible care, and DBT allows just that. In an era when saving time, working efficiently, and maintaining high quality delivery of care are simultaneously at the top of our priority list, it should not be lost on anyone that DBT can help to achieve all of these goals at once with its superior accuracy. Not to mention, each day we’re continuing to learn even more about the complexities of breast cancer, including that a woman’s breast density classification can affect her screening outcome and breast cancer risk, making accuracy that much more critical to attain and perfect.

There is a lot more information for the radiologist to process on the DBT mammogram compared to the conventional 2D FFDM, but overall the learning curve for adoption is fairly quick and intuitive. In fact, in my experience, one of the greatest challenges with transitioning to DBT was not with the technology itself, but rather, working out how to charge for the exam. Initially, insurance companies did not reimburse for DBT, but fortunately, many insurance companies now do because its overall benefit to women has been established, and providing the service to patients does require a capital expense by the radiology practice. At Yale, even at the inception of DBT, we initially decided not to charge patients extra fees for DBT since we believed so strongly that all women should receive its many benefits despite their financial bracket. This is a true testament to the worth my colleagues and I place on this invaluable technology. DBT is a superior mammogram and there is no going back to 2D mammography alone.
Dr. Regina Hooley

About the Author: Dr. Regina Hooley is an associate professor and vice chair for clinical affairs in the Department of Radiology and Biomedical Imaging at the Yale School of Medicine.