Andrew J. Lukaszewicz, MD Raffat Ahmad, MD Mary Maunglay, MD Sarah K. Shields, MD Dustin Covell, MD Cory Trivax, MD

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1 Andrew J. Lukaszewicz, MD Raffat Ahmad, MD Mary Maunglay, MD Sarah K. Shields, MD Dustin Cvell, MD Cry Trivax, MD

2 Nne f the authrs have any financial disclsures

3 1. Learn abut what digital breast tmsynthesis (DBT) is and hw it wrks, including the steps in image acquisitin. 2. Review several studies, which cmpare DBT t digital mammgraphy (DM), and see hw the tw imaging mdalities relate. 3. Understand the prs and cns f each imaging technique. 4. Appreciate hw breast tmsynthesis is being implemented as an adjunct t cnventinal mammgraphy, bth in Canada and arund the wrld.

4 Digital breast tmsynthesis (DBT) allws fr multiple, lw-dse images t be btained frm different angles, and assembled int a threedimensinal image DBT has been apprved by Health Canada fr clinical use in 2009, fllwed by the Fd and Drug Administratin (FDA) in the United States in There is cntrversy ver its efficacy, csteffectiveness and verall rle in breast cancer screening and diagnsis

5 The breast is held statinary and cmpressed in traditinal CC and MLO views 2 An x-ray surce mves alng a fixed linear, circular r elliptical arc abve the statinary breast and detectr 2 Multiple (11-15) x-ray images are acquired as the surce mves alng an arc f varying degrees, dependent n the mdel and manufacturer 2 Images are recnstructed using mathematical algrithms similar t that used in cmputed tmgraphy 3 Wider angles permit thinner slice thickness recnstructins, hwever a 1 mm slice thickness is generally btained 3

6 Images may be acquired by the step and sht methd r by cntinuus pulsed shrt expsures 2 Step and sht leads t lnger imaging time and mtin artifact Cntinuus pulsed expsures may lead t blurring if pulse length is inapprpriately lng X-ray detectrs may be made f selenium r cesium with thallium Selenium based detectrs have high detective quantum efficiency with >95% x-ray absrptin at typical x-ray energies 4

7 Figure 1. As the x-ray surce rtates alng an arc, it takes multiple images (degree interval dependent n manufacturer). These discrete images are recnstructed int a three-dimensinal image, but are als available fr individual viewing.

8 Figure 2. DBT scanner used at ur institutin, with cnsle pictured in the backgrund.

9 Figure 3 (left). DM CC view f the right breast in a patient with hetergeneusly dense breasts. Figure 4 (right). DBT CC image in the same patient allws fr better visualizatin f dense fibrglandular areas, by reducing summatin artifact frm verlapping breast tissue.

10 Figure 5. DM MLO view f a hetergeneusly dense right breast. Figure 6. DBT MLO view in the same patient, making mre apparent an area f architectural distrtin.

11 Initial results frm clinical studies shw higher cancer detectin rates using DBT in cnjunctin with DM 5,6,7, as well as fr DBT alne 8,9 Studies als shw a reductin in recall rates 6,8,10 Recall rates were reduced in all age grups and breast density subgrups, and were significant fr patients in the fifth decade f life, and fr hetergeneusly and extremely dense breast subgrups 7,9

12 DBT used alngside DM shwed significantly greater sensitivity when the dminant radilgical feature was a mass 7 There was als imprved depictin f lesins whse dminant radilgic feature were architectural distrtin r asymmetry In lieu f using a cmbinatin f DBT and DM, synthetic 2D recnstructed images have recently been apprved by the FDA, ptentially eliminating the need fr cnventinal DM in sme patients 10

13 Reduced summatin artifact frm verlapping breast tissue 11 Higher cancer detectin rates 8,9 Reduced recall rates 6,8 Which may lead t fewer missed wrk days, less patient anxiety, fewer additinal imaging evaluatins, fewer unnecessary bipsies and ptentially decreased health care csts 9 Increased cancers fund per recall 12 Dse f inizing radiatin is reduced by half when DBT is used in lieu f DM 13 Overall dse may further be lwered, by reducing the need fr additinal recall-related imaging DBT may be especially useful in yunger patients with dense breasts 7

14 Radiatin dse is increased tw-fld if DM and DBT are use cncurrently 13 Lnger image acquisitin and interpretatin times 14 Higher expenses related t equipment csts, training and strage f larger image files 14 Even thugh DBT may be superir t DM in certain patients, cancers may still be missed 10 Large calcificatins can cause substantial artifact n DBT 10

15 US Preventive Services Task Frce (USPSTF) updated its 2009 recmmendatins fr breast cancer screening in February 2016, stating insufficient evidence t assess : Benefits f DBT as a primary screening methd 15 Benefits and harms f DBT as an adjunct screening, cupled with ther mdalities, in wmen with dense breasts n negative DM screening mammgram 15 Medicare began reimbursing fr DBT in Must be dcumented in dictatin, and be perfrmed in cnjunctin with a screening r diagnstic digital mammgram Nt reimbursed as a stand alne examinatin Mst private insurances d nt cver DBT, citing it t be an investigatinal technlgy

16 In Canada Thugh apprved by Health Canada, regulatry agencies are waiting fr further research int its lng-term efficacy and cst-effectiveness 1 Current clinical trials underway (e.g. Sunnybrk Health Sciences in Trnt) Arund the wrld Has been in sparse clinical use since 2009 in Nrth and Suth America, Eurpe and Asia 1 Currently used in an ad-hc fashin nly 1

17 Shuld DBT be used in screening, diagnsis r bth? As a substitute fr DM, r as an adjunct? Shuld ne r tw-view DBT images be btained? Is it cst-effective t use DBT, given the lnger image acquisitin and interpretatin times? D higher cancer detectin rates lead t better patient utcmes (e.g. imprved survival)?

18 Increased cancer detectin and reduced recall rates have been shwn in studies cmparing DBT t either DM r t a cmbinatin f bth Hwever, there is a lack f evidence frm larger, lngterm studies, which are nging Ecnmic aspects must als be taken int cnsideratin Radilgists invlved in breast imaging shuld be acquainted with current and frthcming literature n DBT, as this mdality will likely becme a part f daily practice in ne way r anther, in the freseeable future

1. Appav S, Aldis A, Causer P et al. CAR Practice Guidelines and Technical Standards fr Breast Imaging. Canadian Assciatin f Radilgists. 2012. car.ca/en/standards-guidelines/standards.aspx.

19 1. Appav S, Aldis A, Causer P et al. CAR Practice Guidelines and Technical Standards fr Breast Imaging. Canadian Assciatin f Radilgists car.ca/en/standards-guidelines/standards.aspx. Accessed n February 25, Niklasn LT, Christian BT, Niklasn LE et al. Digital tmsynthesis in breast imaging. Radilgy. 1997;205(2): Suryanarayanan S, Karellas A, Vedantham S et al. Cmparisn f tmsynthesis methds used with digital mammgraphy. Acad Radil. 2000;7(12): Smith A. Full-field breast tmsynthesis. Radil Manage. 2005;27(5): Lång K, Anderssn I, Rss A et al. Perfrmance f ne-view breast tmsynthesis as a stand-alne breast cancer screening mdality: results frm the Malmö Breast Tmsynthesis Screening Trial, a ppulatin-based study. Eur Radil. 2016;26(1): Vedantham S, Karellas A, Vijayaraghavan G et al. Digital Breast Tmsynthesis: State f the Art. Radilgy. 2015;277(3): Gilbert FJ, Tucker L, Gillan MG et al. Accuracy f Digital Breast Tmsynthesis fr Depicting Breast Cancer Subgrups in a UK Retrspective Reading Study (TOMMY Trial). Radilgy. 2015;277(3): Cnant EF, Beaber EF, Sprague BL. Breast cancer screening using tmsynthesis in cmbinatin with digital mammgraphy cmpared t digital mammgraphy alne: a chrt study within the PROSPR cnsrtium. Breast Cancer Res Treat. 2016;156(1): Sharpe RE, Venkataraman S, Phillips J. Increased Cancer Detectin Rate and Variatins in the Recall Rate Resulting frm Implementatin f 3D Digital Breast Tmsynthesis int a Ppulatin-based Screening Prgram. Radilgy. 2016;278(3): Rth RG, Maidment AD, Weinstein SP et al. Digital Breast Tmsynthesis: Lessns Learned frm Early Clinical Implementatin. Radigraphics. 2014;34:E Peppard HR, Nichlsn BE, Rchman CM et al. Digital Breast Tmsynthesis in the Diagnstic Setting: Indicatins and Clinical Applicatins. Radigraphics. 2015;35: McDnald ES, Oustimv A, Weinstein SP et al. Effectiveness f Digital Breast Tmsynthesis Cmpared With Digital Mammgraphy. JAMA Oncl. 2016; di: /jamancl Svahn TM, Hussami N, Sechpuls I et al. Review f radiatin dse estimates in digital breast tmsynthesis relative t thse in tw-view full-field digital mammgraphy. Breast. 2015;24(2): Gilbert FJ, Tucker L, Yung KC. Digital breast tmsynthesis (DBT): a review f the evidence fr use as a screening tl. Clin Radil. 2016;71(2): Siu AL, n behalf f the U.S. Preventive Services Task Frce. Screening fr Breast Cancer: U.S. Preventive Services Task Frce Recmmendatin Statement. Ann Intern Med. 2016;164: CMS Establishes Breast Tmsynthesis Values in 2015 MPFS Final Rule. American Cllege f Radilgy. News-Publicatins/News/News-Articles/2014/Ecnmics/ CMS-Establishes-Values-fr-Breast- Tmsynthesis-in-2015-Final-Rule. Accessed March 1, 2016.

20 Thank yu fr taking the time t review ur exhibit! Andrew Lukaszewicz, MD may be reached at a.lukaszewicz@utrnt.ca r by pstal mail at: St. Jseph Mercy Oakland Department f Radilgy Wdward Avenue Pntiac, MI USA

2. How are screening and diagnostic mammograms different?

2. How are screening and diagnostic mammograms different? Mammgrams cmprises public dmain material frm the Natinal Cancer Institute at the Natinal Institutes f Health, an agency f the U.S. Department f Health and Human Services. Mammgrams Key Pints A mammgram