CT Colonography recommended as screening option to lower cancer mortality – Press Release – June 16, 2016
Radiologists of Washington State are applauding this week’s announcement by the U.S. Preventive Services Task Force (USPSTF) that adults age 50-75 can be routinely screened utilizing using CT colonography as an alternative to previously recommended methods such as routine colonoscopy.
Washington State Radiological Society (WSRS) President Dr. Eric Stern stated “our member radiologists enthusiastically welcome this announcement which recognizes that many Americans do not get screened for colon cancer and that CT colography may be a way to get more adults to seek screening.” Dr. Stern predicts that this change in recommendation could ultimately save many lives.
The USPSTF recommendations, published in the Journal of the American Medical Association this week, concluded that “screening for colorectal cancer in average-risk, asymptomatic adults aged 50-75 years is of substantial net benefit.”
The newly released conclusion, based on USPSTF’s extensive evidence review, updates the previous recommendations of national health advocacy groups such as the American Cancer Society which had in recent years advocated for screening by colonoscopy and other types of tests on a particular schedule. CT colonography has now been included as one of seven acceptable options for colorectal cancer screening in the task force’s final recommendation. The findings recognize that CT colonography, a radiology-based test which is less invasive than a traditional colonoscopy, is another excellent option for screening. CT Colonography, sometimes referred to as ‘virtual colonoscopy’, is an American Cancer Society-recommended screening exam that has been shown in studies in the United States and abroad to increase screening rates where offered. Virtual colonoscopy has been proven comparably accurate to colonoscopy in most people of screening age.
The USPSTF study recognized that a large percentage of the population ages 50-75 are currently not getting any type of screening. In a recent statement, the American College of Radiology estimated that “a third of those who should be screened for colorectal cancer still choose not to be tested. Patients need more fully covered screening options if we are going to reduce colorectal cancer deaths.”
According to William T. Thorwarth, MD, FACR, chief executive officer of the American College of Radiology, now that the technology of CT colonography has been recognized as effective by the USPSTF, “Private insurers and Medicare should fully cover virtual colorectal colonoscopy [CT colonography] and the other USPSTF-recognized exams.”
The full study is found at http://jama.jamanetwork.com/article.aspx?articleid=2529486
Press Release – November 14, 2014
Radiologists of Washington State are applauding this week’s announcement by The Centers for Medicare and Medicaid Services (CMS) of a draft proposal to cover an annual low-dose CT scan for Medicare beneficiaries at high risk for developing lung cancer.
WSRS President, Dr. Eric Stern stated “Our member radiologists enthusiastically welcome and endorse this draft proposal. Low dose chest CT scan screening will save thousands of lives each year from the nation’s leading cancer killer.” Dr. Stern added, “We strongly advise current and former heavy smokers to speak with their doctors about whether CT lung cancer screening is right for them. If they and their doctor decide that screening is warranted, we encourage patients to seek out care at an ACR lung cancer screening center.”
Medicare has determined that people who meet three criteria—55 to 74 years of age, a smoking history of 30 pack years and still smoking or have quit smoking within the last 15 years— are considered high risk and will be eligible for an annual low-dose CT scan, according to the proposal. In order to receive this scan, Medicare proposes they will need to go to a radiology imaging center whose experts have significant experience in recognizing lung cancer in CT scans. Physicians can help their patients determine whether they meet the criteria for annual screening.
“CT lung cancer screening is the first and only cost-effective test proven to significantly reduce lung cancer deaths” said Ella Kazerooni, M.D., FACR, chair of the American College of Radiology Lung Cancer Screening Committee and American College of Radiology Thoracic Imaging Panel.
Commuted tomography (CT) screening is a test used to detect lung cancer before any symptoms appear. Results of the National Lung Screening Trial (NLST) released in August, 2011, showed that screening with low-dose spiral computed tomography (CT) scans versus standard chest X-rays reduced lung cancer deaths among older heavy smokers by 20 percent. Improved detection at earlier stages, when lung cancer is more easily treated, is key to increased survival, according to the study.
According to the American College of Radiology, more than 220,000 people will be diagnosed with lung cancer nation-wide this year. Nearly 160,000 people will die from the disease– more than breast, colon and prostate cancers combined. Lung cancer is the leading cause of cancer death for both men and women in the United States. The five-year survival rate for lung cancer patients is only 17 percent.
“This is a great day for those at high-risk for lung cancer and their families. We look forward to a future where a lung cancer diagnosis is no longer essentially a death sentence for so many people,” said Dr. Kazerooni.
CMS is allowing the public to submit comments to Medicare in response to its proposal until December 10, 2014. A final announcement is expected in February 2015 at which time coverage for Medicare beneficiaries will begin. Members of the public may comment on the proposal directly from this page of the CMS.gov website.
Digital Breast Tomosynthesis – October 2014
The Washington State Radiological Society is a state chapter of the American College of Radiology with a primary mission to support the highest standards of diagnostic and therapeutic radiology for our members and patients.
Breast cancer affects one woman in eight in the United States and is the most common cancer diagnosed in women worldwide. It is estimated that in the United States in 2014 alone, more than 230,000 women will be diagnosed and nearly 40,000 women will die of breast cancer 1. Early detection is critical to improving long-term survival due to overall earlier stage at diagnosis. Screening for breast cancer with mammography has certainly contributed to improvement in survival from the disease, but there is ongoing debate about benefits, harms and cost-effectiveness of this tool. A limitation of 2D screening full field digital mammography (FFDM) is the inability to distinguish between a real abnormality and overlapping of normal structures. Many women are recalled from screening for evaluation of findings which do not prove to represent cancer. These false positives induce a cost to healthcare expenditures (due to the cascade of tests that follow including diagnostic mammography, ultrasound, and biopsy) and to patient peace of mind. In addition, some cancers are obscured by surrounding normal dense breast tissue, resulting in missed cancer.
The latest technologic advance in mammography is digital breast tomosynthesis (DBT), sometimes referred to as “3D mammography.” This was approved by the FDA on February 11, 2011. In addition to the conventional 2D mammogram, a second set of images is created by the X-ray beam sweeping through the breast creating multiple low-dose projection images. These images are reconstructed and displayed as thin “slices” of the breast with less superimposition of tissue compared to 2D mammography.
Since FDA approval, multiple studies have been published both within and outside the United States evaluating the benefit of adding DBT to standard digital mammography. DBT appears to decrease the recall rate and increase the cancer detection rate for mammographic screening, highly desirable improvements to 2D mammography. Here is a summary of the results of the relevant studies.
The first prospective screening trial to compare DBT to FFDM was published by Skaane et al 2. Researchers reviewed 12,631 screening examinations in a large hospital in Norway to compare FFDM+DBT to FFDM alone. In this interim analysis the researchers found that the addition of DBT resulted in a:
- 40% increase in the detection of invasive breast cancers.
- 27% increase in the detection of all cancers (invasive and in situ cancers combined).
- 15% decrease in false-positive rates.
Skaane’s study demonstrates that FFDM+DBT increased sensitivity and detection of true breast disease without compromising either the specificity for cancer or resulting in an increased rate of false positive results. The authors concluded that the addition of DBT to FFDM in a screening population resulted in a significant increase in cancer detection rates, particularly for invasive cancers and a simultaneous significant decrease in the false positive rate. The increase was observed across all breast densities.
The “Screening with Tomosynthesis OR standard Mammography” (STORM) trial 3 was a prospective comparative study which enrolled 7292 women in two institutions. Cancer detection rate and the rate of false positive recalls were compared between FFDM alone and FFDM + DBT. The cancer detection rate was 51% higher for FFDM+DBT than FFDM alone, while FFDM+DBT was also associated with a 17% reduction in false positive recalls.
Haas et al.,4 in a study of 6100 women receiving FFDM + DBT, recently reported a 30% reduction in recall rate with DBT screening. Rose et al. 5, in a study of 9499 women receiving FFDM + DBT reported a 53% increase in the detection of invasive cancers and a significant increase in the positive predictive value for screening recalls (PPV1) with 3D DBT compared with 2D FFDM alone.
In the largest study to date on the effectiveness of DBT comparing 281,187 conventional mammograms to 173,663 DBT exams, Friedewald et al. 6 , reported the following findings:
- A 41% increase in the detection of invasive breast cancers. (p<.001)
- Invasive cancers have spread beyond the walls of the ducts and into breast tissue. These cancers will continue to spread and require treatment.
- A 29% increase in the detection of all breast cancers. (p<.001)
- A 15% decrease in women recalled for additional imaging. (p<.001)
- A 49% increase in Positive Predictive Value (PPV) for a recall. (p<.001) PPV for recall is a widely used measure of the proportion of women recalled from screening that are found to have breast cancer. The PPV for a recall increased from 4.3 to 6.4%.
- A 21% increase in PPV for biopsy (p<.001). PPV for biopsy is a widely used measure of the proportion of women having a breast biopsy that are found to have breast cancer. The PPV for a breast biopsy increased from 24.2 to 29.2%.
- No significant change in the detection of ductal carcinoma in situ (DCIS). DCIS is a non-invasive cancer which has not spread beyond the milk duct into any normal surrounding breast tissue.
This study demonstrates that DBT is expected to result in the addition of one additional cancer detected per 1000 women screened.
Based on three years of available data reported on the use of DBT as an adjunct to 2D screening mammography, the Washington State Radiological Society acknowledges the following:
- 3D DBT addresses the limitations of 2D mammography in reducing tissue superimposition and presents an advanced imaging technology for the screening and diagnosis of breast cancer.
- Published clinical benefits to population-based screening using 3D DBT include increased detection of invasive breast cancer and a significant reduction in unnecessary call backs from screening mammography. These benefits have direct value in decreasing patient anxiety and reducing costs associated with call backs including diagnostic mammograms, time away from work, anxiety, ultrasounds and biopsies that are generated by false positives.
- 3D DBT should lead to improved detection of early cancers. Smaller cancers may be treated with fewer and/or less invasive procedures, less chemotherapy, less radiation therapy and less breast reconstruction which can improve patient outcomes and again decrease costs.
- 3D DBT has the potential to change the clinical pathway of care, abbreviating subsequent diagnostic services 7, which could also lead to an overall decrease in healthcare costs.
- 3D DBT is becoming more common in clinical practice with approximately 1,100 digital breast tomosynthesis systems currently available in the U.S. (all 50 states).
WSRS supports the adoption of DBT as an important advance in breast cancer screening. The WSRS urges the Centers for Medicare and Medicaid Services (CMS) and private insurers to facilitate access to these exams by adequately reimbursing for tomosynthesis — now that it has been shown to improve key screening parameters compared to digital mammography.
- American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014
- Skaane P, Bandos AI, Gullien R, et al. Comparison of Digital Mammography Alone and Digital Mammography Plus Tomosynthesis in a Population-based Screening Program. Radiology 2013, Apr; 267(1): 47-56.
- Ciatto S, Houssami N, Bernardi D, Caumo F, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Montemezzi S, Macaskill P. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013 Jun;14(7):583-9.
- Haas BM, Kaira V, Geisel J, Raghy M, Durand M, Philpotts LE. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology 2013; 269:694–700
- Rose SL, Tidwell AL Bujnoch LJ, Kushwaha AC, Nordmann AS, Sexton R. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR 2013; 200:1401–1408
- Friedewald S M, Rafferty E A, Rose S L, Durand M A, Plecha D M, Greenberg J S, Hayes M K, Copit D S, Carlson K L, Cink T M, Barke L D, Greer L N, Miller D P, Conant E F Breast Cancer Screening Using Tomosynthesis in Combination with Digital Mammography, JAMA. 2014;311(24):2499-2507
- Greenberg J S, Javitt M C, Katzen J, Michael S, Holland A E. Mammography for Breast Cancer Screening in Community Practice. AJR:203, September 2014
Statement on Breast Density Communication – October 2013
The breast radiologists of the State of Washington support the statement of the Society of Breast Imaging regarding breast density communication. We believe that mandatory reporting of breast density at this time is of unclear benefit to the patient and may actually lead to confusion or other unintended consequences for the patient.
Because there is no clear either scientific or consensus-based follow-up step for women with dense breasts, we oppose requiring specific communication to patients solely informing them of their breast density. At this time, there is no obligate next step. Whole breast ultrasound is not scientifically supported for screening, generates many false positive results and unnecessary biopsies, is usually not paid for by insurers, and is not widely offered in the state. Breast magnetic resonance imaging is very sensitive, but is expensive and invasive, requiring contrast injection, and is usually not covered by insurance as screening for women at average risk of breast cancer.
If there develops a clear opportunity for women to do additional or special screening based on their breast density, we would applaud widespread specific communication to the individual on their density. Until that time, we recommend that breast radiologists promote the availability of the mammogram report to each patient. We also recommend that primary care providers discuss options with their patients with dense breasts and facilitate each patient’s understanding of their individual risk, thereby empowering them to make informed personal choices regarding prevention and screening for breast cancer.