Warning! OUTDATED BROWSER DETECTED!   Please update your browser immediately for a better experience on this website. Learn More
  • Look Ahead: Breast Imaging -1974 to 2015 and Beyond

    Expert D. David Dershaw examines the evolving role of breast imaging from 1974-2015 and beyond. By D. David Dershaw, M.D.

    July 1, 2015

    1975. Early modern mammography
    1975. Early modern mammography was relatively high dose with part of the film unexposed (white border on left side of image) allowing ambient light through to degrade image interpretation. Labeling was limited to date, medical record number and technologists initials. All Images courtesy of D. David Dershaw, M.D.
    1979. Xeromammography
    1979. Xeromammography was a high contrast technique with blue powder adherent to paper to print the image. It did not stand the test of time. All Images courtesy of D. David Dershaw, M.D.
    1985. Image dose was lowered
    1985. Image dose was lowered and grids were introduced, improving the image. Excessive ambient light continued to degrade interpretation. All Images courtesy of D. David Dershaw, M.D.
    1995. Film improved
    1995. Film improved, cassettes enhanced image information capture and finally the film was fully exposed to block out background light. Film labeling was applied with a flasher and a paper date sticker made it possible to separate examinations filed together in a single folder without holding each film up to the light to see the date. All Images courtesy of D. David Dershaw, M.D.
    2015. The image is now electronic
    2015. The image is now electronic. Exposure can be windowed and leveled to compensate for poor exposure due to technical factors. Additional information is now readily available on other breast imaging studies such as MRI and isotope imaging, which is useful for the radiologist when planning interventional procedures. All Images courtesy of D. David Dershaw, M.D.

    Mammography was in its infancy 40 years ago. Prospective randomized trials to test its impact as a screening tool were underway or being planned. The impetus to undergo screening grew from the 1974 breast cancer diagnoses of the wives of President Gerald Ford and Vice-President Nelson Rockefeller, but the annual mammogram was rarely part of routine medical care.

    By 1987, 35 to 44 percent of women who could afford mammography had undergone the test in the preceding two years; for those without this ability, only 13 to 19 percent had undergone a mammogram. In 1991, there were an estimated 10,000 mammography units operating in the U.S. In 2015, the U.S. Food and Drug Administration (FDA) reported that more than 38 million mammograms had been performed in the U.S., with 62 to 73 percent of women 40 years and older having had a mammogram within the past two years. Some 14,000 accredited mammography units are now operating in the U.S.

    In the face of ongoing controversies surrounding the usefulness of mammography, the personal experience of individual women with the early diagnosis of breast cancer and the 30 percent decline in breast cancer mortality in the U.S. continues to override discussions about risks, harm and unnecessary cancer diagnoses. An aggressive approach to imaging screening for high-risk women has become standard practice over the past decade.

    The greater demand for mammography helped convince the industry to work on improving technology. Radiation dose was reduced. Throughout the 1980s, single-emulsion film, screens and grids were developed to improve image quality. In 2000, digital mammography received FDA approval to be marketed in the U.S. Issues with over- or under-exposed film, quality of copied studies, and searches for prior mammograms were obviated. Currently fewer than 5 percent of all mammography units in the U.S. continue to use film. The advancements in mammographic technology have continued with recent introductions of tomography and contrast enhancement.

    Concern about the quality of some mammography in the U.S. resulted in the development of the American College of Radiology’s (ACR) mammography accreditation program in 1987. By 1991 half of the mammography units in the U.S. had voluntarily applied for accreditation and one quarter had received it. The need for national uniformity in mammography standards and the desire to terminate facilities that were performing substandard work caused Congress to pass the Mammography Quality Standards Act (MQSA) in 1992 with the requirement in October 1994 that all facilities be accredited. This legislation regulated standards for personnel as well as equipment. While the number of mammography units in the U.S. increased, the number of certified facilities in the U.S. decreased by 10,000 to 9,011 during the first decade of MQSA-mandated FDA regulation. Further improvement in mammography practice became possible with standardized reporting and assessment of practice quality facilitated by the ACR’s development of the Breast Imaging Reporting and Data System (BI-RADS) in 1993. Along with these changes, mammography was increasingly included in residency programs, propelled by formation of the Society of Breast Imaging in 1985 and the incorporation of breast imaging into the examination of the American Board of Radiology in 1990.

    Of course, mammography is only part of the story of breast imaging. The value of sonography, initially used to differentiate cysts from non-cysts, became evident in the 1970s. Further experience improved differentiation of benign versus malignant masses. Technical advances included Doppler and elastography. Although not greeted with uniform enthusiasm, the use of sonography as a screening tool has also been more widely incorporated into breast imaging practices.

    By the 1990s, MRI was being investigated as an effective breast imaging tool. In 2007, the American Cancer Society included MRI screening for women with a greater than 20 percent lifetime breast cancer risk among their screening recommendations. Now used extensively in breast-imaging practices, the value of MRI for staging and assessing response to treatment as well as screening is widely accepted.

    From Mammographer to Breast Imager

    As well as being diagnosticians, breast imagers have increasingly become interventionalists. In the 1980s, preoperative localization procedures were an important aid in guiding biopsy surgery and for the treatment of nonpalpable breast disease. Over the next decade, breast imagers—rather than surgeons—became the physicians performing diagnostic biopsies. Today, 90 to 95 percent of breast biopsies are performed with imaging guidance.

    The mammographers of 1975 have emerged from their darkened offices lined with view-boxes to become breast imagers—primary care physicians for breast disease who oversee women from screening, through multimodality imaging work-ups, biopsy and on to surveillance after breast cancer treatment. We are pivotal to decisions about breast conservation, neoadjuvant treatment response and genetic testing. Women with breast cancer know our faces and know our names.

    Just 30 years ago a woman’s experience was quite different; if a suspected breast abnormality was found there would be days of consultations with specialists, including radiologists and surgeons, followed by a trip to the operating room for a biopsy under general anesthesia. If the tumor was malignant, mastectomy would be performed at the same time. She would awaken in the recovery room to find that her breast had been removed. She would then be facing the prospects of chemotherapy and radiation.

    More than 10 percent of American women will develop breast cancer. The impact of imaging on these women and those who care about them cannot be understated. More than one third of women who would have died of this disease now survive. Five-year disease-free status is better for women whose cancers are found by mammography than for those who are not screened. Along with other medical advances, the detection of smaller tumors has made it possible for oncologists to use less aggressive treatments in many cases. For these women, breast imaging has improved not only the duration, but also the quality of their lives.

    But what the future might hold is even more spectacular. With technology that now makes it possible to percutaneously ablate tumors and with therapies that suggest that axillary dissection and negative histologic margins are becoming less important, the actual treatment of some breast cancers may become the domain of the breast imager rather than the surgeon.

    And the patient experience may be completely transformed.

    Imagine the day when a healthy woman arrives at the breast center, undergoes screening and a small cancer is found. A biopsy is done at the same time by the breast imager, and the pathology results are quickly available. If the growth is malignant, the breast imager ablates the tumor and the woman goes home. At dinner that evening, her husband asks how her day was. She tells him she had breast cancer for a few hours.

    D. David Dershaw, M.D.