Focusing the Lens on Personalised Breast Imaging in Europe
Published: March 7, 2019
25 years since it settled in Vienna, the European Conference of Radiology achieved record attendance as over 23k delegates made their way to Vienna. Breast imaging was one of the most talked about areas of radiology at the show, however it’s a market traditionally slow to change in terms of technology. Was this excitement reflecting movement then? A larger lens may be required to observe any emerging trends as we explain below.
1. Signs of Increasing Personalisation & Stratification
Upon initial review, the most obvious theme amongst scientific presentations this year concerned the already well-established shortcomings of current screening methodologies, mainly the limitations of conventional 2D mammography supplemented by a variety of proposed solutions. Amongst these, an interesting trend prevailed concerning the use of AI analytics in stratification for supplemental screening. Whilst the methods employed varied, women initially had their breast density evaluated with analytical software after initial mammograms; those categorised as having dense breasts, in which mammography is known to be less effective, were then sent for screening with alternative modalities, such as MRI, handheld ultrasound, ABUS, contrast enhanced mammography and DBT. Of course, subsequent screening technologies each come with their own inadequacies. For an adaptive pathway to be implemented for population-based screening, a considerable amount of evidence must be provided, proving significantly improvement on current practice.
The first published results for the DENSE trial which were announced at the conference on Friday, was one such breakthrough. The Dutch trial has been ongoing for ~10 years, with over 35,000 women screened as part of its research. It investigated the use of supplemental screening in women with extremely dense breasts using MRI and concluded that the practice was a success in significantly reducing the number of interval cancers observed. Such a large and diverse study should inevitably help in building a case for adaptive breast imaging based on breast density in Europe.
On the show floor, vendors also appear to have taken a more personalised patient—focused approach for screening. Examples include the use of AI analytics tailored to provide dose and pressure measurements for individual women (according to breast size and density), and a solution which enables image quality to be monitored in real time. IT solutions to help monitoring of technologist’s performance for exams also shows that the bigger vendors are paying attention to ensuring quality of care in screening exams. Personalisation has even translated well into modality design, as vendors experiment with aesthetics and improving patient experiences; perhaps the most obvious example of this is seen with mammographywhich allow women to control their own compression. Reception of these adaptations should be interesting to watch in the future and could have an impact on screening participation rates.
2. Europe is Traditionally a Slow-Moving Market
But whilst the initial signs for support may be present, in the context of the global market, Europe has been notoriously slow to adapt to change. 2D Mammography is still the mainstay in most screening programmes, and whilst digital breast tomosynthesis (DBT) is well positioned as 2D imaging’s successor (see our featured article in ECR Today), adoption has been markedly slower in Europe compared to the USA and other mature healthcare markets. This is despite widely available trials supporting its superiority in detection and diagnosis. This year on the show floor DBT was present, but still very much in the background against conventional mammography and so we don’t expect adoption into screening programs to speed up anytime soon. However, it is gaining some traction for diagnostic use, though this also comes with some challenges in terms of the time required for interpretation and diagnostic reading.
CAD adoption, although widely embraced in the US, also remains slow in Europe. This is perhaps not a surprise in some markets, as traditionally many vendors have supported CAD as a solution to a shortage of radiologist resources. For example, in the Netherlands where supply of radiologists is plentiful, there is no incentive for its adoption. Many screening programmes also still require two readers to review each image, again limiting any potential for CAD use. While large scale overhaul of screening programs is unlikely to change in the near future, the growing body of evidence around DBT use for screening, increasing development of artificial intelligence and patient awareness of the challenges with conventional mammography screening will all contribute to growing support for more adaptive screening.
However, it will be a slow, gradual and staggered process.
3. Availability of Equipment is Low
Besides adoption, implementation of pathways using different modalities also relies on the availability of equipment. Established technologies such as ABUS/MRI are in relatively short supply for supplemental imaging; in the case of MRI, most systems are shared across departments at hospitals, with breast imaging making up a tiny proportion of scan volumes. Most MRI scanners are also oversubscribed, so substantial investment would be required in dedicated breast MRI to support use in screening. In the case of ABUS, the technology has been available on the market for some time, yet adoption has been slow, suggesting there has been limited confidence from legislators and providers in its merits. Had you taken two steps onto the show floor last week, you would’ve also seen a distinct lack of competing technologies in the space.
Whilst literature and presentations were more heterogenous indicating an appetite for change, only three ‘new’ breast imaging technologies were presented on the show floor. AB-CT, Ennovis, and Micrima employ spiral CT, optoacoustic, and radiofrequency technologies respectively, and each solve a problem presented by conventional imaging. This positions them as key candidates for supplemental pathways. However, whilst presenting promising results, these companies are still in their early stages of development and are all either pre-commercial or new entrants unlikely to be used widely for some time.
To sum up, whilst unlikely to occur widely in the next few years, ECR19 certainly gave encouraging evidence towards providing personalisation in breast screening in both the stratification of larger populations, and at the individual level for women. It certainly adds a level of humanisation to these programmes and softens the almost regimental nature of screening. With current limitations widely publicised, and participation numbers in Europe sometimes well below the target of 70% set by the EU, (and going below 50% in some areas) this focus could help encourage women to participate more actively in their local programmes. For vendors at the show with conventional and DBT mammography systems, this is a positive sign and long overdue. Regardless of where you sit on the mammography screening debate, screening in any form needs to reach people to be effective; thus, any trend which encourages participation and individualisation should be a positive development. The big question for adaptive breast screening pathways in Europe is perhaps not if, but when?
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Signify Research is an independent supplier of market intelligence and consultancy to the global healthcare technology industry. Our major coverage areas are Healthcare IT, Medical Imaging and Digital Health. Our clients include technology vendors, healthcare providers and payers, management consultants and investors. Signify Research is headquartered in Cranfield, UK.
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Breast Imaging 2019Published August 2019
Breast Imaging 2019
A complete overview of the breast imaging market, covering both hardware and software to highlight the interplay of the three technologies: MRI, mammography and ultrasound, broken out at a country level.
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