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The nature of the breast imaging market makes it unlike almost all others. The fact that it is a market centred around national guidelines and screening programmes, which were almost universally paused as part of providers’ responses to the coronavirus pandemic, means that it has been disrupted more so than most others.
This disruption, and the long-term effect it is set to have on the market, as well as the impact of developing trends are detailed in the recently released Breast Imaging – World Market Report 2021.
For providers, the response to this disruption is likely to be varied.
“One statistic in the report,” says Senior Research Analyst and co-author Graham Cooke, “is that the UK’s National Health Service (NHS) expects it to take ten years to clear the backlog.”
“Because of this, if a healthcare provider does have the money to invest in new equipment and upgrade to new technologies then dealing with this backlog provides an incentive to do so. However, it could be the opposite. Breast imaging clinics could well have been stretched with regards to available budget over the previous year, and with restricted funds, they could continue to use the ageing installed base of equipment until there are funds available to replace them.”
A Digital Direction
For some of these providers, however, the answer may not necessarily lie in the replacement of breast imaging hardware, but could focus on maximising the use of existing systems. “That is really where AI could come in,” continues Cooke. “AI isn’t just about finding abnormalities on a mammogram that the human eye may miss, more practically some AI tools could help radiologists detect abnormalities more quickly, or rapidly give some cases a green light where no further attention is needed. This will mean that radiologists can focus their time on more urgent cases.”
While these tools could relate directly to image analysis, in practice, many of the solutions that are set to be of most use in clearing the backlog of postponed breast imaging exams focus their efforts elsewhere. Tools that facilitate operational workflow improvements or triage tools that help prioritise suspicious scans in the worklist are among those that offer the greatest benefit.
“Another interesting tool that will help in this regard is personalised screening and having AI assess a woman’s individual cancer risk, including factors like family history of breast cancer, genetics, lifestyle factors which make some people more at risk, or physiological factors like dense breast tissue.”
This will help providers manage their screening programmes, prioritising those who are most at risk, while individuals at lower risk of breast cancer can wait longer between mammography appointments, thereby reducing the provider’s workload.
This, however, will not happen immediately, cautions Senior Research Analyst Bhvita Jani. “At the moment there are still three main barriers to the widespread use of AI in breast imaging. Firstly, until it is included and recommended in national screening guidelines it is not going to make as much impact as it should.
“Secondly there is a lack of representation in the validation studies. There is, for example, an underrepresentation of some ethnic minorities which makes it impossible to extrapolate the findings to women of different backgrounds.
“The third problem is reimbursement. Unless AI is reimbursed the only way that providers would be convinced to use it is if it will reduce their costs.”
The breast imaging AI market is set to grow rapidly as the barriers to its adoption are overcome
Another factor that could dramatically impact the breast imaging market is the establishment of screening programmes in countries that don’t yet have them. The growth potential for different vendors in the breast imaging market is highly dependent on the country dynamics.
“China, for instance, is quite a price-sensitive market,” notes Cooke, “so even if it were to introduce a screening programme, that screened millions of women, providers would overwhelmingly purchase their systems locally. Not only do Chinese vendors have lower price points than international vendors, but Chinese hospitals often have partnerships with local vendors. Going with a local brand will also often be seen favourably, compared to using an American or European brand for example.”
Jani adds: “But, this would only be the case for 2D mammography systems. Any demand for 3D systems will still primarily be captured by global vendors as Chinese vendors don’t extensively offer 3D systems.
“In some areas that are on the cusp of establishing screening programmes global vendors will be preferred. In the Middle East region, for example, where brand reputation is very important. Screening programmes in other areas could also benefit global vendors, including several CIS (Commonwealth of Independent States) countries. However, within this market, there is a stronger preference for low to mid-range breast imaging systems.
“It is worth noting though, that when it comes to large government tenders, price is often the most important consideration. So, companies that are more flexible when it comes to price negotiations have tended to do well. One company that has been particularly successful is Fujifilm. It has increased its share of the mammography market, through, in part, its aggressive pricing strategy.”
Demand for More Dimensions
For those countries that already have established breast screening programmes, there are still some large and impactful changes on the horizon.
“One of the biggest unanswered questions in the breast imaging market is when will 3D mammography be used outside of the US for screening, which is the only country to have so far really embraced the technology,” Jani explains. “Our prediction is maybe three to five years for Western Europe, which looks set to be one of the next markets to adopt 3D for breast screening.
“This rollout of 3D mammography can only take place when there is enough provision to read the 3D scans, with limited radiologist capacity being a challenge. Because of this, the rollout of 3D will likely go hand in hand with the increased adoption of AI, which will help providers make the transition by reducing the time required to read 3D scans.”
Digital Breast Tomosynthesis is forecast to grow strongly over the coming years
There could also be other technology changes afoot. “There are a number of different emerging breast imaging technologies becoming available,” notes Cooke, “but mammography is still the dominant, unthreatened modality by far.”
“Other modalities, such as ABUS or Cone Beam Computed Tomography have advantages compared to mammography in some ways, but it is difficult for them to penetrate the breast imaging market. “These technologies are not designed to replace mammography but are instead meant to supplement it. They must work alongside mammography to be part of patient pathways. If you consider automated breast ultrasound, for example, that has taken some 20 years or so to really be accepted, and even now there are only a handful of vendors that offer it.
“So, we could see some of these smaller and more niche breast imaging vendors getting acquired by larger breast imaging vendors. There are already examples of this, with Hologic, which dominates the mammography market, diversifying their hardware portfolio to include breast ultrasound, by recently acquired Supersonic Imagine, whose technology should complement Hologic’s own mammography systems.”
There are other changes that will affect providers’ purchasing decisions in the nearer term. For screening mammography at least, screening centres are in competition with one another, in particular in the United States, for footfall of eligible women. Because of this, vendors will happily pay to purchase new and higher-end systems, with features which focus on the patient experience and comfort, if they will attract more women into their centres.
“One-way providers are encouraging more women into their screening programmes is by focusing on enhancing comfort levels, and reducing discomfort and pain,” notes Cooke. “That could have a large role in influencing what systems providers actually purchase.
“This is a prominent trend and as a result, instead of only marketing their systems to providers, breast imaging vendors are targeting women directly. The preferences of these women could then influence what systems providers purchase.”
The Market Matters
These sorts of strategies are only viable in countries where screening programmes are already established. While there will be effort expended to encourage women to participate in screening programmes, for vendors and providers in these countries the priority will be on improving the patient experience and the accuracy of first-time right screening and reducing the rate of rescans and recalls.
“Over the coming years, there will be more focus on personalised screening and risk-based screening, as well increased variation in the breast imaging modality used and the frequency of scans,” details Jani. “These changes could also be very much influenced by AI’s development in this market.
“In developing countries, the creation and establishment of screening programmes will be the biggest change. But this is itself dependent on the subsequent treatment plan that is available afterwards is a diagnosis is made”.
“Overall, though, the next 10 years could really shake up the breast imaging market. New emerging breast imaging technologies could gradually have increased market adoption where there are established screening programmes. Meanwhile there will be some opportunity for niche vendors to increase the uptake of their products and get their systems installed as part of new screening programmes where guidelines are yet to be established.
“It is, after all, easier to penetrate a new market with a lack of guidelines and recommendations, than it is to try and break a well-established market like the US right away.”
The breast imaging market is set for change. Technological developments, primarily in breast AI, will play a part in enabling this change and drive increased uptake of more advanced breast imaging hardware solutions. With current challenges such as the significant backlog of women requiring screening, a fundamental need to reduce the number of false positives or negatives and the need to increase early detection and more accurate diagnosis all being factors that will help drive this movement forward.
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