Tag Archives: Graham Cooke

Strong Revenue Recovery of 15% for Fixed Digital Radiography in 2021, Whilst Fluoroscopy Grew by 18% Year-on-Year

Co-written by Graham Cooke

The fixed digital radiography (DR) rooms market experienced strong growth in 2021, with 15% growth in revenue reported, with revenues estimated at $1.2 billion. Likewise, the fluoroscopy X-ray market returned to growth after a year of retraction in demand in 2020, with 18% year-on-year growth in 2021, with an estimated market size of $509 million. These figures, taken from Signify Research’s General Radiography and Fluoroscopy – World 2022  report, show a strong recovery from the challenges experienced during the heights of the COVID-19 pandemic.

Demand returns to fixed room radiography in 2021.

Demand for fixed room digital radiography systems returned to growth in 2021, as procurement budgets were made available, having been temporarily diverted to fund mobile X-ray purchases in the early phases of the pandemic. This allowed previously planned projects to resume, and upgrades and replacements to be installed. For developed regions and countries, higher end features to help tackle the backlog are now increasingly sought after, including auto-positioning, cameras to ensure minimal patient movement before imaging and AI based image analysis. Such features improve workflow, increase the throughput of an imaging department, and should help healthcare providers gradually clear some of the backlog created from the pandemic.

Conversely, the digital mobile X-ray market retracted by 18% in revenue terms in 2021, closing at $684 million. However, this decline was not as severe as previously forecast, with some sustained demand remaining. During the pandemic, obvious benefits of mobile imaging were reinforced, including portability for bedside imaging. Growth is expected to return for mobile DR in 2024, as replacement of older mobile systems drives demand.

For mobile radiography, the importance of brand loyalty in purchasing decisions also returned, after temporary focus solely on inventory available during the pandemic. This allowed, smaller, local vendors to win significant share in new markets as they could service demand from local inventory more readily than global brands. Once global vendor inventory returned to a more normal level, purchasers often reverted to previous purchasing habits.

The general radiography market has experienced issues across the supply chain. Many components, including steel and semi-conductors, are in short supply. Coupled with rising costs of transportation and limited availability of shipping, average selling prices are expected to rise by approximately 8% in the short term for general radiography systems, before stabilising and declining again. This is also adding to lead times for projects, with systems taking a lot longer to reach customers.

Fluoroscopy also returned to growth, but demand is expected to become more specialised

Demand for fluoroscopy also returned to growth in 2021, with 18% year-on-year revenue growth to $509 million reported, up from $431 million in 2020.  However, fewer fluoroscopic procedures are now being performed, with other modalities like CT and MRI taking precedence for procedures traditionally conducted on fluoroscopy systems. Upper GI and barium swallow procedures remain the most procedures maintaining clinical demand for fluoroscopy and will remain essential for the long-term health of this modality.

With fewer fluoroscopic exams being performed and increased focus on return of investment in purchasing decisions, multi-purpose systems are now even more desirable, especially in North America and Western Europe.

Fluoroscopy revenues will surpass 2019 pre-COVID levels next year, but growth will be limited after this, as other imaging modalities continue to challenge fluoroscopy. The fluoroscopy market is set to reach $614 million by 2026.

Key trends by region

North America

  • The US continues to be one of the few countries still favouring classical fluoroscopy systems, due to historical training practices, concerns of patient movement threatening image quality and potential litigation. Demand is expected to gradually transition to remote systems, as new generations of radiographers are trained on remote systems; classical is however still expected to be dominant in the next five years.
  • In the general radiography market, demand for high end features is increasing, with tools to aid workflow becoming highly desirable for many imaging centres and hospitals.

Latin America

  • The Latin America market continues to be highly cost sensitive, with options like computed radiography, retrofit and analogue systems remaining popular. For many end users, there is a desire to digitalise, but currently, the price point remains prohibitive. For the digital solutions that are sold, low-end systems with a lower price point are by far the preferred option – over 50% of fixed and mobile solutions revenue came from the low-end in 2021.
  • Fluoroscopy remains a very small market in Latin America, with the high price point proving a significant barrier for entry to this market. Brazil is the largest adopter of fluoroscopy in the region, with most other Latin American countries seeing minimal sales.

Western Europe

  • High-end product continues to dominate the general radiography market in Western Europe, with 68% of revenue for fixed room product coming from High-end in 2021. Floor mounted systems sell more in unit terms in Western Europe, but with a lower ASP, revenue from ceiling mounted solutions accounts for a higher proportion of the market.
  • Most Western Europe markets have limited demand for fluoroscopy, with France being the key exception. Almost 30% of all revenue in Western Europe comes from this country. France is also unique in that many healthcare providers prefer to use dedicated fluoroscopy systems, rather than multi-purpose which is generally utilised in the rest of Western Europe.

Eastern Europe, Middle East and Africa (EEMEA)

  • Parts of EEMEA remain very cost sensitive, with Africa and less developed countries in the Middle East seeing high adoption rates of computed radiography, analogue and retrofit. For many, digital solutions are too costly, especially with the added infrastructure costs to enable PACS and other healthcare IT solutions on top of the imaging systems. Servicing imaging equipment can also be a barrier to adoption, with few engineers available locally to quickly fix broken systems.
  • Fluoroscopy remains very small for most of EEMEA. The areas that have stronger installed bases are in French-speaking north Africa, where demand follows France. In parts of the Middle East, such as in Saudi, some trends follow the US, as some radiographers were trained in the States, and therefore follow classical fluoroscopy installation practices.

Asia Pacific

  • Asia Pacific remains cost sensitive in many parts of the region, with 57% of fixed room revenue coming from the low-end segments. In countries like India, high levels of analogue and computed radiography remain significant. In China, CT imaging is increasingly preferred over high-end digital radiography.
  • Japan remains essential to the long-term growth of the fluoroscopy markets, with 45% of all unit sales in the region coming from this country alone. Elsewhere, demand is minimal with costs proving prohibitive to adoption.

Competitive landscape

A return to a more conventional vendor landscape was evident in 2021, with global brands such as Siemens Healthineers, GE HealthCare and Philips regaining market share temporarily lost during the pandemic when demand outstripped the available supply. With these vendors able to fulfil demand, smaller local vendors dropped share.

In the fixed DR market, Siemens Healthineers strengthened its position, with a gain of 2.5 percentage points.  For Mobile DR, GE reclaimed the top position, as Carestream experienced a difficult year after a very strong 2020.

For the fluoroscopy market, Siemens Healthineers led, with a very strong 2021, gaining further share. Shimadzu follows with strong sales in its domestic market.


The Fixed DR market will continue to recover. Budgets will continue to return for fixed room, and projects previously postponed will be able to restart. Additionally, in some countries like the US, replacement cycles will stimulate further growth towards the end of the forecast. Globally, ceiling suspended fixed room product revenue will grow at a faster pace (5% CAGR 2021-26) than floor mounted (4% CAGR), especially in more developed markets, where the desire for high-end features often found in ceiling-mounted solutions, are increasingly required. Low-end system demand will continue to be driven by cost sensitive markets such as Latin America, Africa, the Middle East and parts of Asia. However, the price of digital solutions will need to significantly reduce to be an attainable option for these regions. Until the price falls sufficiently, analogue, CR and retrofit will continue to play an important role.

Fluoroscopy systems will also see limited growth but will also come under increasing pressure from other modalities like CT and endoscopy. At the end of the forecast, low single digit annual revenue growth is predicted.  In many countries and regions, the demand for fluoroscopy will come predominantly from multi-purpose systems; as fewer procedures are performed on the systems, budget holders will want to minimise downtime by enabling other general radiography imaging.

Signify Premium Insight: Breast Imaging: A Market Set for Change

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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

Starting Screening

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.”

Women’s Priorities

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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This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify ResearchTo view other recent Premium Insights that are part of the service please click here