Tag Archives: Screening

Signify Premium Insight: Screening Could Start Sooner Under USPSTF Guidelines

The U.S. Preventative Services Task Force (USPSTF), an independent body of experts which works to make evidence-based recommendations about preventative clinical services, recently revised its guidance to now recommend that the age at which women begin annual breast screening in the US is lowered from 50 to 40.

The group released a draft recommendation statement and evidence review, giving the recommendation a ‘B’ rating, meaning that there is strong confidence in the evidence that the move would be beneficial. According to the guidance, clinicians should encourage their patients to undertake the screening, where appropriate.

In lowering the age at which screening is recommended, the USPSTF reverses 14 years of guidance, after, in 2009, the group raised the age at which mammography screening was recommended, from 40 to 50. Such history makes the reversal of this guidance particularly significant.

Signify Premium Inisght: Paying for AI – Artificial Intelligence and Genuine Costs

Radnet has announced that it is using AI to offer patients more detailed breast screening examinations as part of its Enhanced Breast Cancer Detection (EBCD) service. The new service will enable women attending their annual breast screening examinations to, for an additional fee, receive additional services which include the use of AI tools to assess a woman’s lifetime breast cancer risk.

EBCD utilises the Saige-Dx, a US-FDA cleared mammography diagnostic aid software from DeepHealth (a RadNet acquired company), adds an additional review applied to any suspicious

Signify Premium Insight: AI’s Personal Approach to Breast Imaging

Screening programmes are among the medical imaging use cases where, at least for the majority, there is little urgency. As such, they were one of the first casualties of the cancellations in response to the developing Covid-19 pandemic in 2020, as providers sought to stem the spread of the virus. While the rationale for such action was sound, now, almost three years later the consequences are being keenly felt.

According to Bhvita Jani, Medical Imaging Research Manager and co-author of Signify Research’s Breast Imaging Report – 2022, these consequences are having a significant impact on the breast imaging market, although there are some technologies that are coming to the aid of providers looking to address the challenges.

Signify Premium Insight: Screening Marks the Next Step in Intelerad’s Grand Ambition

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Intelerad added another company to its growing portfolio in August, acquiring breast and lung screening specialist PenRad Technologies. The acquisition of the vendor, which provides software to enhance the efficiency of screening programmes, is the latest in a string of purchases including Ambra Health, Insignia and Lumedx among others.

The deal, which was of an undisclosed value, will bolster Intelerad’s offerings for mammography and lung workflow tools and analytics. Its three core products, PenRad for breast imaging, PenLung from lung screening, and PenTrac for patient tracking and reporting will, according to Intelerad, help radiologists using its enterprise imaging platform to optimise workflows and manage screening programmes more efficiently.

The Signify View

Since Hg Capital became the majority investor in Intelerad in 2020, the vendor’s plans have, over time, become clear. Intelerad has set its sights on building out a fully-fledged enterprise imaging offering, a system that will cater to the needs of most providers and offer a genuine alternative to both other specialist imaging IT vendors as well as the solutions offered by larger international medical imaging vendors.

The acquisition will help in this regard. The integration of screening tools into the core imaging IT platform, while not unique, does add additional competency that will allow the firm to compete against some of the largest imaging IT providers. Furthermore, it will also help differentiate Intelerad from its current peer group of small and mid-size imaging IT “challenger” vendors. Such differentiation will also be particularly attractive to the outpatient sites that presently form the majority of Intelerad’s customer base.

Screening tools are also likely to increase in importance over time. Screening programmes in the US are well established for mammography, but are growing in sophistication, with increased uptake of more advanced modalities such as 3D mammography, ABUS and MRI, as well as additional reporting on harmonised diagnostic metrics such as risk scores and breast density. Another factor that could also mean providers are more willing to invest in tools such as those offered by PenRad are changes to reimbursement rates. Lower rates of reimbursement for screening mammography will increase the importance of screening efficiency. For screening providers, which rely on high volumes to drive revenues, any tools that enable greater reporting automation and more women to be screened, could therefore be very valuable.

In the US, Lung screening on the other hand is still underutilised, with patients often choosing not to participate in screening programmes when they are available. Despite this, the uptake of screening is still being encouraged, with, for example changes to screening rules making more people eligible to participate. Moreover, given the nascency of lung screening so far, PenRad’s lung assets will further differentiate the Intelerad offering.

Timing is Everything

The timing of the acquisition also makes sense. Following on from the Covid 19 pandemic, there has been a greater emphasis of care in outpatient settings. This is a market that Intelerad can serve effectively, although, without PenRad it lacks some of the specialist tools to be able to effectively capitalise on the requirements of screening providers. There are, for example, specialist workflow elements, registry integration requirements, and AI integrations which, among other needs, are distinct enough from typical radiology use cases to necessitate the acquisition if Intelerad is to succeed in the screening market.

While many PACS vendors offer some screening capability, these complexities mean that many informatics vendors also lack the specialist screening capability that Intelerad has acquired through its purchase of PenRad. In many cases, PACS vendors will “white-label” tools from vendors such as PenRad, or work with breast modality workstation vendors such as Hologic. Developing this capability in-house is not impossible for a vendor such as Intelerad, but it would have taken time to get right. By buying PenRad, Intelerad gets this capability right away, while also preventing any of its competitors picking up the firm.

The deal also makes sense for PenRad. While its tools are valuable, as a specialist company it is at risk of enterprise imaging vendors, whether smaller specialists or larger, broader imaging vendors and growing breast AI specialists increasingly encroaching on its turf as they too look to capitalise on the resilient screening market.

Acquisitive Ambitions

Despite the potential that the acquisition of PenRad offers in the outpatient and screening space, the capability it brings is not transformative for Intelerad, nor will it likely mark the end of the vendor’s acquisitive streak. Intelerad is, after all, focused on assembling a complete enterprise imaging solution, and, as long as Hg Capital is willing to support the vendor, Intelerad will look to make deals for the remaining gaps in its capability.

One such opening would be for digital pathology capability. While such tools are not yet necessitated by providers, they are, as discussed in a previous Premium Insight, increasingly looking for their vendors to be able to offer a plan which allows them to take advantage of digital pathology when they choose to. This requirement has led several imaging IT vendors to ensure they can meet this need, with Sectra and Philips offering the capability in-house, while the likes of Siemens Healthineers and Fujifilm have chosen to partner with Proscia and Inspirata respectively to offer the capability. Not to be outdone, Intelerad could choose to pick up a company focused on digital pathology and integrate it with its broader imaging IT offering. However, given the nascency of digital pathology, particularly in Intelerad’s key market of the US, partnering might represent a viable near to mid-term alternative as it has for Fujifilm and Siemens. Partnership is also an option that Intelerad is also willing to take, as illustrated by its partnership with Blackford Analysis for AI platform capability, for example.

Another area arguably more deserving of Intelerad’s focus is Advanced Visualisation (AV). Not only does this absence represent a gap compared to most of its peers, being able to offer AV capability would give the vendor a better chance of sealing deals at acute sites and helping the company expand beyond its core outpatient customer base. There are opportunities for Intelerad to offer white label solutions to customers, however, this route is more limited in terms of customisation and does not offer the same long-term certainty as offering solutions developed in house. Taking such an approach also means that Intelerad would not be able to keep all the revenues from the solution, a factor which could impede its ability to innovate in the future. Solving the “AV” challenge is not urgent, but as AV is increasingly de-coupling from modalities sales channels and gradually overlapping with AI image analysis tools, the firm will not want to wait too long without a clear plan of how to address the AV gap in its offering.

Acute Solutions

There are other capabilities that are also increasingly important, particularly if Intelerad has designs on the acute space. Many deals are now agreed on a long-term basis and include professional service and consulting elements. At present, Intelerad could miss out on some major contracts given that it is not among the vendors best placed to deliver on these requirements at scale and on multiple geographic fronts, a headache that has also challenged fast-growing peer Sectra. Other elements also important given growing pressures on imaging services are fleet management and operational analytics tools. Not only would such tools stand Intelerad in better stead as it competes for major deals with acute providers, but these allow the vendor to use them as a foundation to increasingly engage in lucrative service activities, helping providers realises their performance targets and meet their KPIs for example.

While adding these and other capabilities would not be cheap, if Intelerad were willing to invest the time and resource in fully integrating them, it would emerge with one of the most complete enterprise imaging solutions available. This in itself is no guarantee of long-term success; the imaging IT market moves slowly, and organic growth is hard to come by. As such, further acquisitions may be necessary for Intelerad to continue to gain market share and the revenues that it brings. However, the investment made by Hg Capital, along with additional investment from TA Associates, suggests that the vendor is not finished, and that more acquisitions are likely on the way.

The more pertinent question is how long HG continues to back Intelerad. It has proved its commitment in the near term, but at some point, it is likely to want to exit and realise a return. When this is, and how advanced the integration of its acquisitions is at this point is something that remains to be seen.

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Signify Premium Insight: RadNet is Full Screen Ahead with AI Acquisitions

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 Research. To view other recent Premium Insights that are part of the service please click here.

Last week, imaging services provider RadNet announced it had acquired Dutch artificial intelligence developers Aidence and Quantib. Aidence is a radiology AI vendor which specialises in the development of clinical solutions for pulmonary nodule detection and lung cancer screening, while Quantib is an AI developer which, offers solutions for prostate cancer and neurodegeneration.

Aidence and Quantib will build on the AI capability RadNet acquired when it purchased Nulogix and DeepHealth in 2019 and 2020 respectively and leaves the American company with considerable potential in the field of cancer screening, an area in which RadNet will increasingly focus.

The Signify View

Many investors are impatient creatures. This impatience often serves them well, allowing them to spot a suitable opportunity and make a tidy return in a relatively short time frame. For the companies they invest in, however, this impatience can force them to alter and adapt their strategies, and ensure they must react to opportunities.

This flexibility is particularly important if a company is running at a loss of around $4-$5m dollars a year, against a figure of just $13m raised from venture capital investors. This is the situation that Aidence and Quantib found themselves in. Both vendors had developed promising AI technology but, with AI adoption in its infancy, commercialising and capitalising on this technology is still something of a challenge.

RadNet believes that in acquiring Aidence and Quantib, it will be able to address this issue. In combining Aidence and Quantib, with the AI capability it already possesses (via DeepHealth) as well as the extensive network of more than 290 outpatient radiology centres, the American provider believes it can create a powerful cancer screening network. It will also look to bolster the capability it has now assembled in breast, lung, and prostate, with colon cancer screening, to be able to offer a screening solution that detects around 70% of cancers that are imaging detectable at an early stage. Currently breast is the only cancer that is widely screened for, but RadNet’s strategy will see it increasingly push for greater levels of screening of these (and other) cancers, aiming to see them become as mainstream as breast screening. As this happens, RadNet will be able to leverage both its new and older acquisitions to be able to offer and deliver multi-cancer screening, capitalising on the comparatively vast numbers of patients that this would entail.

As a strategy this is shrewd, as offering screening is an additive rather than binary development. RadNet can, in the immediate term, use its breast AI tools for breast screening, offering lung and prostate scans as diagnostic clinical decision support tools, but, deriving increasingly greater proportions of revenue from them as these screening types become more common.

Screening’s Scale

The fact that potentially vast numbers of patients will be imaged under screening programmes also reinforces RadNet’s decision to turn to AI tools. As a provider, RadNet will be competing with other outpatient imaging centres, as well as acute sites. This growing competition means that investments which give a provider such as RadNet even a slight competitive advantage will be worth considering. Bringing separate companies and their technology to create an efficient screening solution at present, when screening programmes outside of breast cancer are nascent, is somewhat speculative, but it will give RadNet an advantage, enabling it to drive forward and help create the market for such practices.

Even without the additional impetus given by screening programmes, prioritising the acquisition of AI capability is a sound strategy for RadNet. Both of RadNet’s latest acquisitions, but particularly Quantib’s solutions, are focused on time consuming medical imaging examinations. These involved examinations are comparatively expensive requiring large amounts of radiologist time. Radiologists are among RadNet’s most significant expense, with the provider, according to CEO Howard Berger, spending around 20% of its global net revenue on this resource.

AI solutions which streamline the reading workflow and enable radiologists to be more accurate and efficient, can represent a significant saving for the outpatient imaging provider, and therefore give it increased pricing flexibility and bolster its competitive credentials. This will both allow it to compete directly with other providers, as well as establish itself as an outsourcing option for larger providers for these highly time-consuming exams. If acute hospitals realise that an AI-equipped RadNet can perform and read imaging exams, take a share of the revenue, and still undercut acute centres, then those centres are likely to simply outsource some imaging procedures to them, rather than trying to compete with them on cost. This outsourcing looks particularly attractive for high volume and time-consuming examinations, such as brain MRI and prostate MRI exams.

Sold on Strategy?

One of the more unexpected aspects of RadNet’s acquisition of Aidence and Quantib is the provider stating its ambition to expand its presence both in North America and Western Europe, and positioning itself as  an imaging IT and AI vendor as well as provider. RadNet intends to use its newly curated multi-cancer screening AI tools as a potential lead for its self-developed eRad products. This will prove a challenging task, with the imaging IT market increasingly saturated  in mature regions making organic growth hard to come by. Most providers are already committed to lengthy deals with better established vendors, meaning that RadNet or other vendors eying a provider’s custom will, in most cases, have to wait several years before even having the opportunity to tender for their business. What’s more, providers are becoming less likely to “rip and replace” their existing imaging IT platform. Challenger vendors therefore need to present a significant value proposition that makes the time and cost a worthwhile investment for a provider.

RadNet, for its part, has pushed acquired centres to use its eRad products, regardless of the incumbent solutions or deal lengths. Although this has worked to date, it is less likely to translate to outside of outpatient imaging in international markets.

RadNet does have some advantages, though. As a provider itself, the AI solutions and eRad products will be used internally, and meet the company’s own need, as such, revenue brought in by the sale of the imaging IT software will, in the near term at least, be supplementary to RadNet’s core business. It is deriving another revenue stream, even if small, from already sunk cost.

If RadNet can bring its DeepHealth, Aidence and Quantib acquisitions successfully into a multi-cancer screening solution it could also hold a seriously advantageous position in the cancer screening market. While there are some AI developers that have focused on breast screening solutions, such as Volpara Health, RadNet will be among the first to offer a more broadly capable package targeting multiple cancers. This could put it in a particularly strong position if screening for other cancers becomes more common. Guidance around lung screening in particular is becoming more encouraging, with bodies broadening the criteria for which screening can be used and new studies (the latest taking place in France, funded by the Ministry of Health and the National Cancer Institute), all helping to build momentum for screening. RadNet’s position makes it look likely to capitalise on any rapid increase in screening, from both a vendor and a provider point of view. In fact, RadNet’s unique position may even enable to become a driving force for other cancer screening programmes beyond breast cancer to be adopted. However, whether it commits to such a plan highly depends on whether it has the appetite to champion such initiatives at a legislative level whilst growing its AI division.

A Matter of Timing

Although RadNet’s move to acquire Aidence and Quantib harbours some risk in that it is counting on cancer screening programmes growing in prevalence and becoming more widespread, it is a move that makes sense. The AI market is maturing and, as highlighted by MaxQ’s failure last month, developers that have been surviving off shrinking venture capital (especially in Europe), and which have failed to gain significant market traction will find themselves in increasingly precarious positions. RadNet has therefore chose an appropriate time to make such acquisitions. This timing will look particularly well-judged should the cancer screening market beyond breast cancer, take off as the provider expects.

In their decisions to sell, Aidence and Quantib also acted prudently. Their VC investors have enabled them to grow into companies harbouring competent, regulator approved solutions, but, on their own, both would face uphill battles trying to commercialise their solutions, a process that could be difficult to sustain given the losses they are making. To sell now allows the developers to, as part of a larger company, build on these foundations and become part of a more valuable whole.

Many AI developers that are finding further VC funding hard to come by, and watching their bank balances dwindle, will be hoping to be as fortunate. The AI market continues to move on, as it does, more companies will follow RadNet’s lead and decide it could well be the right time to jump on board.

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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 Research. To view other recent Premium Insights that are part of the service please click here