The past several years have seen the development of a de facto stealth campaign against screening mammography. “Vast Study Casts Doubts on Value of Mammograms,” the New York Times bullhorned in 2014. “Why Getting a Mammogram May Cause More Trouble Than It’s Worth,” a Prevention headline blared in 2016. “It’s Time to End Mammograms, Some Experts Say,” trumpeted Time this past December. All of this is fueled, of course, by the never-ending disputes over guidelines issued by numerous authoritative groups.
Meanwhile, in and around Rochester, N.Y., the longest-operating dedicated breast-care center in the U.S. and one of the busiest, is quietly making a powerful counter-case against the mammography naysayers. Seven-physician (Destounis, Seifert, Somerville, Murphy, Hedegard, Paulis, Levit), five-site Elizabeth Wende Breast Care (EWBC) saw approximately 105,000 women in 2017 alone. More to the point, the practice performed 1,791 core biopsies—and diagnosed 765 cancers. Of the latter, 301 were found on diagnostic exams and 464 on routine screening exams. The patients are well cared for and the practice is thriving.
“Most of our patients who turn out to have cancer have no family history of the disease, and they didn’t have any risk factors for breast cancer,” says EWBC radiologist and managing partner Stamatia Destounis, MD. “We feel validated in our work every day, because we help save the lives of so many women and allow them to go back their lives and take care of their families.”
Putting patients first
EWBC launched in 1975 when founder Wende Logan Young, MD, opened the practice’s doors partly on the idea that breast radiologists ought to interact directly with patients. Local surgeons and primary care physicians were less than thrilled with the then-novel approach, but EWBC’s intense focus on optimizing patient experience proved unstoppable—not least because it has a salutary effect on care quality.
Today EWBC has 140 staff members, including 38 technologists and five IT professionals, and it offers just about everything possible to find breast cancers while avoiding false positives. That includes digital breast tomosynthesis for all patients at all facilities, breast ultrasound, breast MRI, multimodality biopsy and cancer risk assessment with genetic counseling. All screening mammograms are double-read to ensure accuracy, and 50 percent of screening patients wait onsite for results. The practice also offers bone-density testing. The main office’s comfort amenities include two cozy fireplaces in each waiting room, as well as hot tea and blankets.
Equally impressive as the comprehensiveness of the woman-centered care provided daily at EWBC is the physician team’s achievement at reducing its overall recall rate. Not long ago this stood at an acceptable 9 to 10 percent. Last year the team cut call-backs, which can be acutely stressful for many patients, to just 6 percent, thanks to digital breast tomosynthesis. That’s at the highly desirable low end of the 5-to-12 percent rate recommended by the American College of Radiology and the U.S. Agency for Health Care Policy and Research.
Destounis credits two key components for EWBC’s still-improving performance across all measurable metrics. The first is the dedication of the entire staff and physician team to EWBC’s mission and vision.
To succeed as a radiologist in such a busy and clinically distinguished practice, “you need staff who are knowledgeable and supportive and can help you get everything done,” says Destounis, who is an active clinical researcher with a teaching appointment at the University of Rochester School of Medicine. “Our staff put worklists together in our Sectra PACS, make sure all images are hanging properly, call referring doctors for prescriptions, get releases from patients to obtain prior pathology reports, get the pathology reports—everything our physicians need to have done so that we can concentrate on interpreting imaging results and taking care of patients.”
The future is all 3D
The second secret to EWBC’s success is its belief in the worthiness of investing in the best technology tools on behalf of its patients. This is nowhere more evident than in the mammography systems in all five sites: The practice has phased out its entire fleet of 2D digital systems and replaced them with 16 digital breast tomosynthesis units for 3D-exclusive mammographic imaging.
EWBC purchased its first tomo unit in 2011 after the FDA approval, Destounis recalls. “Every year since, as our digital systems got older and needed replacing, we went with tomo,” she says. “The more tomo we did, the more we realized how much better it is. It has helped us increase our cancer detection rate and has been even more helpful reducing those recalls.”
With imaging datasets that dwarf those for 2D digital mammography, digital breast tomosynthesis on a 16-unit scale requires adaptable IT infrastructure and the expertise to manage it. EWBC has both, along with a homegrown RIS and such patient-friendly technology touches as an online patient portal and survey tablets available at the front desk.
The RIS is integrated with the Sectra Breast Imaging PACS, which has been a natural fit for the practice ever since the American College of Radiology Imaging Network (ACRIN) multicenter Digital Mammographic Screening Trial (DMIST) in the early 2000s.
“We performed around 3,000 studies for DMIST and then got Sectra,” Destounis says. “I feel like EWBC and Sectra kind of grew up together with this technology.”
The Breast Imaging PACS is a true multi-modality breast imaging workstation, allowing images from any modality, such as ultrasound, MRI or breast tomosynthesis, to be displayed side-by-side with mammograms.
Tomosynthesis support squad
To keep up with the demands of high-tech, high-touch, high-volume breast care, EWBC’s IT team prioritizes workflow support above most everything else on its daily to-do list.
“We have a very tailored workflow to accommodate the number of patients we see, and we do bi-weekly workflow meetings to continue improving our workflow,” says Diana Frillici, EWBC’s manager of IT and one of its two PACS administrators. “We work very hard to make each doctor’s job as easy as we can, so they can concentrate on patient care and not have to be concerned with anything outside of that.”
The IT staff is rounded out by a RIS expert and two system administrator/network infrastructure specialists. “We all work hard on workflow here, and the IT staff is a big part of that,” Frillici adds. “We try to have all the best equipment, maintain the best network and do everything we can to make sure everything is as fast and efficient as it can be.”
Destounis notes that it takes twice as long to interpret a 3D study as a 2D, so any supporting technology that would put the brakes on the process in any way wouldn’t make sense for EWBC. The need for speed, she suggests, is particularly keen in PACS.
“With Sectra PACS, I am able to read the tomo studies right away, I don’t have lost images and I can scroll through priors or cine loop and view everything I need to see,” she says. “Whether a prior ultrasound comes up, or a prior MRI, I can go back and forth between RIS and PACS, get the pathology reports—really just everything—and make a diagnosis. The Sectra PACS is user-friendly and it’s very fast.”
“We have looked at other PACS vendors, just out of curiosity,” Frillici says. “We always come back to Sectra.”
“We look at other PACS at RSNA, and nobody else can do what Sectra can,” adds Destounis. “When we ask them if their system can do this or that or the other, the answer is always no. And these are things Sectra is already doing and is constantly updating. So there really has been no comparison, for us at least.”
Care quality never goes out of date
Looking toward the tech-enabled future, Destounis mentions an updated version of a technology from the past. “We frequently work with different technology companies, and we are pretty excited about the water bath ultrasound that we’re investigating right now for women with dense breast tissue,” she says. The technique involves having the patient lie on her stomach and place her breast into a bath. The entire breast in scanned with sound waves in two to four minutes.
EWBC first tried water bath ultrasound back in the 1980s, but it’s back because sonography has come a long way since then—and so has EWBC. “We are always interested in looking at new things that may help our patients and may help us provide better care,” Destounis says.
That includes old things made new again, such as patient-centered care.
“I’ve been doing this work for 25 years, and I still find the patient contact and the patient interactions very important to what we do,” Destounis says. “We feel validated and quite protected from the outside world, from the New York Times and the other newspapers and magazines that say negative things about mammography and how it is expensive and a waste and is not helping women. Come the end of the day, all of us at EWBC are here because we want to take care of our patients and do a good job of it.”
Dr. Wende Logan Young, who retired in 2012, must be pleased to see her vision so fearlessly carried forward into the future.