Governance, Mission, Growth

by Elaine Sanchez

PEM Comes to NYC
Beating Breast Cancer in Tennessee
Radiology Work and Play Outlined in ACR Survey

PEM Comes to NYC

With more than 50 years in the business, Manhattan Diagnostic Radiology (MDR) has had a long history of firsts. It was one of the first centers in New York to offer PET technology in an outpatient setting, and it was one of the pioneers for bringing breast MRI into the outpatient environment.

Now, MDR has another first to add to its ever-growing list. It will be the first in New York City to offer positron emission mammography (PEM) from Naviscan Inc.

Craig H. Sherman, MD, said that as director of PET/CT imaging at the facility, he had closely followed the evolution of PEM.

"We looked at several iterations of this new technology, and after careful study, I decided that the Naviscan PEM system would indeed serve a positive role in our practice and had the potential to set a new standard in the fight against breast cancer," Sherman said.

According to Naviscan, its PEM Flex scanner utilizes PET technology to produce high-resolution tomographic images of 1.5 mm resolution, which enables physicians to visualize the smallest lesions. "Such resolution is achieved by using PET detectors with thousands of 2 mm detector elements attached to top-of-the-line photodetectors," Sherman explained. "In order to ensure the best image quality, PET detectors can be moved close to imaged body parts, such as the breast or extremities, to acquire high-statistics, low-noise PET images."

Benefits also include the ability to eliminate motion artifacts and, in combination with high spatial accuracy, the introduction of PET-guided inter-ventional techniques. The system features sophisticated electronics "capable of rejecting background noise events better than the most advanced systems on the market," Sherman continued, adding that the scanners "produce images of unprecedented clarity and are on the cutting edge of PET technology."

To illustrate the effectiveness of PEM technology, Sherman mentioned results from an independent study that compared the accuracy of PEM and MRI in the presurgical planning of 136 breast cancer patients. PEM demonstrated more sensitivity than MRI in detecting the smallest cancers, with 91% sensitivity in ductal carcinoma in situ versus MRI’s 83%. Moreover, it exhibited better sensitivity in cancers less than 5 mm in size and detected a 2-mm DCIS case shown to be negative on MRI, Sherman noted.

Patients are also pleased with the ease Patients are also pleased with the ease and comfort of the 45-minute PEM exam. "The patient is seated during the study and the breast is gently immobilized, not compressed like with mammography," Sherman said. "Also, there is no potential for claustrophobia as there is with breast MRI."

MDR is the only fully self-contained continuum of breast cancer diagnostic services in New York, including digital mammography, high-resolution Doppler ultrasound, 64-slice CT, high-field breast MRI, whole-body PET/CT, nuclear medicine, and a complete range of percutaneous breast biopsy technologies with in-house pathology.

The center currently performs 100,000 imaging exams per year, but Sherman foresees a change in these numbers. “We expect this number to increase as awareness of PEM technology disseminates through the medical and patient community,” he said.

Beating Breast Cancer in Tennessee

As the women of Tennessee battle against breast cancer, statistics show the fight is a grueling one. It is the most commonly diagnosed cancer among the state’s female population, an illness diagnosed almost twice as often as any other malignancy, according to the Tennessee Cancer Registry’s report, "Cancer in Tennessee." It is also the leading cause of cancer-related deaths among Tennessee women ages 25 to 44.

Understanding that breast cancer mortality rates can be reduced through early detection, the MaryEllen Locher Breast Center in Chattanooga recently acquired an Aurora 1.5 Tesla Dedicated Breast MRI System. According to J. Lanett Varnell, MD, the facility’s co-medical director, the center’s goal is to provide advanced imaging technology to the region’s women, who would benefit from the improved diagnosis and treatment of breast disease achieved through Aurora.

"This includes identifying and contacting the high-risk patients and their primary care providers, and providing it as an additional service to our diagnostic patients," Varnell continued. "We believe that the potential benefits of breast MRI are maximized when it is used in a dedicated breast imaging center, correlating all breast imaging modalities to provide appropriate patient diagnosis and treatment, in conjunction with a dedicated breast MRI system with the capabilities of MRI-guided biopsy on-site."

As the only FDA-cleared dedicated breast MRI system specifically developed for the detection, diagnosis, and treatment monitoring of breast disease, the Aurora system is primarily being used at the center to screen women who are at high risk for developing breast carcinoma, to provide pre- and post-operative evaluation in women with known breast carcinoma, and to facilitate diagnostic evaluation in women with breast abnormality.

Before installing the Aurora system, the center shared a full-body MRI system with the Memorial Health Care System’s general imaging center, which was at more than 100% of its capacity. Although the situation was an inconvenience for patients who needed a timely breast MRI, the facility needed to convince its administration that the purchase was necessary.

“There were concerns as to whether it would be adequately utilized to justify the expenditure and whether it would be overutilized, thereby causing an unjustified increase of health care,” Varnell said. “We addressed these issues by working with our referring clinicians to establish appropriate utilization guidelines for identifying the patients who would benefit from screening or diagnostic breast MRI scans.”

The Aurora system includes a precision gradient coil design that offers a large homogeneous elliptical field of view to image both breasts, the chest wall, and axillae in a single bilateral scan. Varnell said this feature solidified the purchase, with the center believing the system to be “clearly superior to the traditional MRI with add-on breast coils produced by other vendors.”

Varnell noted several benefits of using a dedicated breast MRI system. For example, she said doctors are better able to identify early malignancies in high-risk patients who typically present at an earlier age when a dense breast pattern may obscure an underlying lesion. “A breast MRI provides an earlier stage of diagnosis and improved length of survival,” she said. She added that it offers improved preoperative evaluation for secondary lesions in the same or opposite breast in newly diagnosed breast carcinoma patients, as well as improving the identification and extent of lesions in patients who may have equivocal findings on mammograms and ultrasound.

MaryEllen Locher Breast Center is the first breast health facility, and only the second center in the state, to house the Aurora Dedicated Breast MRI system.

Radiology Work and Play Outlined in ACR Survey

Radiologists worked an average of 50 In May and June of last year, the hours per week, took 8 weeks of vacation per year, and performed 14,000 annual imaging studies last year, according to recently published results of an American College of Radiology survey.

Also, CT and MRI topped the list of most frequently owned modality types, at about 80% for both. Least likely to be owned were PET scanners.

"The timing of the latest survey in 2007 was propitious, because it occurred as radiology practices were adapting to the latest round of Medicare payment reductions," concluded James W. Moser, PhD, lead author of the article, in the September issue of the Journal of the American College of Radiology.

Moser said one of his purposes was to acquire up-to-date data on top-line parameters on radiologists and their practices.

In May and June of last year, the research team gathered information from a stratified random-sample telephone quota survey of ACR radiologist members and practice leaders, excluding radiation oncologists, trainees, and retirees. Participating states included Arkansas, California, Georgia, Iowa, Louisiana, Michigan, Montana, New Jersey, New York, North Dakota, Texas, West Virginia, and all other states grouped by the four census regions.

After e-mails and follow-up calls, a total of 601 responses were received from currently practicing radiologists, with 488 from the ACR member list and 113 from the practice presidents list; 457 responses were given through the Web survey, and 144 through computer-assisted telephone interview. Results were weighted to yield statistics that represented the entire population of active, post-training US radiologists.

According to the report, "the regional distribution of radiologists in 2007 did not shift in any significant ways from the situation that existed in 2003."

About one-third of the participants hailed from the South, with one-half of the remainder practicing in large metropolitan areas. At the top of the list of subspecialties were interven-tional radiologists at 20% and neuro-radiology at 16%. Slightly more than half of the radiologists were in private, radiology-only practices, though in 2003, only about 40% worked in these settings. This shift accompanies a reduction in multispecialty practices.

The share in academic practices increased slightly.

“The trend toward larger practice sizes could reflect increasing pressure on radiology practices to become more efficient by scaling up and to gain more market power with payers and hospitals in an era of ever tightening public and private payer reimbursements,” Moser said. “It is also likely due in part to the proliferation and diffusion of teleradiology and the ability to transmit digital images to a centralized location.”

The number of full-time radiologists in the practice ranged up to 120, with the average at 20.1. They enjoyed an average of 8 weeks of vacation a year, with half taking between 6 and 10 weeks. While radiologists performed an average of 14,000 studies a year, there was significant variation around the average. For example, one-quarter did no more than 7,500, and another 25% did at least 18,000.

More than half of the respondents indicated that they had an ownership interest of equity partnership in a practice setting that owns diagnostic imaging equipment outside the hospital.

CT and MRI tended to be among the most frequently performed imaging in the nonhospital setting, Moser found, and while modality ownership and utilization are not the same thing, they are probably highly correlated, he figured. “Ownership of these expensive, complex scanning machines can yield an attractive financial rate of return compared with other types of investments,” he said.

A particularly distressing find for Moser was mammography ownership in large cities, which is significantly below ownership rates in other locations. If low utilization correlates with ownership, “the implications are that some women in large cities may not be getting mammograms at recommended intervals because of long waits for appointments,” he gathered. Sampling variability, nonresponse bias, and incorrect or illogical responses may have led to inaccuracies in statistics.