Hedvig Hricak, MD, PhD, chair, Department of Radiology, Memorial Sloan-Kettering Cancer Center

The days when radiology played only a supporting role in the treatment of cancer are over, particularly at institutions where achieving the best possible patient outcomes takes priority. At the renowned Memorial Sloan-Kettering Cancer Center in New York City, radiologists are now as pivotal to the success of cancer treatment as the center’s medical oncologists, surgeons, and other specialists.

Hedvig Hricak, MD, PhD, chair of the Department of Radiology, says, “The role of radiology at our institution is tremendous because radiology is so deeply and fully involved in every step of the care provided to patients. Cancer care today is all about teamwork and team effort. We are all working together toward better patient care and improved outcome.”

The hospital’s clinical and research activities are organized into 17 disease management teams (eg, gynecologic, hepatobiliary, thoracic). According to Hricak, it is fascinating to observe the way these teams carefully discuss every detail of complex cases. In treatment planning and follow-up, radiologists are among the most frequent contributors of information to help the care team make decisions.

“We’re engaged in full collaboration,” Hricak says. “For example, in prostate cancer treatment-planning discussions, results of the radiology tests are viewed together with clinical, laboratory, and histology findings. In prostate cancer, radiology’s role usually includes a review of MRI images, since we use MRI so extensively in pretreatment planning. Imaging reviews often also include bone scan or PET/CT results. All available information is reviewed at a single setting, and radiologists actively participate in the treatment decision, whether the best course of treatment is surgery, radiation therapy, chemo-radiation, or watchful waiting.”

Hricak continues, “If the choice of treatment is radiation therapy, radiologists participate in a separate tumor planning conference, and for each patient, tumor location and extent will be discussed. Because there are different methods of radiation therapy, radiology input is crucial not only to the initial choice of treatment, but to detailed treatment planning as well.”

Cross-Sectional Imaging

This view of radiologists as equal partners with surgical and medical oncologists emerged at Memorial Sloan-Kettering, as it did at many other university-based cancer centers, in the late 1990s. Various factors (not all of which were of a clinical nature) served to spark this development, including the proliferation of advanced cross-sectional imaging technology. “Improved CT and MRI capabilities added significantly to the value offered by radiology,” Hricak says, “so much so that it simply wasn’t possible to do anything other than bring in radiology and make radiologists equal members of the team.? Before the development of cross-sectional imaging, all that radiology could offer the team was radiography, which meant our added value was minimal.”

At present, the Memorial Sloan-Kettering Cancer Center radiology department has two positron-emission tomography (PET)-CT units and one PET unit; the hope is that in the near future, the latter will be replaced by PET-CT. “PET-CT is an extremely valuable clinical tool in oncology, as it combines precise anatomy with metabolic tumor activity,” Hricak says. “With this technology, the fight against cancer is raised to a new level. The development of PET-CT is probably one of the reasons why new applications for PET are being approved more rapidly now than in the past. PET-CT allows us not only to detect cancer-site activity, but to identify the exact tumor location, and it improves the overall confidence level in image interpretation. A figure sometimes quoted is that PET-CT allows you to see 60% more lesions than PET alone. Not being a nuclear medicine physician, I can’t confirm that this is correct, but I can say that the tumor location and extent are seen with greater confidence when PET and CT are combined.”

The radiology department also has 16-slice CT units at its main campus and is upgrading to 16-slice CT at the satellite imaging centers. “Sixteen-slice CT is another important tool that allows us to obtain higher-quality images consistently,” Hricak says. “It’s faster and therefore easier on the patients; consistently high-quality images are acquired during the single breath-hold that every patient can perform. It used to be that the required breath-hold was 27 seconds long; not everyone could do it. Now, with 16-slice CT, it’s down to 12 seconds, which is much more feasible. Image quality and consistency are much better.” Hricak adds, “Even the radiation dose is lower than it was with the older scanners, if the 16-slice CT technique is properly performed.” Five MRI units are also deployed in the department, and three of them are equipped for 3D spectroscopy and functional imaging.

Advances in Informatics

Recent improvements in informatics and telecommunications also have markedly changed the practice of radiology at Memorial Sloan-Kettering. A picture archiving and communications system undergirds the entire institution’s operations. “We are filmless, paperless, and use speech recognition, and this allows uniform quality of studies and service throughout all sites,” Hricak explains. “Being filmless means that it makes no difference whether a CT study is done at the main campus or at one of the outpatient imaging centers; all images are instantly transmitted for reading. Being a paperless department is equally important. We read from an on-screen work list, and this assures that the oldest study is always read first, regardless of the site at which it was performed. We have voice recognition for report dictation. The joke is that sometimes the report is dictated and signed before an inpatient is returned to her or his room.”

She notes that all medical records are stored electronically, “so, while we read images, we have access to all patient information needed to offer better interpretations. We have an order-entry system in place. Furthermore, our scheduling is electronic and is performed centrally. Any radiologic examination can be scheduled from any physician’s office in the MSKCC enterprise. Everything is electronic, so the user logs in and sets up the date, time, and site of a needed radiology examination. This represents a tremendous patient convenience, as all the radiology studies can be scheduled by an assistant in the physician’s office, while the patient is present. The long-term goal is that radiology scheduling, just like airline ticketing, will be done by patients themselves in the comfort of their own homes.”

Hricak reports that these advances have, of course, called for a considerable investment (of undisclosed size). She says, “These investments were authorized because we have administrative leaders who truly understand global patient care. Everybody, at every level of leadership, is driven to achieve excellence and continuous improvement in cancer care. Our mission is patient care, research, and educationin that order. We are really here for the patients. This explains why the investments that the institution makes in radiology are quite spectacular. We are always at the cutting edge of technology, and patient comfort and safety are constantly addressed.”

A Leading Light

Hricak came to Memorial Sloan-Kettering in 1999 after years of distinguished service at the University of California San Francisco, where she was a professor of radiology, radiation oncology, urology, and gynecology, as well as chief of the abdominal section of the Department of Radiology at the UCSF Medical Center. At MSKCC, in addition to her responsibilities as department chair, Hricak has a senior position within the program of molecular and pharmacology therapeutics at the Sloan-Kettering Institute. She is also a professor of radiology at the Weill Medical College of Cornell University, New York. Hricak is a member of the executive board of the Academy of Radiology Research, the Radiological Society of North America’s board of directors, the National Cancer Institute’s board of scientific advisors, and the Institute of Medicine of the National Academies; she is also an executive board member and president-elect of the New York Roentgen Ray Society. In addition, she has served as president of the Society for Advancement of Women’s Imaging, the California Academy of Medicine, and the Society of Uroradiology (SUR). She was a member of the board of the International Society of Magnetic Resonance in Medicine (ISMRM) and is a fellow of the American College of Radiology, ISMRM, and SUR. In 1996, she was elected honorary professor of the University of Zagreb, Croatia, and corresponding member of the German Roentgen Society.

Hricak has given 21 named lectures nationally and internationally and received the Marie Curie Award from the Society of Women in Radiology (in 2002) as well as the gold medal from the ISMRM (in 2003). She is an associate editor and editorial-board member for many radiology journals and is the author or coauthor of 19 books. More than 271 original papers by Hricak have appeared in peer-reviewed journals, and 131 reviews and 137 textbook chapters by her have been published.

Despite her accomplishments, Hricak rejects special attention for her stature in the field. “Medicine is not about heroes,” she says. “Medicine is about teamwork. I view my team as an orchestra and and myself as their conductor. In an orchestra, if one player is off-key, then the whole performance is affected. The excellence of every player is essential.”

Commitment To The Future

With 50 radiologists and about 385 employees, the radiology department at MSKCC is not a passive player in the future of imaging: in fact, the center maintains an active research program with seven imaging laboratories. “To advance patient care, research is essential,” Hricak says. “Today there are unprecedented opportunities in biomedical research for the integration of biology and imaging. Such research will expand not only the field of diagnostics, but also image-guided intervention. Among the many areas to which research funds are headed, molecular imaging has surfaced as the frontrunner. Institutional success in clinical care and the future of molecular medicine depend on strong imaging programs. At MSKCC, we have seven imaging laboratories. Such facilities require a tremendous fiscal investment. Equally importantly, they require a commitment to our faculty.

“As the chairman, I have the opportunity and the privilege to support research and perpetuate the intellectual traditions of the department. It is my job to recruit, and above all, to retain basic scientists and outstanding academic radiologists. You can commit space and equipment to research, but people are the most important engines of success. You have to commit to people and secure them the research time they need.”

Evidence-Based Guideline

Hricak states that within medicine, a dynamic science often characterized by uncertainty, radiology is a data-driven specialty. “Much of medicine still relies on empirical methods, but I see radiology helping to influence medicine toward a more evidence-driven process,” she says, although even imaging protocols are not always established along purely evidentiary lines. “I would like to say that our daily practice is all evidence based, but unfortunately, there are no evidence-based imaging guidelines for many cancer sites,” she acknowledges. “In our department, we design imaging protocols (type and sequence of imaging studies for a particular cancer site, separate for primary and metastatic work-up) through literature reviews supplemented by our individual expertise. We discuss the protocols with the disease-management team, which includes surgeons and medical and radiation oncologists. If they concur, the protocols are then adopted. New protocols and changes to existing protocols are always initiated in the radiology department by the appropriate experts, although final implementation occurs only after the others on the team are able to evaluate them and offer input to refine them,” Hricak says. “Where patients are concerned,” she adds, “the dynamic aspect of disease management work flow helps patients, as new treatments always require new and innovative imaging strategies for better patient selection and treatment follow-up.”

At Memorial Sloan-Kettering, patient comfort is considered an integral part of patient care. “In our patient environment there has to be a high degree of comfort,” Hricak notes. “The stress and anxiety levels of cancer patients are, perhaps, higher than those of almost any other patients, so making sure that they are comfortable is very important. Being in a pleasant environment goes a long way toward helping patients feel better. Very often, hospitals have elegant physician and administrative offices, but the patient waiting areas and facilities are not as attractive. That is not the case at Memorial. If you care for your patients, then you have to care about how their waiting rooms, bathrooms, and ancillary spaces look. I believe that comfort should be a primary concern whether the patient has cancer or a simple musculoskeletal injury.”

The leadership of Memorial Sloan-Kettering sets the tone not only for patient comfort, but for all services, defining oncological radiology’s role and where it fits within a multidisciplinary approach, Hricak believes. “Memorial Sloan-Kettering Cancer Center is similar to the Mayo Clinics in that all of the physicians here are full-time, salaried employees of the hospital,” she says. “I believe that this results in a different culture and set of values. As such, the philosophy of collaboration among the various departments is much stronger and turf battles are rare. Radiology has a very important and permanently established role to play here.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.