Anna K. Chacko, MD

Over the past two decades, breast imaging has been the focus of attention from a variety of interest groups, including the government. The arena is replete with meaningful work, but, at the same time, there is also an overabundance of gestural and relatively useless effort littering the landscape. To assess the effect of new innovations, to derive answers from old data, to plot trends, and to actually effect change on a national and meaningful scale, nationwide access is needed. This is best accomplished via a nationwide picture archiving and communications system (PACS) network.

A nationwide network for transmitting breast imaging data is an issue that should have been addressed and implemented long ago. With the several modeling and simulation techniques at our disposal,1 it should be relatively painless to grow an artificial mammography database and observe how outcomes could be affected with unfettered communication and access to expertise regardless of geographic limitations. In any case, until we are able to carry out an in silico et in simulo exercise, we must first look at what general radiology PACS has accomplished for the same audience and then assess if these benefits are applicable to breast imaging. Generalized radiology PACS has driven several tectonic shifts:

  • Both industry and the American College of Radiology were galvanized to advance an entire library of standards, which ultimately facilitated communication between users.
  • The ubiquitous availability of images has garnered an enormous savings in time and effort on the part of the clinician. Studies have shown that availability of relevant prior images electronically precluded a repeat visit in 37% of patient visits (all comers) to the acute care clinic/emergency department.2

In summary, PACS allows democratization of image information, facilitating access to expertise irrespective of geographic and time constraints. Can PACS do this for breast imaging? I believe that it will do this and more.

Mammography has long been the focus of attention from multiple areas leading to a schizophrenia of sorts. While the government has chosen to regulate every aspect of the performance and practice of mammography, little has been done to facilitate the exchange of information between practitioners and purveyors besides dispatching images by snail mail.

Introduction of PACS in mammography/breast imaging presents several challenges. Mammograms are quite possibly the most memory-intensive images in radiology. More and more women in this country obtain mammograms. This is further compounded by the fact that self-referral for mammograms is the norm. When one adds the fact that mammograms must be stored far longer than any other image, the need for storage becomes daunting. However, when one considers that large amounts of storage are routinely used in industries such as banking, storage of mammograms should not present an insurmountable obstacle.

Computer-aided diagnosis (CAD) is far more advanced in mammography than in any other subdiscipline of radiology. At present, it makes perfect sense with analog mammography to digitize the film and then perform a CAD maneuver. With the analysis of these digitized mammograms, one is dealing with a limited data set. Digital acquisition of mammograms gives the reader a far less restricted amount of data. Development and application of pattern recognition algorithms on a digitally acquired data set should become a natural next step.

The ability to acquire and transmit breast images electronically will foster the democratization of information in an arena where it is sorely needed. With the tremendous shortage of radiologists nationwide, the poor reimbursement for mammograms, and the litigious nature of the business, the field is besieged with numerous problems. Fostering and developing a nationwide MammoPacs initiative could solve some of these problems.

Value of a Nationwide Network

The advantage and value of having a nationwide electronic network, which allows exchange and examination of breast images, are manifold. Conceptually, it could allow practitioners of radiology to develop expertise where a paucity of patients prevents it. This would increase the pool of radiologists available for interpretation of mammograms. A nationwide PACS effort in mammography will allow patients to access expertise irrespective of geographic constraints. Since mammograms are rarely an absolute emergency, timeliness of transmission and receipt of images is less of a problem than with other types of patient images. Second reads could be done with far greater ease than currently, where one is restricted to one set of mammograms and fear of loss of images is ever-present.

Most important, MammoPACS would be the foundation of an enormous national database that could be used for data mining, visualization of disease trends, development of new and better quality control standards, and development of search engines to analyze every aspect of the disease, its demographics, trends, and response to therapies. This had been described, with reference to national databases for radiology, several years ago by the late Marcus Hedgecock, MD, of the San Francisco Veteran Affairs hospital, in a monograph on regional archives.

Advances in breast imaging, including fusion imaging, vibrational resonance with Doppler spectroscopy, laser mammography, MR elastography, and scintigraphy with agents such as tetrofosmin, are some of the exciting prospects before us. Electronic commerce and democratization will only improve the landscape. Having a nationwide network with access to vast amounts of pathology, tissue characterization, demographics, and disease progression data can make our attack on a dread disease-breast cancer-an effort of tsunami proportions instead of the perturbations in tidal pools that it is now.

Where do we go from here? Breast cancer is a growing global problem needing a global viewing glass and globally applicable solutions. A nationwide MammoPACS is a way to get us there. The government should step in and make a serious and meaningful impact by providing the development of a network and infrastructure for MammoPACS. Government intervention would become less meddlesome and more productive.

A recent article in the Wall Street Journal3 describes “an estimated 39 million miles of fiber-optic cable [that are] stretched under the US-only 10% of which is in use today according to the latest estimate by Merrill Lynch & Co.” A nationwide breast imaging network would be a worthy cause for lighting up some of this dark fiber.

Anna K. Chacko, MD is chairman of radiology , the Lahey Clinic, Burlington, Mass.

Jacob Chacko completed his baccalaureate at the United States Naval Academy, Annapolis, Md.


  1. Rauch J. Seeing around corners. Atlantic Monthly. April 2002.
  2. Benson AD, Chacko, AK. The use of soft copy to enhance the interpretation of hard copy digital images [abstract]. Proceedings of the Fourth International Conference on Image Management and Communication (IMAC 95). Washington, DC: IEEE Computer Society; 1997.
  3. Blumenstein R, Zuckerman G. Domino effect: telecom’s troubles spread from upstarts to sector’s leaders. Wall Street Journal. March 13, 2002.