Advancing the big picture

Behind millions of pink ribbons, well-publicized races and the awareness generated by fund-raisers lies the reality of breast cancer for one woman out of every eight in the United States. Against these odds, physicians and other health-care providers work to stay one step ahead of the disease. And while researchers everywhere are making great strides against breast cancer, a group of radiologists at the Seattle Cancer Care Alliance is out in front.

The Breast Imaging Center at the SCCA leads the country in expertise with its breast magnetic-resonance imaging (MRI) program. Several international trials on the appropriate use of breast MRI have been conducted by the SCCA, where physicians have developed new techniques for MR-guided biopsy and interventions.

The breast-imaging clinic is successful where others have struggled because of a combination of the right staff, equipment and space design.

A physician who has completed a radiology residency and a specialized fellowship in breast imaging interprets every mammogram that's obtained. "There aren't other clinics in our community where every radiologist reading every mammogram has those credentials," said Dr. Connie Lehman, director of the breast-imaging clinic. Every radiologist on staff is also a researcher, so the team is helping to build the general knowledge base. The technical staff also has high levels of specialized training in mammography.

Same-day screening

At many locations, the technologists are greeting the patient, helping the patient change clothes and fill out paperwork, which slows the system. At the SCCA and University of Washington, technologists are dedicated strictly to breast imaging, said Lehman, who is also section head of breast imaging at the UW. "Where you want that technologist is in the room taking mammograms — a medical assistant can help with those other processes," she said.

The clinic excels in its consistent use of MRI and digital technology. While some sites offer a percentage of digital mammograms, the center performs every exam using digital mammography, a technique known to be more effective in diagnosis and screening than other methods. Of all imaging tools that complement mammography, MR is the most promising because of its high sensitivity in detecting breast cancer.

Many sites, working with low funding and strict governmental regulations, are trying to accommodate more patients but lack the resources and space, so some women are waiting months before being screened.

By making sure that every person on staff is performing their specialized task, the breast-imaging program is able to maximize the number of patients seen. Instead possibly waiting months, with the appropriate referral from their physician, the program can offer women can get same-day screening mammography appointments. Between the SCCA location, another clinic in the University District and a mobile clinic, the program serves 19,000 patients every year.

Minimizing anxiety

"We identified the log jams and corrected those with better space planning and better support staffing," Lehman said. The clinic, designed with input from the radiologists, technologists and support staff, provides a network of rooms, each designed for a specific purpose. Patients fill out paperwork in one room and change in another, which funnels into the mammography room, which leads patients into a separate consultation room. The design allows more patients to be seen quickly and expedites the flow of information, which can help minimize the anxiety that can accompany a mammogram.

If a woman has a palpable lump or an abnormal mammogram, her next appointment and biopsy are often on the same day of her mammogram. "You might think that the worst time for any woman would be while she's having her surgery or her radiation, or when she's so sick from her chemotherapy," Lehman said. "But actually the highest levels of anxiety are from waiting and not knowing whether or not you have breast cancer."

Supported by the combined resources of the SCCA and UW, along with funding from National Cancer Institute, the American College of Radiology Imaging Network, and private donations from Avon Foundation and Susan G. Komen Foundation — the Breast Imaging Center is at the forefront of the field. The picture is quite different across the country, where the decline in the number of clinics is a concern.

"Nationwide, there is a mammography crisis," Lehman said. "We have increasing numbers of women needing to be screened with mammography. At the same time, we have clinics closing because they're not able to sustain those programs. We're seeing women without easy access to high-quality mammography."

Lehman said that historically, radiologists have been apprehensive about specializing in breast imaging, so the numbers of specialists have been declining. Breast imaging has some of the most stringent governmental regulations. It is not reimbursed at the same level as other areas of radiology, so some practices have cut back mammography services. Furthermore, breast imagers face higher risks of malpractice because radiologists are involved in some way in most lawsuits including those of delayed diagnosis.

Despite the challenges facing the field, the SCCA and UW have been successful in attracting new physicians. "What I feel so good about is that while we have this national shortage of mammographers, and need to find ways to encourage radiology residents to go into breast imaging, we have to turn away residents applying to our fellowship program because we have more applications than we can accommodate," said Lehman.

Dr. Wendy DeMartini, a former SCCA fellow who is now a member of the breast-imaging team and an assistant professor of radiology at the UW, was drawn by the opportunity to interact with patients.

Personally impacting lives

"The fact is that it's an important area where I feel like I'm making a real difference in patients' lives," DeMartini said. "It's also one of the areas in radiology in which you continue to have a fair amount of contact with patients, whereas in some of the other areas of radiology that's not the case. Those of us in breast imaging tend to like that."

"Ultimately, it is that feeling at the end of the day that I saved somebody's life that's really the driving force," said Dr. Peter Eby, breast-imaging team member, assistant radiology professor and former SCCA fellow.

Lehman is delighted with the progress the team has made and the interest from potential fellows.

"It's the greatest specialty, and it is an area where people can really make a contribution, whether in the clinical area, in teaching or in research — or being a physician-scientist and doing all three," Lehman said. "They can know that with training in breast imaging, they're going to make a big difference in women's lives."