November 23, 2011

Dr. Elaine Chin, a physician residing in Toronto Canada, speaks up about the ethical implications of restricting patient’s access to MRI Breast Screening.

In her blog article titled “Cost Trumps Life” Dr. Chin brings to light the limitations the Canadian Task Force on Preventive Health Care have rendered upon the citizens of Canada regarding the breast health of its population. The Canadian Task Force has declared that Canadian women between the ages of 40 -49 do not necessarily need to have a screening mammogram. They recommend that women between the ages of 50 to 74 get a screening mammogram every two to three years while the American Cancer Society recommends women over age 40 get a screening mammogram yearly.

The mammogram consists of a registered radiologic mammogram technologist using x-ray beams to image through the soft breast tissue. Lesions (most commonly marble sized) can often be detected with the use of mammogram.  X-ray images are taken of the entire breast area in several different directions, while the breast tissue is compressed for imaging.

Ultrasound requires registered ultrasound technologists using the ultrasound machine, which uses very high frequency sound waves to visualize lesions inside the breast tissue. Very often, since ultrasound is linear, the area across each breast needs to be scanned in order to cover the entire breast area. Ultrasound exams in the hand of an expert can often detect pea size lesions.

Breast MRI uses a large superconductive magnetic resonance imaging scanner and covers both breast areas in 3D. An IV injection is required while images are acquired dynamically over time. Post processing evaluations of tiny lesions (as small as 1mm) are often visible. The dynamic curves of the lesions evaluated help determine whether an area is cancerous, fibrocystic, or of concern to be monitored and checked on over time.

Bilateral Axial Breast MRI showing a vascular fed lesion on the right side medially behind the nipple..

The chances of living longer are directly related to early detection of disease. The chance that breast cancer will be found at a reverse-able stage is directly correlated to when the looking is being done.

Doctor speaks up about new Canadian guidelines on breast MRI. Dr. Elaine Chin recommends genetic testing( for the BRCA1, BRCA2 breast cancer genes), in addition to the possibility of using additional imaging modalities such as ultrasound and breast MRI to ensure the accuracy of each testing method. Ultimately, what she tells the reader is that you will probably need to pay for your own breast MRI, if the provincial ministry of health has not allocated money for those exams for the population of each Canadian province. These exams usually range from $1000-$1500 often without the radiologist reading fee, and Dr. Chin recommends paying for this yourself if you cannot get it paid for through a social program or insurance.

August 2011- A moldable MRI breast coil was under development according to the notice I received from my Google alerts.

Currently, we know that MRI breast coils are designed to be placed on the MRI scanning table, with the patient lying prone and the breasts dangling down into the MRI breast coil. With the size of some women being rather large, not all women will fit into the MRI scanner while lying prone on the MRI breast coil. Some of the larger bore scanners can accommodate many of these patients, but not all will then fit into the smaller cones of the MRI breast coils. The largest MRI breast coil we know of to date can house breast cup size E, but there are some coils that only go to a size D, such as the one pictured below.

Size limitations are one of the many challenges for the patient and MRI technologist while performing breast MRI.  Add to the formula the time involved for the study, the critical nature required in which the patient must hold very still for a viable study, the intravenous access point and the consistent delivery of MRI contrast during the dynamic phases of the breast MRI study.

The  SBIR Link HERE shows that a firm out of Lincolnshire, Illinois called Bio-Imaging Research, Inc was awarded a first phase $50,000 SBIR award to perform phase one level research on developing a moldable MRI breast coil.

Surprisingly, this alert cropped up in August 2011, but the award shows the date given was 1993.

We attempted to call the name and number listed at the bottom of the award for Timothy R. Fox, and the found phone number was disconnected.

Knowing now in 2011, that some particular MRI breast coils can house breast sizes up to cup size E, what would you propose to a scientist who was going to develop a moldable MRI breast coil?

Here is what we would suggest:

1- Flexibility

2- adaptability to size and distortion

3- multiple hardware coil channels

4- ability to be cleaned immediately between uses

If this research grant were to be awarded today, what might you tell an investigator to help contribute a better use to your science?

Breast MRI imaging offers an opportunity for a radiology practice to differentiate itself.
By Catherine Leyen, ARRT(R)(MR)(CV)

(*This Optimizing Breast MRI article appeared in the March Issue of Advance Magazine for Imaging.  One of the goals of this information was to present to reading breast radiologists that the national average for breast mri is five to six percent of their mammography volume. )

Just a few years ago, the American College of Radiology predicted a lucrative 20 percent increase per year in the utilization of breast MRI, and a 2008 study concluded that, “Breast MRI is recommended for preoperative evaluation of the newly diagnosed breast cancer patient.”1
Despite this, many patients are not getting recommended for preoperative breast MRI or as follow-ups. Some centers do not have the dedicated coil; others believe imaging breast MRI isn’t worth the trouble because of the liability associated with the high number of false positives (averaging 9 percent), lesions that need biopsied which turn out to be negative, and the possibility of other lesions missed.
The national average for breast MRI recommendations after mammograms ranges from 5 percent to 6 percent. One practice I know performs approximately 10,000 mammograms annually, yet recommends less than 1 percent of those mammograms for breast MRI follow-up.
Breast MRI imaging offers an amazing opportunity for a radiology practice to differentiate itself. However, remember that breast MRI only should be attempted at centers with high-field systems and experienced MRI technologists who understand the critical nature that every small decision could impact the outcome of breast MRI results.
Technology, patient preparation, and practice will play an important role in getting accurate results. Bruce Porter, MD, FACR, one of the leaders in breast imaging nationally, has instructed and supported second reads for many radiologists to bring successful MRI breast imaging to their practices and communities.

Technological advances
Sentinelle Medical, makers of multi-channel RF breast coils, detachable breast imaging tables, and Aegis evaluation software, recently sold to Hologic Medical, who seem to be positioning themselves as breast diagnostic supply providers. The Aegis software reports in real-time, so the software does not require a load up and processing timeframe.
In addition, the high number of multi-channel RF coils has lead to the ability to increase slice thinness and still retain high resolution and signal-to-noise ratio. The Sentinelle coil was designed for thin axial slices (showing 0.7mm), said Sentinelle CEO Cameron Piron. Yet, I have seen some centers using the 16 channel Sentinelle coil at 3 mm slice thicknesses in the sagittal plane on 3 Tesla systems, based on the radiologists’ personal preferences.
Invivo also has been making dedicated high-resolution RF coils that comply with multiple high-field MRI system manufacturers.
Steven Harms, MD, FACR, radiologist and developer of the dedicated Aurora breast MRI system, said that he knows of several situations where the Aurora breast scanner and a 3T system are side by side, using multi-channel breast coils. In those situations, all breast cases are sent to the Aurora scanners because of the higher spatial resolution, high contrast, and early detection, despite the 3T’s higher signal-to-noise ratio.
For centers not currently employing a high-resolution dynamic breast MRI portion to their practice—but would like to employ breast imaging immediately, Alliance Imaging now has eight of the Aurora dedicated breast MRI-only mobile systems for use around the country.

Optimizing Breast MRI

Comfortable care

New technology, including a 3-D dynamic post-processing system, is just one part of the picture, though. To provide the best in breast MRI, centers should feature highly critiqued MRI protocols, experienced MRI technologists, radiologists who know breast MRI reads, and enough routine breast MRI cases to consistently deliver accurate results.
To make women feel more comfortable for breast MRI, some imaging centers have created a health spa-type feel with décor, thick lush robes, sealed slippers, and even personal nurse guides. I’ve also seen centers give away a rose to every patient.
Other important tips for a successful breast MRI include: scheduling patients according to their menses cycles and temporary discontinuation of hormone replacement therapy; removing all street clothes to avoid artifacts; and fostering clear communication to the patient on what to do and expect during the procedure.
But ultimately, what works best is allowing patients to get some personal time with the reading radiologist so they understand the diagnosis and complexity of the diagnosing process.

Catherine Leyen, ARRT(R)(MR)(CV), is co-founder of MRI Optimize Consultants LLC, Tempe, Ariz. For more info, visit www.mrioptimize.com.

Reference
1. Hollingsworth AB, Stough RG, O’Dell CA, Brekke CE. Breast magnetic resonance imaging for preoperative locoregional staging. Am J Surg. 2008;196(3):389-97.

Suggestions from an MRI Technologist in helping you complete your important study:

1) If you find a radiology center that answers “yes” to the 7 questions about scanning your dynamic breast MRI, then you may request to attend early or at a scheduled time, and have the team work with you in overcoming your claustrophobia and mri exam.  Visit the scanner exam room, meet the team, and reassure yourself that they will work with you in completing your exam.  Many centers will work with the patient in helping them understand the procedure involved, in order to attain the best study possible.  Good technologists will attend to you from all aspects despite busy schedules. If the site appears neglectful to you or other patients, then choose another center.  This is your battle, and you are fighting for yourself and the best exam possible.  You have choices.

2) Ask if they normally scan the breast MRI study with the patient going into the scanner feet first. (You will be prone during the scan, which means on your stomach, so this may not actually affect your claustrophobia and mri exam.) On some of the older scanners, the physics of acquisition in combination with the coil (antenna) for your images denies scanning the patient feet first for breast MRI, but on many of the newer systems, it is possible for you to go into the scanner feet first. (Do not ask the site to do this if they are not used to performing studies this way. A plethora of problems may result from requesting this when the MRI system and coils are not designed to be used this way (feet first). Too often, this may not be discovered until your case is done, so don’t risk it.)

3) Discuss the option of taking a sedative with your ordering physician prior to the MRI study and if it might benefit you. For those who are claustrophobic, the nervousness many experience from doing something different like getting the exam, and the possibility of discovered findings are just as nerve racking as having the study.  You may need a driver to take you home, or ask the center to call you a taxi.  Many will do this at their expense.

4) Do not drink coffee,tea or caffeinated sodas prior to your MRI study, but instead drink water (this may make it easier for the phlebotomist to find a vein to start your IV with.)  Try to reduce the stimulant levels in your body so you can relax.

5) Request a family member or friend hold your hand during your exam. The MRI does not use x-radiation, and is therefore safe for other people to be in the exam room during the study, IF they pass the MRI screening process first. While in the exam room, a friend could hold your hand during the exam.  It is important they not talk to you or disturb you during the study, and that you both remain very still.  Not only does the scanner “shim” to your body type, but the active physics involves “shimming” to everything around the scanner in the room.  Every little bit of jiggling on the MRI table during your study decreases your image quality.   

6) Do not deny yourself the opportunity to get the MRI breast exam, by succumbing to your fears. This technology can often find lesions earlier and smaller than most of the other exams, and with guided follow-up and planning can save your life.  In addition, many of the staff members at radiology centers understand the fears and will work with you in getting you comfortable for a successful outcome.  When dealing with claustrophobia and mri examinations, use the modern tools necessary to help you get the images needed to promote your health and well being.

7) If you are having any other mri exams done, and are battling claustrophobia, ask for a washcloth over your eyes. Most MRI exams are performed with patients on their back looking up at the inside of the mri bore, which can seem closer than it is. The feeling of claustrophobia overcomes a person when they feel like they are trapped.  While this may seem like a simple solution, the simple act of putting a washcloth over your eyes fools the psyche, and allows for completion of the exam.

MRI is an acronym abbreviation for magnetic resonance imaging.

MRI breast is very different from a mammogram.

A mammogram uses low dose x-radiation only takes about 15 minutes, pictures are snapped quickly and developed within a few minutes, checked with a physician for completion, and do not usually involve any imaging contrast. With a mammogram, you get an average of anywhere from four to eight or ten images taken from different directions of both breasts.

With an MRI breast exam, there are hundreds of very thin images required which are reconstructed into a 3 dimensional plane, and then reconstructed in the different planes of the body. Typically, MRI of the breast is done in what is termed 4D imaging. In other words, the images are done in 3 dimensions and then acquired also over time, with time being the fourth dimension.

What is an MRI? An MRI is a very large magnetic scanner, in which the patient goes inside of and gets pictures taken while using an antenna coil designed specifically for the body part getting imaged.

In the case of breast mri, most coils have two holes where the breasts insert into when the patient lies prone, on their stomach, on the mri table.

Unlike many other diagnostic imaging procedures in radiology, mri of the breast does not involve any x-radiation or dangerous exposure to ionizing radiation. Mammograms require x-radiation, and many women feel that mammograms are very painful due to the compression techniques used by many technologists. The pain produced by uncaring mammography technologists deters many women from attending for their yearly mammogram exams, and as such, the possibility that cancer may evolve undetected can become an issue.

MRI has been around for almost thirty years, but you should probably have your breast mri done on a newer high field mri system, meaning a 1.5T or a 3Tesla system. There are questions you should ask prior to having an mri, to make certain the facility you are getting imaged at is experienced in performing quality mri breast exams.

Not only have I sometimes heard complaints from medical staff when exams are ordered to be performed on the elderly, but worse yet, I have heard complaints when they are ordered on children.

“Why are we working on this person?” is the usual statement I’ve heard, but I want to say to those health care workers who work on the elderly and the very young, you are making a difference in somebody’s life.  If you don’t want to do the procedure out of inappropriateness, double check with the ordering physician first, to confirm the exam. Once confirmed, accept your work as challenging with variety and move forward.

Would you believe me if I told you the youngest breast cancer patient is 4 years old?

This short web entry is a reminder that if you are a health-care practitioner, you should view every order for finding a diagnosis as a sort of “hunt”. Good hunters find their prey, even if it is a disease process.  The sooner the culprit is found, the sooner the patient can be on their way to a curative and healing existence.

This following story is included here, because here’s real evidence of the youngest survivor of breast cancer. Remember what you do in your profession makes a difference everyday, and people sent your way are on their path to wellness and healing. What you perform in imaging them is a step on their journey.

“They cut my booby off”, four year old Aleisha said.

Aleisha Hunter, Photo courtesy of The Hamilton Spectator

http://www.lex18.com/news/four-year-old-survives-breast-cancer

Most of our readers are mothers, so we hope you understand when we encourage our readers to take extra special care of children and the elderly.  Great technologists do whatever they can to make the patient comfortable, and get the best images possible for the most accurate diagnosis.

If you have any questions or comments, please add your comments below!

We call this the, “Invictus poem for strength”

Invictus

Out of the night that covers me, Black as the Pit from pole to pole,

I thank whatever gods may be, For my unconquerable soul.

In the fell clutch of circumstance, I have not winced nor cried aloud.

Under the bludgeonings of chance, My head is bloody, but unbowed.

Beyond this place of wrath and tears, Looms but the Horror of the shade,

And yet the menace of the years Finds, and shall find, me unafraid.

It matters not how strait the gate, How charged with punishments the scroll.

I am the master of my fate: I am the captain of my soul.

By William Ernest Henley

invictus poem for strength "Warrior Woman"

We encourage our readers and anybody doing research about breast imaging to be proactive for their own interest and good health. Learn about the tests available to you, how they should be performed, the proper preparations for them and more.

Afterward, you might also want to get your reports and copies of any images to keep for your own records and follow-up. Centers are required by law to keep your breast images indefinitely now (this being edited and updated July 2011), but we have seen situations where radiology imaging centers have closed, been bought out, and essential images have been lost.

Be sure to follow up with your ordering physician for the results of your breast imaging tests. If you get copies (often on a CD or DVD) a few days after your exam, you might also get the dictated report to keep for your records.

Be your own warrior and fight.  Join a group of other warriors and support them as well.

SUSAN_G_KOMEN for the CURE

Never ever give up!

A woman in the United States is diagnosed with breast cancer every two minutes, making it one of the leading cancers in women. Now, new medical technologies are giving women, who are at high-risk for abnormalities, another option in early detection.

Statistics are around an average of one in every eight women fall victims to breast cancer. With yearly mammograms, early detection through the use of MRI, many are conquering the dreaded disease and living long and healthy lives.  That is especially important for one of the reasons the American Cancer Society says Breast MRI is useful.

If a breast cancer lesion is found when it is very very small, the cancer can often be removed with the biopsy, and does not require invasive surgery, radiation treatments and chemotherapy. Much depends upon the size of the lesion, and if the lymph nodes are involved, which is “staging” of the cancer.

has determined that breast MRI is a very useful exam and should be used regularly in certain patient groups. Their guidelines were published in the ACS journal CA:A cancer Journal for Clinicians in 2007.

Annual Breast MRI Screening is recommended in addition to mammograms for women who meet at least one of the following criteria:

• Dense breast tissue
• BRCA1 and BRCA2 gene mutation
• First-degree relative of a BRCA carrier, even if patient is untested
• Lifetime risk of breast cancer is 20-25% or greater, as defined by the BRCAPRO*
• Radiation to chest between age 10-30 years of age
• Li-Fraumeni syndrome, or a first-degree relative
• Cowden syndrome, or a first-degree relative
• Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative
• Have a personal history of breast cancer 

• Have ductal carcinoma in situ (DCIS) 

• Have lobular carcinoma in situ (LCIS) 

• Have atypical ductal hyperplasia (ADH) 

• Have atypical lobular hyperplasia (ALH)

The American Cancer Society recommends that if you are at high risk, you start getting annual checks with mammograms and MRI at age 30 and continue yearly while you are in good health.

It is also recommended that you have MRI exams in conjunction with your mammogram, and not as a replacement.

FULL RECOMMENDATIONS HERE…

July 7th, 2010 it was announced that Sentinelle Medical will be acquired by Hologic Imaging for $85 Million.

Almost a year ago, Cameron Piron, CEO of Sentinelle Medical and Ian Heynan, CFO invited MRI Optimize Consultants business partners, Rosemary Fisher and Catherine Leyen to Toronto to meet with them and discuss dynamic breast MRI imaging.  After several conference phone calls from the busy CEO and CFO, they flew up to Canada, met with the two powerhouses, and reviewed ways in which they could optimize their marketing and MRI Applications team as they had requested.

Sentinelle Medical has an add-on/aftermarket sixteen (16) channel radio-frequency coil designed specifically for high resolution breast imaging.  The multiple channel coil is designed for essentially newer MRI systems with integrated parallel or multiple RF-channel use.  In addition, they provide an optional MRI safe scanning table that  detaches from specific MRI systems for patient staging, namely the GE and Toshiba scanners. With patient flow and comfort in mind for the design, one MRI technologist can be prepping a patient in a private room (getting the patient on the table positioned on her stomach into the breast coil) while another patient is actively being scanned on the machine. This allows for optimal prep-time, privacy and interaction with the patient prior to the exam while the scanner is fully utilized.

The MRI Optimize Consultants team was scheduled to meet with Cameron and Ian on the 8th floor of their office near the fashion district in Toronto, Canada. Rosemary and Catherine had ventured from the opposite sides of the continent to meet with these gentlemen, and while the meeting was intended to last for two hours, it ended up lasting over six.  With a history of 300% growth in Sentinelle for the previous few years, it was no wonder they were busting at the seams.

After a brief tour through their R & D division, the MRI Optimize team saw history in the making through upcoming developments and were honored that Cameron shared his developments with them.

It was announced through a press release that “Sentinelle Sells to Hologic for 85 Million“.

MRI Optimize Consultants would like to wish a hearty congratulations to Cameron, Ian and their crew, many of whom had worked alongside and known MRI Optimize members in other MRI circles for many years.  Brian, Eric, Mike, Ian, Jae and Cameron….Congratulations to you all!

Now what guys?!

Blending the old with the new at the Royal Ontario Museum, where Cameron told us the Dead Sea Scrolls were on display. We could not miss this!

The CN Tower in Toronto amid new construction to the myriad of skyscrapers surrounding it.

This non-profit foundation (based in Arizona) was setup for patients who wanted, but cannot afford a second opinion. Phoenix is very fortunate to have a professional group of this caliber who are truly concerned about positive outcomes for their patients.

The AIBH is an innovative medical support group of physicians and health-care support specialists. They meet weekly and carefully evaluate each single case carefully together.  After meticulous review of each patient history and diagnosis, with patient involvement and calculated outcomes,  they analyze and openly discuss what the best treatment plan would be customized to each patient.

This is directly from their AIBH Website.

“The Arizona Institute for Breast Health, a local non-profit organization, offers a woman who has been diagnosed with breast cancer a second opinion, completely free of charge. The volunteer team of physicians and medical professionals are breast health experts whose specialties include breast radiology, breast surgery, medical oncology, radiation oncology, reconstructive surgery, and breast pathology. This team evaluates the best medical and surgical options for the preservation of a woman’s life, body and emotional well-being, as well as the continued quality of her life. In a caring, expedient and objective manner, the team will provide a comprehensive evaluation and recommendations for treatment.

The Patient Advocate at the Arizona Institute for Breast Health organizes the breast cancer cases for weekly discussion and supports each patient through the process. The volunteer governing Board of Directors oversees strategic planning for the Institute and meet regularly to coordinate fund-raising, media and marketing details, corporate and private donors, and website updates.”

The Arizona Institute for Breast Health Mission Statement

Breast health is the only specialty at the Institute. Therefore, everyone from the radiologists, to the surgeons, to the oncologists are focused on one thing and one thing only: providing the very best care possible for breast cancer patients. Their collaborative team approach raises the level of medical and emotional support to facilitate the healing process. Please call them directly at (480) 860-4200. They are open during normal business hours, Mountain Standard Time.

To contact them directly via confidential e-mail, go HERE.