Thirty-four states currently require some type of breast density notification after a patient undergoes a mammogram. The patients and their physicians have to then decide what to do next.

Automated breast ultrasound (ABUS) is touted as a useful supplemental screening option for the women with dense breasts. Ultrasound can detect lesions in this population that mammography misses, and the automated feature makes the exam less operator dependent.

Carolina Breast Imaging Specialists in North Carolina recently implemented GE Healthcare’s Invenia ABUS. Dr. Bruce F. Schroeder, owner of the practice, anticipates this new addition will improve their detection of small cancers that cannot be seen with mammography alone.

HCB News chatted with Schroeder about the benefits of ABUS as well as how his technologists were trained to operate this new technology and how his radiologists learned to interpret the images.

HCB News: Why did Carolina Breast Imaging Specialists decide to begin offering ABUS?
Dr. Bruce F. Schroeder: We have known for a long time that most missed breast cancers happen in dense breasts. Even tomosynthesis, which we have done on all patients since 2014, still misses cancers in the densest tissue. 

The ABUS literature shows a significant improvement in cancer detection in dense breasts, so we were eager to finally have something to offer to these patients.

Most states, including North Carolina, now require breast density notification. We tell the patients who are dense that they could be at higher risk of breast cancer and that mammography is less effective in dense tissue. We also have them to ask their doctor if supplemental imaging is needed.  

Until now, we have not had any reasonable option for the supplemental testing we suggest in the notification. It was very difficult to enthusiastically offer whole breast screening ultrasound with a hand-held system because it is very time consuming and operator dependent. 

MR and other functional imaging tests are not recommended in average risk women simply because they are dense. ABUS solves these issues by being relatively easy to do without significant cost or radiation.

HCB News: What is the reimbursement situation like for ABUS?
BFS: There is no specific code for the automated whole breast ultrasound, even though it requires a dedicated piece of equipment and provides more information than a traditional hand-held system. 

We use the same code we would bill for handheld. However, it is still a much better situation than just a few years ago when we had only one breast ultrasound code that was used whether or not we did limited or complete scans of one or both breasts.

HCB News: Can you describe the learning curve for performing ABUS scans?
BFS: This is very different from the usual handheld ultrasound both in terms of technologist technique and radiologist training. Our technologists each spent three full days learning the system and scanning 15 volunteers. 

The radiologists have to have at least eight hours of training, which was provided by GE and included self-paced video sessions and a five hour real-time online training course with hands-on case review. Despite all of the training, it will take many cases to become comfortable with the appearance of lesions and normal tissue on these scans. 

Unlike traditional ultrasound, we are presented with a coronal image of the breast. This can only be obtained with a 3D system like ABUS and is not something we are used to seeing.

This view, however, shows distortion and other significant features that are simply not seen on the axial images. The greatest "risk" of ABUS is its relative lack of specificity, which can lead to higher recall and biopsy rates, especially during the early phases of the learning curve.

HCB News: Does your facility provide any other secondary breast imaging? If so, what factors determine the best secondary scan for different patients?
BFS: We offer contrast-enhanced mammography in our office as well as MR interpretation for scans done at the local hospital. However, neither of these functional imaging tools is appropriate to use for screening average risk women.