Changing the future of breast screening at South Lancashire

Performance ranks on par with an MRI, and with the waiting list for MR breast scans often extensive, contrast-enhanced mammography is a welcome opportunity to help alleviate waiting lists. 

Alongside contrast mammography’s greater cost effectiveness, shorter scanning time and lesser impact on claustrophobic patients, the results are clear. 

With this service, the team have been able to problem solve more efficiently and diagnose more breast cancers than ever before. A faster process means more patients being seen. 

Charlotte Mullineux, deputy clinical lead for breast screening at South Lancashire, has worked for the WWL since 2023 and has been working in mammography for 10 years. “Contrast is really new in mammography,” she explains. “In all my years in mammography, we’ve never done anything like that. It’s used in other areas of imaging, like CT, but never in mammography. It’s been a challenge implementing this new imaging technique, but it’s been really exciting.”

While contrast mammography is available in a lot of other countries, its availability in breast imaging departments in the NHS is varied. The technology requires some substantial shifts within departments to roll it out, including software upgrades to existing computer systems and extensive training of the team using it. As more literature is published on its potential, the South Lancashire Breast Screening Unit team expects departments around the country to pick up on its value. 

Fiona Ryder and Toni Duncan are radiographers in the unit who specialise in breast imaging. “Previously, patients would have to wait to get an appointment in MRI, which takes weeks, and is obviously expensive. All that time, patients are anxious about their potential results. Reducing that anxiety is great. And having an MRI itself isn’t a nice experience. Not only is it claustrophobic, it’s also quite technically challenging,” says Toni.

“[For contrast-enhanced mammography], we had to learn to cannulate, which was quite challenging, because we had to go to training sessions and take an exam. And this is all in work time, so our duties are still ongoing. We’ve got to meet demand, but we’ve got to find space on our job plans to free up in order to go and learn.”

Fiona adds: “It’s a big project to implement, because mammography has never used contrast in a day-to-day clinical environment. In terms of health and safety processes, resuscitation processes – you need the infrastructure in place to support that. It’s not something that can happen quickly; there’s a lot of work needed to make sure it’s patient safe and that the staff are trained appropriately.

“It’s important because it’s speeding up the early stages of the cancer pathway for patients. Doing all the investigations at the same time, without the need for additional appointments, means that patients can get to the multiprofessional team meeting quicker than they would do if additional investigations were needed. We’ll see an improvement in cancer performance, ultimately.”

The journey to implement the technology has been long, but rewarding. Over the past year, with the help of the Boot Out Breast Cancer charity, members of the team received training in administering and interpreting images enhanced with contrast, something that the radiographers in the breast screening unit have never done before. 

Grace explains that there had been a slew of governance processes and training sessions to work through to ensure safe implementation. “Time spent training meant it was harder to relieve the staff and not reduce our capacity during the working week,” she says. “That was a massive issue, because they needed to learn to cannulate while we made sure we kept our numbers up.

“We needed standard operating procedures in place. We needed resources in case there was an allergic response, because we’re based at an outpatient centre, not attached to the main hospital, so the emergency procedures are different. We needed Patient Group Directions so that we didn’t need a doctor to administer the contrast, we needed to free up the room to get the equipment installed, we needed training on the injector, training for anaphylaxis and adrenaline, we needed quality assurance testing and the machine passed by medical physics.”

But at the end of that lengthy process, the team is happy to announce that they are already seeing real impact for patients – not just in terms of finding cancers faster, but also for ruling them out.One such patient was on a surveillance path that called for extra imaging, which unfortunately came back inconclusive for cancer. Without contrast-enhanced mammography, the team would have had to wait for an MRI scan appointment. With it, the team identified no contrast enhancement in the breast tissue, and was able to discharge the patient far more quickly.

Dr Amruta Talwalkar, director of Breast Screening and consultant radiologist at the South Lancashire Breast Screening programme, explains that this technology means patients can get almost immediate answers. “When we see breast patients, a lot of the time we have to send them away for extra tests, or we have to do biopsies and call them back a week later with their results,” she says. “But with this new technique, we’re able to immediately tell them ‘we see an enhancement in the breast; this is something we need to look at’, or just that everything is fine.

“For the majority of our patients, that relief of knowing there’s nothing wrong immediately, without having to wait, is a big factor. Any patient who comes through for any sort of breast assessment, there’s a big emotional component to it, regardless of whether they felt a lump or not. Even if we tell them everything’s benign, an element of worry stays with people until they get a final result. With this, we’re able to tell a lot of patients we aren’t worried at all, and they can go on. That emotional reassurance is a massive thing for patients.”

Next, the team is looking into contrast biopsy training to enhance their diagnostic capabilities. With that, if an abnormal area is identified during a scan, they can perform the biopsy right there and then – the presence of the contrast allows them to highlight the exact area they need to check. “The patient is effectively on a one-day diagnostic work-up. The pathway is going to be completely sped up. It will be a brilliant service for patients,” says Grace.

Amruta adds: “We are also in the process of setting up training for other centres to come and take advantage of. None of the other large centres nearby offer [contrast-enhanced mammography]. Manchester doesn’t, Liverpool doesn’t; the closest centre that does is in Leeds.”