Examine | Mammography: Viewpoint: The Case for Film

Mammography printing in the digital age

Even in an increasingly digital imaging environment, there is still a need for hard copy. In this edition of Examine | Mammography, find out why printers still play an important role in mammography.

File rooms are shrinking. Darkrooms have gone dim. The digital age has unquestionably arrived in the mammography suite. But at most sites, filmless simply means less film – certainly not the elimination of hard copy imaging. Film printers remain an essential part of the mammography equipment mix, even in sites relying exclusively on full-field digital mammography (FFDM). As work environments continue to evolve, mammography practices would be well served to regard a high-quality film imager as an essential part of their practice and to select one that caters to the new demands of the digital age.

The Continued Demand for Film

Look around you – in today’s medical facilities, hard-copy images are not hard to find.

What is driving this continued demand for film? In large part, the answer is that referring physicians – the radiologist’s customers – often request hard copy. This is because doctors who review images as a small part of their workflow typically do not derive major benefits from transitioning to soft-copy reading – which may demand significant changes in reading style, complex IT set-up, and major reorganization in patient record-keeping.

Another driver of the continued demand for film are the patients themselves. Women frequently request copies of mammograms for second opinions. If patients change annual screening providers, they also need copies of prior exams for their new practice. The most universally acceptable format for image-sharing is hard copy – taking a chance on a physician’s ability to view images electronically can cost time and money if the format is unacceptable.

Naturally, another very important reason for maintaining a printer is simply the need to back up a PACS so that an IT failure does not bring workflow to a screeching halt. And finally, there are still those radiologists who will always prefer film.
   
Smaller Volume, Greater Efficiency

While the bottom line is that printers are still essential to today’s mammography practices, the image volume they support clearly has diminished. As new generations of radiologists and clinicians trained in reading soft copy begin to enter the field, the demand for hard copy will drop off even further. At the same time, today’s shrinking healthcare budgets mean that sites need to spend their money appropriately as they place increasing emphasis on digital workflow and less on hard copy.

The challenge is clear. Mammography calls for an easy-to-implement, affordable printing solution that simultaneously delivers the high-quality images the modality demands.

Image Quality

Just how do you judge image quality? One of the best ways is simply to compare the actual image output from several different vendors. Naturally, resolution is key and generally ranges from 504 to 604 DPI for most mammography devices. But, also consider contrast and grayscale curves. How black are the blacks? Does the background eliminate most extraneous light and improve your view of the image?  When examining imagers, be sure to compare apples to apples – look at all images on the same film size and in the highest resolution output available.

Catering to the specific demands of today’s mammography printing, Sony recently introduced a specialized high-resolution mammography device to its FilmStation™ dry imager family. Radiologists have commented that the new UP-DF750 FilmStation Mammography Film Imager, with an image resolution of more than 600 DPI, delivers an extremely high-quality image that almost exactly duplicates the image on the diagnostic monitor. That level of clarity and precision is crucial for exacting mammography applications.

FDA Clearance and the Quality Control Process

Another important consideration in selecting a printer is U.S. FDA clearance specifically for breast imaging. Meeting strict FDA standards further validates the quality and consistency of a printer’s output. While, perhaps surprisingly, FDA clearance is not mandatory, the agency does strongly recommend that mammography sites use a printer that has obtained its approval specifically for FFDM.

Whether or not a printer is FDA-cleared, a site must comply with the FDA’s strict Mammography Quality Standards Act (MQSA) quality control (Q/C) program to ensure printer performance. For many users, an FDA-cleared printer represents the most efficient and effective way to comply with MQSA. For 510(k)-cleared devices, the FDA provides easy-to-follow, definitive Q/C guidelines. For others, the site must follow guidelines provided by the image receptor manufacturer (FFDM system) vendor. 

FDA-cleared mammography printers are available from a wide range of imaging vendors, including Sony.

The Q/C process itself – which ranges from phantom image quality measurement to detector calibration and artifact detection – also can be complex and time-consuming. Technologists are required to run some of these checks weekly and even daily. Therefore, a site should select a printer that will streamline the process and make the most of the busy technologist’s time.

Clearly, a printer with reliable and consistent performance simplifies the Q/C and minimizes the time spent making image adjustments. Michael Glennon, administrative director of radiology for Sleepy Hollow, N.Y.-based Phelps Memorial Hospital, evaluated the new Sony mammography device. He notes, “In the year we have had the original or non-mammography Sony FilmStation system, we have not experienced any downtime. FilmStation worked flawlessly for us.” Of course, reliability is difficult to measure, but talking with other radiology professionals about their experience with various printers is often an effective way to anticipate performance.

Some imagers, like FilmStation, are also designed to simplify print adjustments with easily accessible front-panel controls and allow the device to be calibrated both manually, as well as automatically, so that images can be fine-tuned as required.

Naturally, when it comes to printer consumables and media, this same ease of access will save time and ensure the device is ready when needed. Film, in particular, should be easy to load.

Size, Speed, and More

As women’s imaging sites rely increasingly more on complex equipment, space is even more at a premium than in the past. In a crowded environment, printer size, of course, is another key consideration. High-volume medical imagers traditionally have been synonymous with extremely large footprints. However, when playing a supporting role to filmless technologies, high print capacity is generally unnecessary. Today, manufacturers, including Sony, are designing compact, efficient printers specifically for mammography printing in the modest-print-volume digital age. For example, FilmStation Dry Film Imager weighs less than 150 pounds and can be sited both horizontally and vertically to make the most of available space.

A compact and lightweight printer also simplifies the siting process and enables the device to be easily moved if the room layout is altered, as often happens when new equipment is added. Plug-and-play connectivity also is desirable to support flexible placement.

Speed is also an important consideration. With an abbreviated warm-up time of one minute, the FilmStation Mammography Film Imager allows sites to switch quickly between soft- and hard-copy reading. Rapid printing speed also enhances workflow and keeps the wheels of radiology turning at a fast pace. Slow printers always create a bottleneck with multiple users waiting for their films. The FilmStation system delivers output at 90 8x10 films per hour, and other printers on the market today also offer similar speed.

Another key factor is the versatility of the printing device. For multimodality sites, an adaptable printer such as the Sony FilmStation can help meet printing needs beyond mammography. Selecting an imager that supports multiple media sizes is also a good idea – because needs and preferences change.  A device equipped with multiple media trays is a time-saver because it eliminates the need to constantly swap out film of different sizes.

Printers may incorporate a broad range of special features. Conducting a thorough survey of the marketplace will help sites select the imager that best meets their needs. For example, FilmStation user Robert Perelman, MD, director of radiology for Phelps Memorial Hospital, notes, “With FilmStation, the image extends to the edge of the film, so when we hang it on the view box, it is easier to see.” Small benefits such as this can add up to significant time-savings during the course of a busy day.

Price and Service

Naturally, cost is one of the most important considerations. The purchase price of high-resolution mammography printers can vary significantly and typically is not an accurate indicator of image quality, speed or overall performance. Generally, more costly imagers are designed for high-volume use, which today may be unnecessary. These imagers typically are also larger and more expensive to operate and maintain. Today’s more efficient and compact devices like the FilmStation Mammography Film Imager, with a suggested list price of less than $25,000, gives mammography sites another option.

Remember, printing costs do not end with the purchase price. Cost of ownership, including consumables and parts, adds extensively to the price tag. From media to printheads, be sure to investigate the total package before committing to a device. What seems like a bargain-priced selection can become a real drain on a budget during day-to-day operations. Make sure to examine not only costs, but also the quantity ratings of consumables to get the complete picture.

Everyone hopes they will never be needed, but service and support are vital if technology fails. Printer warranties and service contracts should be carefully investigated in advance. Naturally, immediate onsite service is preferable to keep business moving forward if printer problems occur. Some manufacturers swap out a malfunctioning printer with a new or refurbished model overnight, but that still leaves sites without hard copy for an entire day. Also, the effort to pack and ship heavy equipment should not be underestimated.

The FilmStation Mammography Film Imager

The Sony FilmStation UP-DF750 was specifically designed to be the hard-copy workhorse for the digital mammography site and illustrates many of the qualities desirable in a quality
mammography imager. Like all FilmStation Dry Film printers, it offers advanced speed, image quality, and flexibility. With a special high-resolution thermal printing system, the device is optimized for mammography applications and designed to help mammography facilities meet MQSA standards. It has a built-in DICOM 3.0 interface and accepts a variety of film sizes.

The Sony FilmStation UP-DF750 weighs in as one of the smallest competing mammography devices and has the smallest footprint of any similar printer on the market today. It delivers the FilmStation system’s unique horizontal and vertical positioning option and can stand right alongside a CPU under a desktop. Wherever positioned, it frees up valuable space in today’s crowded medical environment.

“What I like about the Sony Mammography printer most is the image quality. The resolution and contrast are terrific,” comments Perelman. “The film’s dense black background cuts down on extraneous light. You can easily see the dense central tissue in the breast.”
   
– Julie Holodak is the marketing manager for radiology at Sony Electronics’ medical group based in Park Ridge, N.J. (www.sony.com/radiology). Direct all questions and comments to editorial@rt-image.com.