Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain.

With the shift of the healthcare system toward patient-centered, value-based care, the role of the breast radiologist is essential and increasingly multifaceted. Beyond sole image interpreters, breast radiologists serve as subject matter experts within multidisciplinary care teams, acting as advocates and initiators into the healthcare system and providing patient-centered care through effective communication and patient education. These vital roles are well demonstrated through the imaging evaluation and management of the most common breast symptom that affects the majority of the patient population-mastalgia. By leveraging the opportunities provided during the evaluation of the symptomatic breast to optimize patient communication and education, as well as integration of care delivery, breast radiologists add significant value to patient care and ultimately improve patient outcomes.

Virtual Interviews for Breast Imaging Fellowship During the COVID-19 Pandemic: Perspectives of Program Directors and Applicants.

OBJECTIVE: To compare in-person and virtual breast fellowship interview experiences from the perspective of fellowship program directors (PDs) and applicants. METHODS: Three separate voluntary, anonymous, e-mail delivered surveys were developed for PDs, in-person interview applicants in 2019-2020, and virtual interview applicants in 2020-2021. PD and applicant survey responses regarding the two interview cycles were compared. RESULTS: The response rate was 56% (53/95) for PDs, 19% (23/123) for in-person applicants, and 38% (49/129) for virtual applicants. PDs reported significantly lower cost for virtual compared to in-person interviews (P < 0.001). They reported no significant difference in number of applications received, number of applicants interviewed, applicant pool geographic regions, number of interview days offered, or format of interviews. Most PDs (31/53, 58%) felt the virtual format still allowed them to get to know the applicants well. Cost was significantly higher for in-person compared to virtual applicants (P < 0.001). More in-person applicants (11/23, 48%) listed cost as a barrier compared to virtual applicants (7/49, 14%) (P = 0.002). Virtual and in-person applicants reported a similar number of program applications, but virtual applicants completed more interviews (P = 0.012). Both groups preferred scheduled time to speak with the current fellows and a one-on-one interview format with two to four faculty members. Most applicants (36/49, 73%) felt the virtual format still allowed them to get to know each program well. CONCLUSION: Virtual interviews provide a reasonable alternative to in-person interviews for breast imaging fellowship applicants, with decreased cost being the main advantage.

The American College of Radiology/Society of Breast Imaging Updated Fellowship Training Curriculum for Breast Imaging.

Since the publication of the most recent breast imaging resident and fellowship curriculum in 2013, there have been widespread changes to the field of breast imaging. Screen-film mammography has been nearly completely replaced, and there has been widespread adoption of breast MRI and digital breast tomosynthesis. Fellowship training programs are increasingly one year in length, which accommodates the rapidly evolving subspecialized field of breast imaging. Recent surveys have identified deficits in nonclinical training related to patient communication and practice audits. This updated fellowship curriculum focuses on four discrete skill sets: clinical, noninterpretive, collaborative, and scholarly. Updates to the clinical curriculum include familiarity with new and emerging imaging technologies and biopsy techniques, as well as a more comprehensive understanding of breast pathology and appropriate follow-up and/or treatment recommendations. There is an increased focus on noninterpretive skills related to the practice audit and quality control. A formal communication curriculum tailored toward discussions with patients is highly recommended. The collaborative value of multidisciplinary care and the benefits of mentorship are emphasized. Finally, scholarly activities including both the opportunity for teaching and research, as well as dedicated lectures and journal clubs, will establish a platform for lifelong learning. This updated curriculum, which has been approved by the Executive Committee of the American College of Radiology and the Society of Breast Imaging Board of Directors, is designed to develop well-rounded fellowship graduates who are positioned to be breast imaging leaders within their future practices.

Performance of 2D Synthetic Mammography Versus Digital Mammography in the Detection of Microcalcifications at Screening.

OBJECTIVE. The purpose of this study is to compare the performance of 2D synthetic mammography (SM) to that of full-field digital mammography (FFDM) in the detection of microcalcifications and to evaluate radiologists' preference between the two imaging modalities for assessing calcifications. MATERIALS AND METHODS. A fully crossed, mode-balanced, paired-case (n = 160), retrospective, multireader (n = 3) performance study was implemented to compare screening mammograms acquired with digital breast tomosynthesis and both FFDM and SM between 2015 and 2017. The study cohort included 70 patients with mammograms recalled for microcalcifications (35 with malignant findings and 35 with benign findings) and was supplemented with 90 patients with mammograms with negative findings. In separate sessions, readers interpreted SM or FFDM images by recording a BI-RADS assessment and the probability of malignancy. In a final session that included 70 mammograms with microcalcifications, readers recorded their subjective assessment of microcalcification conspicuity and diagnostic confidence. RESULTS. There was no difference in diagnostic accuracy as assessed by comparing the likelihood of malignancy based on the AUC of plotted ROCs, with AUCs of 91% (95% CI, 83-97%) and 88% (95% CI, 79-95%) observed for SM and FFDM, respectively (p = 0.392), and with noninferiority of SM compared with FFDM (p = 0.011). No significant difference was observed between SM and FFDM in terms of sensitivity (77% vs 73%, respectively; p = 0.366) or negative predictive value (84% vs 82%, respectively; p = 0.598). The specificity and positive predictive value of SM were lower than those of FFDM (91% vs 98%, respectively [p = 0.034], and 87% vs 96%, respectively [p = 0.034]). All readers found calcifications to be more conspicuous on SM (p < 0.0001); however, no significant difference in subjective diagnostic confidence was seen. CONCLUSION. SM is noninferior to FFDM in the detection of microcalcifications. Despite the increased conspicuity of microcalcifications on SM, the subjective diagnostic confidence in the two modalities is comparable.

Assessing the Positive Predictive Value of Architectural Distortion Detected with Digital Breast Tomosynthesis in BI-RADS 4 Cases.

OBJECTIVE: The purpose of this study was to evaluate the positive predictive value of biopsy (PPV3) of architectural distortion (AD) detected on digital breast tomosynthesis (DBT) in BI-RADS 4 cases, where suspicion for malignancy remains broad. METHODS: This Institutional Review Board-approved, retrospective study included screening and diagnostic mammograms performed from August 2015 to December 2017 with DBT and digital mammography (DM) revealing suspicious AD with a BI-RADS 4 assessment. Medical records were reviewed for clinical data, imaging, and pathology results. Malignancy rate was assessed by lesion visibility on DM and DBT. Multivariate analysis was performed to assess the odds ratio (OR) of malignancy. RESULTS: A total of 63/179 cases were malignant, yielding a PPV3 of 35%. No significant difference in PPV3 was found by race, personal or family history of breast cancer, presence of microcalcifications, or mammogram type. Architectural distortion was more likely to be malignant when an US correlate was present (PPV3 49% vs 19%; P < 0.0001). Multivariate analysis demonstrated a 3-fold increased OR for malignancy with an US correlate present (P = 0.005). Lesion visibility analysis revealed a higher PPV3 for AD visible on DM-DBT compared with DBT alone (44% vs 26%; P = 0.01) and when an US correlate was present (DM-DBT 54% vs 30%, P = 0.02; DBT-only 43% vs 11%, P < 0.001). CONCLUSIONS: Tomosynthesis-detected BI-RADS 4 AD are malignant in 35% of cases and are more likely to be malignant if an US correlate is present and if visible on both DM and DBT.

Breast Imaging Fellowship Match: Applicants' Perspectives of Years Two and Three.

OBJECTIVE: The purpose of this study is to summarize the results of a survey distributed by the Society of Breast Imaging (SBI) to assess applicants' experience with the 2018 and 2019 Breast Imaging Fellowship Match process. METHODS: In this institutional review board-exempt study, the SBI issued an anonymous survey to all matched applicants in an attempt to gauge their experience with the 2018 and 2019 Match process. RESULTS: The survey was sent to all 2018 and 2019 matched applicants and 105/236 (45%) responses were received. The majority (75%, 79/105) of respondents reported a positive experience with the Match, with at least a 4/5 rating, and only 3% (5/105) reported a rating below 3/5. There was some improvement in 2019, with 86% (24/28) of respondents reporting at least a 4/5 rating compared to 71% (55/77) in 2018. No respondent reported a score below a 3/5 rating in 2019. The most commonly cited issues with the Match were the timing of the Match process, the need for a universal application, and the burden of travel. Location and program reputation were the two most important factors contributing to the final rank order of programs. CONCLUSION: The great majority of applicants felt that the Match created a positive experience. Planned areas of improvement include the implementation of a universal application, the transition to virtual interviews, and a condensed timeline. These measures are likely to increase applicant satisfaction and provide a fair and efficient experience for future breast radiologists.

Breast Imaging Fellowship Match: Program Directors' Perspectives in Year Two.

OBJECTIVE: The purpose of this study was to summarize the results of a survey distributed by the Society of Breast Imaging to assess Breast Imaging programs' experience with the second year of the Breast Imaging Fellowship Match process. METHODS: In July 2018, the Society of Breast Imaging sent out an anonymous 11-question survey to all Breast Imaging programs in attempts to gauge their experience with the previous Match cycle. The survey included dichotomous questions and Likert-scaled questions. Follow-up to several questions allowed for unstructured free text responses. In this institutional review board-exempt study, responses were then summarized and categorized into appropriate categories. RESULTS: The survey was sent to 88 program coordinators and 90 program directors of the 89 existing programs. In total, 66 responses from program directors were received, representing 74.2% of the existing programs. The majority (68%) of programs reported a positive experience with participation in the Match (at least 4/5 stars). The most commonly cited issues with the Match were interview dates/timeline, programs participating outside of the Match, and need for a universal application. Eighty-four percent of programs stated that they were planning on participating in the Match for the upcoming application cycle, with 11% undecided and 5% stating they were not planning on participating. CONCLUSIONS: Despite recognized areas for improvement, the great majority of programs felt that the Match is an improvement over the prior application process and that it significantly improved the experience for the applicants.

Evaluation of Palpable Breast Abnormalities.

A palpable breast abnormality is one of the most common presenting clinical breast complaints. Although the majority of palpable abnormalities are benign, they are among the most common presenting symptoms of breast cancer, and those breast cancers detected symptomatically tend to have poorer prognosis than their screen-detected counterparts. Clinical breast examination is a vital part of the workup of palpable abnormalities. However, as physical exam features of most masses are not reliable for categorization of malignancy, imaging evaluation is necessary. Choice of imaging modality, which includes diagnostic mammography and breast ultrasound, is dependent upon patient age. Ultrasound is the primary imaging modality for evaluation of palpable masses in women younger than 30 years of age because of its high negative predictive value and sensitivity and lack of ionizing radiation. For women aged 30-39 years, ultrasound or mammography can be performed as the initial imaging evaluation, with ultrasound maintaining a high sensitivity in women younger than 40 years old. Mammography, often followed by ultrasound, is the recommended imaging evaluation sequence for women aged 40 and older. Utilization of advanced imaging modalities for evaluation of the palpable area of concern is not supported by evidence.

Impact of Advancing Technology on Diagnosis and Treatment of Breast Cancer.

New emerging breast imaging techniques have shown great promise in breast cancer screening, evaluation of extent of disease, and response to neoadjuvant therapy. Tomosynthesis, allows 3-dimensional imaging of the breast, and increases breast cancer detection. Fast abbreviated MRI has reduced time and costs associated with traditional breast MRI while maintaining cancer detection. Diffusion-weighted imaging is a functional MRI technique that does not require contrast and has shown potential in screening, lesion characterization and also evaluation of treatment response. New image-guided preoperative localizations are available that have increased patient satisfaction and decreased operating room delays.