Breast Imaging and Intervention during Pregnancy and Lactation.

Physiologic changes that occur in the breast during pregnancy and lactation create challenges for breast cancer screening and diagnosis. Despite these challenges, imaging evaluation should not be deferred, because delayed diagnosis of pregnancy-associated breast cancer contributes to poor outcomes. Both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating. US is the preferred initial imaging modality for the evaluation of clinical symptoms in pregnant women, followed by mammography if the US findings are suspicious for malignancy or do not show the cause of the clinical symptom. Breast MRI is not recommended during pregnancy because of the use of intravenous gadolinium-based contrast agents. Diagnostic imaging for lactating women is the same as that for nonpregnant nonlactating individuals, beginning with US for patients younger than 30 years old and mammography followed by US for patients aged 30 years and older. MRI can be performed for high-risk screening and local-regional staging in lactating women. The radiologist may encounter a wide variety of breast abnormalities, some specific to pregnancy and lactation, including normal physiologic changes, benign disorders, and malignant neoplasms. Although most masses encountered are benign, biopsy should be performed if the imaging characteristics are suspicious for cancer or if the finding does not resolve after a short period of clinical follow-up. Knowledge of the expected imaging appearance of physiologic changes and common benign conditions of pregnancy and lactation is critical for differentiating these findings from pregnancy-associated breast cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Patient, Provider, and Practice Characteristics Predicting Use of Diagnostic Imaging in Primary Care: Cross-Sectional Data From the National Ambulatory Medical Care Survey.

OBJECTIVE: To determine imaging utilization rates in outpatient primary care visits and factors influencing likelihood of imaging use. METHODS: We used 2013 to 2018 National Ambulatory Medical Care Survey cross-sectional data. All visits to primary care clinics during the study period were included in the sample. Descriptive statistics on visit characteristics including imaging utilization were calculated. Logistic regression analyses evaluated the influence of a variety of patient-, provider-, and practice-level variables on the odds of obtaining diagnostic imaging, further subdivided by modality (radiographs, CT, MRI, and ultrasound). The data's survey weighting was accounted for to produce valid national-level estimates of imaging use for US office-based primary care visits. RESULTS: Using survey weights, approximately 2.8 billion patient visits were included. Diagnostic imaging was ordered at 12.5% of visits with radiographs the most common (4.3%) and MRI the least common (0.8%). Imaging utilization was similar or greater among minority patients compared with White, non-Hispanic patients. Physician assistants used imaging at higher rates than physicians, in particular CT at 6.5% of visits compared with 0.7% for doctors of medicine and doctors of osteopathic medicine (odds ratio 5.67, 95% confidence interval 4.07-7.88). CONCLUSION: Disparities in rates of imaging utilization for minorities seen in other health care settings were not present in this sample of primary care visits, supporting that access to primary care is a path to promote health equity. Higher rates of imaging utilization among advanced-level practitioners highlight an opportunity to evaluate imaging appropriateness and promote equitable, high-value imaging among all practitioners.

Mammography Screening Outreach Through Non-Primary Care-Based Services.

OBJECTIVE: To estimate the proportion of patients visiting urgent care centers or emergency departments or being hospitalized who were not up to date with recommended mammography screening to assess the potential impact of non-primary care-based cancer screening interventions. METHODS: Adult participants from the 2019 National Health Interview Survey were included. Among participants not up to date with breast cancer screening guidelines based on ACR recommendations, the proportion of patients reporting an urgent care, emergency department visit, or hospitalization within the last year was estimated accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and mammography screening adherence. RESULTS: The study included 9,139 women between the ages of 40 and 74 years without history of breast cancer. Of these respondents, 44.9% did not report mammography screening within the last year. Among participants who did not report mammography screening, 29.2% reported visiting an urgent care center, 21.8% reported visiting an emergency room, and 9.6% reported being hospitalized within the last year. The majority of patients receiving non-primary care-based services, who were not up to date with mammography screening, were from historically underserved groups including Black and Hispanic patients. CONCLUSION: Nearly 10% to 30% of participants who have not obtained recommended breast cancer screening have visited non-primary care-based services including urgent care centers or emergency rooms or have been hospitalized within the last year.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review.

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

Analysis of Geographic Accessibility of Breast, Lung, and Colorectal Cancer Screening Centers Among American Indian and Alaskan Native Tribes.

PURPOSE: To evaluate geographic accessibility of ACR mammographic screening (MS), lung cancer screening (LCS), and CT colorectal cancer screening (CTCS) centers among US federally recognized American Indian and Alaskan Native (AI/AN) tribes. METHODS: Distances from AI/AN tribes' ZIP codes to their closest ACR-accredited LCS and CTCS centers were recorded using tools from the ACR website. The FDA's database was used for MS. Persistent adult poverty (PPC-A), persistent child poverty (PPC-C), and rurality indexes (rural-urban continuum codes) were from the US Department of Agriculture. Logistic and linear regression analyses were used to assess distances to screening centers and relationships among rurality, PPC-A, and PPC-C. RESULTS: Five hundred ninety-four federally recognized AI/AN tribes met the inclusion criteria. Among all closest MS, LCS, or CTCS center to AI/AN tribes, 77.8% (1,387 of 1,782) were located within 200 miles, with a mean distance of 53.6 ± 53.0 miles. Most tribes (93.6% [557 of 594]) had MS centers within 200 miles, 76.4% (454 of 594) had LCS centers within 200 miles, and 63.5% (376 of 594) had CTCS centers within 200 miles. Counties with PPC-A (odds ratio [OR], 0.47; P < .001) and PPC-C (OR, 0.19; P < .001) were significantly associated with decreased odds of having a cancer screening center within 200 miles. PPC-C was associated with decreased likelihood of having an LCS center (OR, 0.24; P < .001) and an CTCS center (OR, 0.52; P < .001) within the same state as the tribe's location. No significant association was found between PPC-A and PPC-C and MS centers. CONCLUSIONS: AI/AN tribes experience distance barriers to ACR-accredited screening centers, resulting in cancer screening deserts. Programs are needed to increase equity in screening access among AI/AN tribes.

Impact of High Neighborhood Socioeconomic Deprivation on Access to Accredited Breast Imaging Screening and Diagnostic Facilities.

PURPOSE: The aim of this study was to evaluate the presence or absence of accredited breast imaging facilities in ZIP codes with high or low neighborhood socioeconomic deprivation. METHODS: A retrospective ecological study design was used. Neighborhood socioeconomic disadvantage rankings at the ZIP code level were defined by the University of Wisconsin Neighborhood Atlas Area Deprivation Index. Outcomes included the presence or absence of FDA- or ACR-accredited mammographic facilities, accredited stereotactic biopsy or breast ultrasound facilities, and ACR Breast Imaging Centers of Excellence. US Department of Agriculture rural-urban commuting area codes were used to define urban and rural status. Access to breast imaging facilities in high-disadvantage (≥97th percentile) and low-disadvantage (≤3rd percentile) ZIP codes was compared using χ2 tests, stratified by urban or rural status. RESULTS: Among 41,683 ZIP codes, 2,796 were classified as high disadvantage (1,160 rural, 1,636 urban) and 1,028 as low disadvantage (39 rural, 989 urban). High-disadvantage ZIP codes were more likely rural (P < .001) and less likely to have FDA-certified mammographic facilities (28% versus 35%, P < .001), ACR-accredited stereotactic biopsy (7% versus 15%, P < .001), breast ultrasound (9% versus 23%, P < .001), or Breast Imaging Centers of Excellence (7% versus 16%, P < .001). Among urban areas, high-disadvantage ZIP codes were less likely to have FDA-certified mammographic facilities (30% versus 36%, P = .002), ACR-accredited stereotactic biopsy (10% versus 16%, P < .001), breast ultrasound (13% versus 23%, P < .001), and Breast Imaging Centers of Excellence (10% versus 16%, P < .001). CONCLUSIONS: People living in ZIP codes with high socioeconomic disadvantage are less likely to have accredited breast imaging facilities within their ZIP codes, which may contribute to disparities in access to breast cancer care experienced by underserved groups living in these areas.

Community-based Participatory Research: A Practical Guide for Radiologists.

Community-based participatory research (CBPR) is defined by the Kellogg Community Health Scholars Program as a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each community member brings. The CBPR process begins with a research topic of importance to the community, with the goal of combining knowledge and action with social change to improve community health and eliminate health disparities. CBPR engages and empowers affected communities to collaborate in defining the research question; sharing the study design process; collecting, analyzing, and disseminating the data; and implementing solutions. A CBPR approach in radiology has several potential applications, including removing limitations to high-quality imaging, improving secondary prevention, identifying barriers to technology access, and increasing diversity in the research participation for clinical trials. The authors provide an overview with the definitions of CBPR, explain how to conduct CBPR, and illustrate its applications in radiology. Finally, the challenges of CBPR and useful resources are discussed in detail. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A Framework for Developing Health Equity Initiatives in Radiology.

PURPOSE: In recent years, radiology departments have increasingly recognized the extent of health care disparities related to imaging and image-guided interventions. The goal of this article is to provide a framework for developing a health equity initiative in radiology and to articulate key defining factors. METHODS: This article leverages the experience of three academic radiology departments and explores key principles that emerged when observing the experiences of these departments that have begun to engage in health equity-focused work. RESULTS: A four-component framework is described for a health equity initiative in radiology consisting of (1) environmental scan and blueprint, (2) design and implementation, (3) initiative evaluation, and (4) community engagement. Key facilitators include a comprehensive environmental scan, early stakeholder engagement and consensus building, implementation science design thinking, and multitiered community engagement. CONCLUSIONS: All radiology organizations should strive to develop, pilot, and evaluate novel initiatives that promote equitable access to high-quality imaging services. Establishing systems for high-quality data collection is critical to success. An implementation science approach provides a robust framework for developing and testing novel health equity initiatives in radiology. Community engagement is critical at all stages of the health equity initiative time line.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI.

Despite significant advances in health care, many patients from medically under-served populations are impacted by existing health care disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge tool kit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, the four pillars provide a helpful framework to advance health equity efforts as a step toward social justice in health.

Breast Cancer Screening Modalities, Recommendations, and Novel Imaging Techniques.

Among women, breast cancer remains the second leading cause of cancer death in the United States. Mammography remains the only validated screening tool to reduce breast cancer mortality. The American Society of Breast Surgeons recommends that average-risk women undergo breast cancer screening every year starting at age 40. This article reviews the fundamentals of mammography screening, current age-based mammography screening recommendations, supplemental breast cancer screening recommendations in high-risk women, and novel imaging technologies. This review summarizes recommendations from the American Society of Breast Surgeons and published guidelines from major societies to reflect a range of evidence-based perspectives regarding mammographic screening.