Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review.

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring providers to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities including interventional procedures, thus requiring multiple room types. Practices need to consider variables that affect workflow efficiency throughout the process of scheduling, examination performance, interpretation, and results delivery, as well as options in facilities design to create inviting yet functional environments for patients. Breast imaging appointments provide opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize patient experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions that include private and academic breast imaging experience.

Antithrombotic Therapy and Hematoma Risk during Image-guided Core-Needle Breast Biopsy.

Background For image-guided core-needle breast biopsy (CNBB), it remains unclear whether antithrombotic medication should be withheld because of hematoma risk. Purpose To determine hematoma risk after CNBB in patients receiving antithrombotic medication and to stratify risk by antithrombotic type. Materials and Methods This HIPAA-compliant retrospective study included US-, stereotactic-, or MRI-guided CNBBs performed across six academic and six private practices between April 2019 and April 2021. Patients were instructed to continue antithrombotic medications, forming two groups: antithrombotic and nonantithrombotic. Hematomas were defined as new biopsy-site masses with a diameter of 2 cm or larger on postprocedure mammograms. Hematomas were considered clinically significant if management involved an intervention other than manual compression. Patient age, type of antithrombotic medication, practice type, image guidance modality, needle gauge and type, and outcome of pathologic analysis were recorded. Multivariable logistic regression analysis was used to analyze variables associated with hematomas. Results A total of 3311 biopsies were performed in 2664 patients (median age, 60 years; IQR, 48-70 years; 2658 women). The nonantithrombotic group included 2788 biopsies, and the antithrombotic group included 523 biopsies (328 low-dose aspirin, 73 full-dose antiplatelet drugs, 51 direct oral anticoagulants, 36 warfarin, 32 daily nonsteroidal anti-inflammatory drugs, three heparin or enoxaparin). The antithrombotic group had a higher overall hematoma rate (antithrombotic group: 49 of 523 biopsies [9.4%], nonantithrombotic group: 172 of 2788 biopsies [6.2%]; P = .007), but clinically significant hematoma rates were not different (antithrombotic group: two of 523 biopsies [0.4%], nonantithrombotic group: one of 2788 biopsies [0.04%]; P = .07). At multivariable analysis, age (odds ratio [OR], 1.02; 95% CI: 1.01, 1.03; P < .001), 9-gauge or larger needles (OR, 2.1; 95% CI: 1.28, 3.3; P = .003), and full-dose antiplatelet drugs (OR, 2.5; 95% CI: 1.29, 5.0; P = .007) were associated with higher hematoma rates. US guidance (OR, 0.26; 95% CI: 0.17, 0.40; P < .001) and 10-14-gauge needles (OR, 0.53; 95% CI: 0.36, 0.79; P = .002) were predictive of no hematoma. Conclusion Because clinically significant hematomas were uncommon, withholding antithrombotic medications before core-needle breast biopsy may be unnecessary. Postbiopsy hematomas were associated with full-dose antiplatelet drugs, patient age, and 9-gauge or larger needles. No association was found with other types of antithrombotic medication. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chang and Yoen in this issue.

Breast Cancer Screening and Outcomes Disparities Persist for Native American Women.

Over the past three decades, mortality rates from breast cancer have decreased for multiple racial groups but have remained constant for American Indian and Alaskan Native (AI/AN) women. Additionally, AI/AN women are less likely to receive timely breast cancer screening and are more likely to be diagnosed with advanced stage breast cancer at younger ages than their White counterparts. These disparities can be explained, in part, by the unique barriers to accessing care faced by AI/AN women. The Indian Health Service provides care to many AI/AN patients; however, their scope of practice is limited, and the service is chronically underfunded, leaving many women without appropriate and timely care. Additionally, geographic access to care is limited because of the sparsity of clinics and limited transportation resources. American Indian and Alaskan Native patients also harbor a history of mistrust in health care systems, and there is a paucity of culturally sensitive education regarding the importance of screening. There have been some grassroots efforts to address these barriers; however, large-scale coordinated efforts are lacking. In order to provide equitable breast health care, more awareness and widescale initiatives are needed and can be championed by breast radiologists.

An Asset-Based Quality Improvement Tool for Health Care Organizations: Cultivating Organizationwide Quality Improvement and Health Care Professional Engagement.

In the United States, health care organizations are often biased toward deficit-based quality and safety improvement techniques, such as incident reporting and peer review. However, deficit-based techniques may elicit negative sentiments from frontline health care professionals, causing disengagement and adverse event underreporting. To complement deficit-based quality improvement, our institution developed an organizationwide asset-based quality improvement tool. Inspired by asset-based quality improvement methodologies such as appreciative inquiry, Safety-II, and positive deviance, this tool facilitates the identification and analysis of clinical excellence. Resultant best practices and quality improvement projects are then propagated throughout our organization. Ultimately, asset-based quality improvement tools are logistically and technologically feasible for organizationwide deployment, and they potentially improve care quality and team culture. Health care organizations should consider adding these tools to their quality and safety improvement initiatives.

A Breast Radiology Department-operated, Proactive Same-day Program Identifies Pathogenic Breast Cancer Mutations in Unaffected Women.

RATIONALE AND OBJECTIVES: Pathogenic mutations in some genes elevate women's breast cancer risk, necessitating risk-reduction strategies. Unfortunately, women are underscreened for cancer risk, and when identified as potentially high risk, women seldom pursue genetic counseling or testing. To improve cancer risk management, this project determined the feasibility of radiology-operated, proactive, same-day risk assessment and genetic testing programs to diagnose high-risk women undergoing breast imaging. MATERIALS AND METHODS: The Comprehensive Assessment, Risk & Education Program launched on June 5, 2019. Data was tracked through July 22, 2020. Women undergoing breast imaging completed questionnaires that calculated Tyrer-Cuzick risk and assessed genetic testing eligibility using National Comprehensive Cancer Network criteria. To encourage eligible women's genetic testing adherence, pretest counseling and saliva sample collection occurred that same day in the imaging center. Samples were tested by a 34-multigene panel. Genetic counselors called women with positive results. Women with negative results or variants of uncertain significance were mailed notifications. Summary statistics were calculated. RESULTS: A total of 3345 women completed questionnaires. 1080 (32.3%) met genetic testing criteria. 468/1080 (43.3%) submitted genetic samples, and 416/1080 (38.5%) completed testing. Of 416 completed tests, 269 (64.7%) tested negative, 109 (26.2%) had variants of uncertain significance, and 38 (9.1%) diagnosed pathogenic mutations. 13/38 (34.2%) women with pathogenic mutations implemented risk-reduction strategies at our institution. CONCLUSION: Breast imaging centers can operate same-day cancer risk assessment and genetic testing programs, identifying high-risk women that conventional risk assessment methods may not have diagnosed. These proactive programs add value to radiology departments' cancer care beyond traditional imaging services.

Collaborative interdepartmental teams: benefits, challenges, alternatives, and the ingredients for team success.

Radiology practices often employ collaborative interdepartmental teams to address complex projects. These teams benefit from their diversity of viewpoints and the potential for innovative, high-quality solutions. However, collaborative interdepartmental teams also suffer from challenges: interpersonal conflicts, team member mistrust, competing individual priorities, and obstructive turf concerns. When tackling projects, radiologists should consider alternative group models such as single department teams, two-person partnerships, and small workgroups. Each of these group models has strengths and weaknesses relative to collaborative interdepartmental teams and may be more efficient in some scenarios. Finally, when radiologists launch collaborative interdepartmental teams, four key ingredients should be optimized to improve team performance: right goal, right culture, right leadership, and right people.

Anxiety and Its Association With Screening Mammography.

Anxiety is often cited as a risk of screening mammography, and organizations such as the U.S. Preventive Services Task Force list anxiety as a screening-associated "harm" that should be mitigated. However, the level of mammography-related anxiety risk is difficult to assign clearly for myriad reasons, including the variability of individuals' baseline susceptibility to anxiety, the self-reported nature of subjective anxiety states, and the multiple sources of breast cancer screening-related anxiety. In addition, anxiety measures differ between studies and psychological responses to screening mammography vary across racial and ethnic groups. Nonetheless, breast radiology practices should acknowledge the existence of mammography-associated anxiety and consider strategies to decrease it. These strategies include immediate screening interpretations, patient education efforts, and relaxation techniques.

The Role of Cognitive Bias in Breast Radiology Diagnostic and Judgment Errors.

Cognitive bias is an unavoidable aspect of human decision-making. In breast radiology, these biases contribute to missed or erroneous diagnoses and mistaken judgments. This article introduces breast radiologists to eight cognitive biases commonly encountered in breast radiology: anchoring, availability, commission, confirmation, gambler's fallacy, omission, satisfaction of search, and outcome. In addition to illustrative cases, this article offers suggestions for radiologists to better recognize and counteract these biases at the individual level and at the organizational level.

Enhancing the Value Chain to Increase Customer Satisfaction and Build Successful Breast Imaging Practices.

The US health care industry is increasingly shifting to a value seeking mindset. The breast imaging value chain elucidates how breast imaging radiologists generate and deliver value to their customers, who include both patients and referring health care providers. The breast imaging value chain can be used by radiologists to improve operational effectiveness and to plan new value creation strategically. The overarching goals are increased customer satisfaction and successful practices.

Nipple Discharge: Imaging Variability Among U.S. Radiologists.

OBJECTIVE: The purpose of this study was to assess radiologists' choice of imaging modality for the evaluation of clinical symptoms of physiologic nipple discharge (e.g., bilateral discharge, multiple-duct orifices, and yellow, green, or white color) and pathologic nipple discharge (e.g., unilateral discharge, single-duct orifices, spontaneous and serous discharge, and clear or bloodstained color). MATERIALS AND METHODS: An online survey was sent to lead interpreting physicians at mammography facilities accredited by the American College of Radiology (ACR). Statistical analysis was performed using chi-square tests for frequency data and multinomial logistic regression. RESULTS: A total of 849 responses to 8170 distributed surveys were received, for a response rate of 10.4%. For the workup of physiologic nipple discharge, 30% of respondents recommended screening mammography (SM); 24%, diagnostic mammography (DM) only; and 46%, both DM and targeted ultrasound (US) (DM plus US). For the workup of physiologic nipple discharge, practitioners in nonacademic settings and those who read breast images during less than 50% of their practice were significantly more likely to recommend DM (with or without US), compared with SM (the standard recommended by the ACR). Those reading breast images less than 50% of the time were also more likely to recommend MRI after conventional imaging revealed negative results. For the workup of pathologic nipple discharge, 91.0% of respondents recommended DM plus US; 8.5%, DM only; and fewer than 1.0%, SM. Nonacademic providers and those who read breast images less than 50% of the time were significantly less likely to recommend DM plus US (the standard recommended by the ACR), compared with DM only. CONCLUSION: The present study shows variability in imaging modality selection among U.S. radiologists handling the imaging workflow for benign and pathologic nipple discharge. Radiologists do not uniformly follow ACR practice guidelines, which potentially leads to unnecessary workups and extra health care costs.

Time Is Not on Our Side: How Radiology Practices Should Manage Customer Queues.

As health care shifts toward patient-centered care, wait times have received increasing scrutiny as an important metric for patient satisfaction. Long queues form when radiology practices inefficiently service their customers, leading to customer dissatisfaction and a lower perception of value. This article describes a four-step framework for radiology practices to resolve problematic queues: (1) analyze factors contributing to queue formation; (2) improve processes to reduce service times; (3) reduce variability; (4) address the psychology of queues.

Preoperative Breast MRI: Surgeons' Patient Selection Patterns and Potential Bias in Outcomes Analyses.

OBJECTIVE: The purpose of this study is to determine which patient- and tumor-related and clinical variables influence dedicated breast surgeons' and general surgeons' referrals for preoperative breast MRI for patients with newly diagnosed breast cancer. MATERIALS AND METHODS: Surgeons who perform breast surgery responded to a survey from June 16, 2014, through August 11, 2014. Participants self-identified as breast or general surgeons and provided professional practice details. They used Likert scores (range, 1-7 with increasing likelihood to order MRI) to weigh numerous patient- and tumor-related and clinical variables. Mean likelihood scores were calculated and compared using a linear mixed model. A p ≤ 0.05 was considered statistically significant. RESULTS: Two hundred eighty-nine surveys from 154 (53%) breast surgeons and 135 (47%) general surgeons showed an overall likelihood to refer for patients with a BRCA mutation (mean Likert score, 6.17), familial (mean Likert score, 5.33) or personal (mean Likert score, 5.10) breast cancer history, extremely dense breasts (mean Likert score, 5.30), age younger than 40 years (mean Likert score, 5.24), axillary nodal involvement (mean Likert score, 6.22), tumor that is mammographically occult (mean Likert score, 5.62) or fixed to the pectoralis (mean Likert score, 5.49), tumor that is a candidate for neoadjuvant treatment (mean Likert score, 5.38), multifocal or multicentric disease (mean Likert score, 5.22), invasive lobular carcinoma (mean Likert score, 5.20), T3 (mean Likert score, 4.48) or T2 (mean Likert score, 4.41) tumor, triple-negative breast cancer (mean Likert score, 4.66), a patient who is a candidate for mastectomy requesting breast conservation therapy (mean Likert score, 5.27), and radiologists' recommendations (mean Likert score, 5.19). Across all patient ages, breast surgeons referred more often than did general surgeons (mean Likert score, 4.32 vs 3.92; p = 0.03), especially for patients with BRCA mutation (mean Likert score, 6.39 vs 5.93; p = 0.01) and tumors smaller than 1 cm (mean Likert score, 3.84 vs 3.40; p = 0.002). Breast surgeons referred less often than did general surgeons for multifocal or multicentric disease (mean Likert score, 5.02 vs 5.44; p = 0.001). Breast surgeons and general surgeons similarly weighed other variables. CONCLUSION: Preoperative breast MRI referral trended with certain higher risk patient- and tumor-related and clinical variables and were nonuniform between the breast surgeons and general surgeon cohorts. Selection bias could affect outcomes analyses for preoperative breast MRI.

Monte Carlo simulation to analyze the cost-benefit of radioactive seed localization versus wire localization for breast-conserving surgery in fee-for-service health care systems compared with accountable care organizations.

OBJECTIVE: In breast-conserving surgery for nonpalpable breast cancers, surgical reexcision rates are lower with radioactive seed localization (RSL) than wire localization. We evaluated the cost-benefit of switching from wire localization to RSL in two competing payment systems: a fee-for-service (FFS) system and a bundled payment system, which is typical for accountable care organizations. MATERIALS AND METHODS: A Monte Carlo simulation was developed to compare the cost-benefit of RSL and wire localization. Equipment utilization, procedural workflows, and regulatory overhead differentiate the cost between RSL and wire localization. To define a distribution of possible cost scenarios, the simulation randomly varied cost drivers within fixed ranges determined by hospital data, published literature, and expert input. Each scenario was replicated 1000 times using the pseudorandom number generator within Microsoft Excel, and results were analyzed for convergence. RESULTS: In a bundled payment system, RSL reduced total health care cost per patient relative to wire localization by an average of $115, translating into increased facility margin. In an FFS system, RSL reduced total health care cost per patient relative to wire localization by an average of $595 but resulted in decreased facility margin because of fewer surgeries. CONCLUSION: In a bundled payment system, RSL results in a modest reduction of cost per patient over wire localization and slightly increased margin. A fee-for-service system suffers moderate loss of revenue per patient with RSL, largely due to lower reexcision rates. The fee-for-service system creates a significant financial disincentive for providers to use RSL, although it improves clinical outcomes and reduces total health care costs.

Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women 30-39 years of age.

OBJECTIVE: The purpose of this study was to determine the accuracy and value of breast ultrasound for primary imaging evaluation of women 30-39 years of age who present with focal breast signs or symptoms. METHODS: We identified all women 30-39 years of age who underwent imaging evaluation (ultrasound and mammography) at our institution between January 1, 2002, and August 31, 2006, for focal breast signs or symptoms. Each area of concern was designated a study case. Benign versus malignant outcomes were determined by biopsy or imaging surveillance and through linkage with a tumor registry with a minimum 24-month follow-up. Overall cancer yield, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of ultrasound and mammography were calculated. RESULTS: We identified 1208 cases in 954 patients. Outcomes were benign in 1185 of 1208 (98.1%) and malignant in 23 of 1208 (1.9%) cases. Sensitivities for ultrasound and mammography were 95.7% and 60.9%, respectively. Specificities for ultrasound and mammography were 89.2% and 94.4%, respectively. NPV was 99.9% for ultrasound and 99.2% for mammography. PPV was 13.2% for ultrasound and 18.4% for mammography. Mammography detected one additional malignancy in an asymptomatic area in a 32-year-old woman who was subsequently found to have a BRCA2 gene mutation. CONCLUSION: Breast imaging is warranted in women 30-39 years of age with focal signs or symptoms because of the small (1.9%) but real risk of malignancy. Ultrasound has high sensitivity (95.7%) and high NPV (99.9%) in this setting and should be the primary imaging modality of choice. The added value of adjunct mammography is low.

Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications.

OBJECTIVE: The purpose of this article is to assess the accuracy of targeted breast ultrasound in women younger than 30 years presenting with focal breast signs or symptoms. MATERIALS AND METHODS: Retrospective review of the electronic medical records identified all ultrasound examinations from January 1, 2002, through August 30, 2006, performed for focal breast signs or symptoms in women younger than 30 years. BI-RADS assessments were recorded. Outcomes were determined by biopsy, 24 months of ultrasound surveillance, and linkage with the regional tumor registry. The overall cancer yield, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) 2, and PPV3 of ultrasound were calculated. RESULTS: Among 830 study patients, lesions were assessed as BI-RADS category 1 or 2 in 526 (63.4%), BI-RADS category 3 in 140 (16.9%), BI-RADS category 4 in 163 (19.6%), and BI-RADS category 5 in one (0.1%) patient. Three malignancies were detected, for a cancer yield of 0.4%. No BI-RADS category 3 lesions, two BI-RADS category 4 lesions, and the single BI-RADS category 5 lesion were malignant. Ultrasound sensitivity was 100%, specificity was 80.5%, NPV was 100%, PPV2 was 1.8%, and PPV3 was 1.9%. CONCLUSION: Women younger than 30 years with focal breast signs or symptoms have a very low (0.4%) incidence of malignancy. The 100% sensitivity and NPV of targeted ultrasound in our study substantiates its use as an accurate primary imaging test in this clinical setting. We found no malignancies in BI-RADS category 3 lesions, supporting ultrasound surveillance over biopsy in this patient population.

Scaphoid Fracture Fixation with an Acutrak(®) Screw.

We report a case of fixation of a scaphoid fracture using an Acutrak(®) screw. This screw is cannulated and headless, which allows it to be implanted below the surface of the bone. It uses the same concept of variable thread pitch as the Herbert screw, but unlike the Herbert screw, is fully threaded, with continuously varying pitch along its length. This variable pitch creates constant compression across a fracture as the screw is advanced, and gives the screw its unique appearance. This feature may improve internal holding power, as well as allow a fracture or osteotomy site to lie anywhere along the length of the screw.

Potential of dual-time-point imaging to improve breast cancer diagnosis with (18)F-FDG PET.

UNLABELLED: The purpose of this study was to assess the utility of dual-time-point imaging for identifying malignant lesions in the breast by (18)F-FDG PET. METHODS: Fifty-four breast cancer patients with 57 breast lesions underwent 2 sequential PET scans (dual-time-point imaging). The average percent change in standardized uptake values (SUVs) between time point 1 and time point 2 was calculated. All PET study results were correlated with follow-up surgical pathology results. RESULTS: Of the 57 breast lesions, 39 were invasive carcinoma and 18 were postbiopsy inflammation. Among the invasive carcinoma lesions, 33 (85%) showed an increase and 6 (15%) showed either no change or a decrease in SUVs over time. The percent change in SUVs from time point 1 to time point 2 (mean +/- SD) was +12.6% +/- 11.4% (P = 0.003). Of the 18 inflammatory lesions, 3 (17%) showed an increase and 15 (83%) showed either no change or a decrease in SUVs. The percent change in SUVs from time point 1 to time point 2 (mean +/- SD) was -10.2% +/- 16.5% (P = 0.03). Of the 57 normal contralateral breasts, 2 (3.5%) showed an increase and 55 (96.5%) showed either no change or a decrease in SUVs. The percent change in SUVs from time point 1 to time point 2 (mean +/- SD) was -15.8% +/- 17% (P = 0.005). CONCLUSION: There is increasing uptake of (18)F-FDG over time in breast malignancies, whereas the uptake of (18)F-FDG in inflammatory lesions and normal breast tissues decreases over time. A percent change of +3.75 or more in SUVs over time is highly sensitive and specific in differentiating inflammatory lesions from malignant lesions.

User-defined vascular input function curves: influence on mean perfusion parameter values and signal-to-noise ratio.

The authors reviewed 40 computed tomographic (CT) perfusion studies to determine the effect of arterial and venous input function properties on perfusion parameter values and tissue signal-to-noise ratio (SNR). A 10-subject subset was analyzed to evaluate the effect of varying venous region of interest (ROI) locations. Venous peak enhancement correlated significantly with mean tissue cerebral blood flow (CBF) and cerebral blood volume (CBV); venous and arterial peak enhancement correlated significantly with SNR of perfusion maps. Different ROI locations within the same vein resulted in significantly different CBV and CBF values. Perfusion map parameters are related to peak enhancement within user-selected ROIs. Optimal ROI selection should limit variability and increase quality of CT perfusion images.