Breast Radiologists' Perceptions on the Detection and Management of Invasive Lobular Carcinoma: Most Agree Imaging Beyond Mammography Is Warranted.

OBJECTIVE: To determine breast radiologists' confidence in detecting invasive lobular carcinoma (ILC) on mammography and the perceived need for additional imaging in screening and preoperative settings. METHODS: A 16-item anonymized survey was developed, and IRB exemption obtained, by the Society of Breast Imaging (SBI) Patient Care and Delivery Committee and the Lobular Breast Cancer Alliance. The survey was emailed to 2946 radiologist SBI members on February 15, 2023. The survey recorded demographics, perceived modality-specific sensitivity for ILC to the nearest decile, and opinions on diagnosing ILC in screening and staging imaging. Five-point Likert scales were used (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). RESULTS: Response rate was 12.4% (366/2946). Perceived median (interquartile range) modality-specific sensitivities for ILC were MRI 90% (80-90), contrast-enhanced mammography 80% (70-90), molecular breast imaging 80% (60-90), digital breast tomosynthesis 70% (60-80), US 60% (50-80), and 2D mammography 50% (30-60). Only 25% (85/340) respondents were confident in detecting ILC on screening mammography in dense breasts, while 67% (229/343) were confident if breasts were nondense. Most agreed that supplemental screening is needed to detect ILC in women with dense breasts (272/344, 79%) or a personal history of ILC (248/341, 73%), with 34% (118/334) indicating that supplemental screening would also benefit women with nondense breasts. Most agreed that additional imaging is needed to evaluate extent of disease in women with newly diagnosed ILC, regardless of breast density (dense 320/329, 97%; nondense 263/329, 80%). CONCLUSION: Most breast radiologists felt that additional imaging beyond mammography is needed to more confidently screen for and stage ILC.

Overcoming Burnout and Promoting Wellness in Radiation Oncology: A Report From the ACR Commission on Radiation Oncology.

Burnout, defined by the presence of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment, impacts a significant portion of radiation oncologists. This has been exacerbated by the COVID-19 pandemic, is notably worse for women, and has been identified as an international concern. Key contributors to burnout within radiation oncology include inadequate clinical and administrative support, imbalanced personal and professional lives including time with family and for self-care, decreased job satisfaction secondary to increased electronic medical record and decreased patient time, unsupportive organizational culture, lack of transparency from leadership and inclusion in administrative decisions, emotionally intensive patient interactions, challenges within the radiation oncology workforce, financial security related to productivity-based compensation and increasing medical training-related debt, limited education on wellness, and fear of seeking mental health services due to stigma and potential negative impacts on the trajectory of one's career. Limited data exist to quantify the impacts of these factors on the overall levels of burnout within radiation oncology specifically, and additional efforts are needed to understand and address root causes of burnout within the field. Strategies should focus on improving the systems in which physicians work and providing the necessary skills and resources to thrive in high-stress, high-stakes work environments.

Breast Imaging After Dark.

Patients may present to the emergency department with breast complaints due to traumatic or nontraumatic changes in the breast. Benign and malignant breast pathologies may mimic each other both in clinical presentation and imaging appearance. A complex cystic and solid mass seen on ultrasound in a patient with a palpable mass can represent breast cancer, abscess, or hematoma. A unilateral swollen breast may result from inflammatory breast cancer, mastitis, or other benign etiologies; correlation with clinical history, physical exam, and close follow-up are required to ensure complete resolution of symptoms. Uncommon breast entities such as granulomatous mastitis and breast implant-associated anaplastic large-cell lymphoma may cause changes in the appearance of the breast that prompt a patient to seek initial evaluation in the emergency department. Imaging evaluation of the breast in the emergency department is limited, and it is important that patients with a breast complaint be referred to a dedicated breast center for complete evaluation at an appropriate time interval after their discharge from the emergency department.

Patient Diversity in Breast Imaging: Barriers and Potential Solutions.

Recent reports have highlighted disparities in breast cancer care related to patient diversity. Breast radiologists represent the face of breast imaging and are key players in advocating for patients to reduce these disparities. Diversity-related barriers for breast imaging patients, as they journey from screening to survivorship, include impediments to access and quality of care, gaps in communication, and lack of knowledge in both providers and patients. Potential strategies for overcoming these specific barriers include "culturally tailored" nurse navigators, mobile mammography, improved communication, patient and provider education, and breast radiologist involvement in advocacy efforts promoting diversity. As current trends in recommendations and guidelines for breast imaging include more numerous and advanced imaging modalities, it is important to acknowledge and address diversity-related disparities.

Using Facebook Live to Advocate Breast Cancer Screening.

With current conflicting and confusing screening mammography guidelines between major medical organizations, radiologists have an opportunity to educate and advocate for patients using the power of social media. The authors provide a brief overview on the impact of social media in radiology, in particular Facebook, as well as challenges encountered by radiologists as they establish an online presence, and how to effectively use Facebook Live to advocate for screening mammography.

Immediate Migration of Biopsy Clip Markers After Upright Digital Breast Tomosynthesis-Guided Vacuum-Assisted Core Biopsy.

RATIONALE AND OBJECTIVES: The goal of this retrospective study was to evaluate the rate of immediate post-biopsy clip migration on an upright digital tomosynthesis-guided vacuum-assisted core biopsy unit and determine if any factors were associated with immediate clip migration. MATERIALS AND METHODS: We performed a retrospective review of patients who had undergone a biopsy performed at one facility from November 1, 2014 to September 30, 2016. Post-biopsy mammograms were reviewed to assess immediate clip position relative to the targeted lesion. The effects of age, lesion type, breast density, biopsy approach, number of samples, size of the biopsy chamber, and clip type on clip migration were examined using logistic regression analysis. RESULTS: One hundred ninety-seven biopsies were performed on 188 patients for calcifications (n = 159), architectural distortions (n = 29), masses (n = 5), and asymmetries (n = 4). The clip migration rate was 38% as defined as greater than 0.5 cm from the site of the biopsied lesion. The only independently predictive variable of clip migration was breast density in a numeric covariate in the logistic regression model, as migration was more likely with decreased breast density. The estimated odds ratio for a single level increase in BI-RADS breast density was 0.60 (95% confidence interval: 0.40, 0.91) with p = 0.018. CONCLUSION: Immediate clip migration following biopsy was more likely with decreased breast density. Radiologists should be aware of immediate clip migration as correct clip location guides preoperative localization and allows the biopsy site to be monitored for changes on future mammograms.

Optimizing patient experience scores in outpatient breast centers.

High patient experience scores in outpatient radiology is a goal that impacts patient care and compliance. There are secondary positive effects on employee engagement and retention as well as reimbursement and increased market share. Effective administrative and physician leadership is critical in obtaining employee buy-in to the importance of customer experience. Training for employees at all levels in understanding the patient psyche empowers them to offer personalized care to a diverse patient population. Given the multiple benefits of high patient experience scores, a leading patient experience survey was assessed in detail to assist radiologists in breast imaging and other subspecialties, to understand and implement steps to optimize their own patient experience scores.

Variation in Technical Quality of Breast MRI.

PURPOSE: Breast magnetic resonance imaging (MRI) quality may vary across the United States. Our aim was to investigate the quality of outside breast MRIs presenting for second opinion at a tertiary cancer center following implementation of the American College of Radiology (ACR) Breast MRI Accreditation Program. MATERIALS AND METHODS: We retrospectively reviewed the technical quality of the MRI studies of 100 consecutive cases submitted for second opinion in 2013. The image quality was blindly reviewed per ACR Breast MRI Accreditation Program by three fellowship-trained breast radiologists and one breast imaging fellow. RESULTS: In total, 88 of the 100 cases were referred from facilities in the United States. Sixty (68%) of the 88 cases had at least one technical deficiency. In 10 cases (11%), more than five different technical deficiencies occurred. The most frequently encountered deficiencies were related to artifacts (74%), with shimming (N = 17) and motion (N = 16) being the most common. In total, 38% of cases (N = 33) had a deficient T2-weighted sequence, mostly due to low signal to noise ratio (N = 25). A total of 27% cases (N = 24) had deficiencies in the delayed phase postcontrast T1-weighted sequence, mainly due to low signal to noise ratio (N = 21) and 23% had deficiencies in the early phase postcontrast T1-weighted sequence, predominantly due to low signal to noise ratio as well. (N = 19). CONCLUSION: Our study demonstrates variability of breast MRI quality across the United States. Radiologists should become familiar with the requirements of the ACR breast MRI accreditation program and strive to meet the expected standards in order to enhance patient quality and safety.

Telemammography: Technical Advances Improve Patient Access in Breast Care.

Screening mammography's efficacy in reducing breast cancer deaths depends on patient compliance with screening recommendations and the radiologist's interpretative skills. Reasons for suboptimal screening compliance may be multifactorial, including possible limitations in access. Additionally, while studies show experienced breast radiologists are more accurate in their mammographic interpretation, only a minority of the nation's mammograms are interpreted by breast imaging specialists. To simultaneously optimize the benefit of early breast cancer detection while minimizing the harms associated with a false positive interpretation, delivery models that help improve access to breast expertise should be considered. Telemammography is one such delivery model that may be underutilized in current practice. While radiologists and other stakeholders of healthcare have accepted teleradiology interpretation of non-mammography studies as routine, telemammography use and acceptance is less well known. In this article, we review the operational components of a telemammography practice in today's information- and technology-dependent society. Current use of telemammography and remaining potential challenges are discussed. Telemammography can improve healthcare delivery and access by bringing together patients and breast expertise. If accepted, use of telemammography can help meet Centers for Disease Control's Healthy People 2020 goals related to breast cancer.

Role of Breast Imaging Radiologists as Advocates for Screening Mammography.

The objective of this article is to outline opportunities for breast imaging radiologists to advocate for screening mammography. Despite breast cancer being the second most common cancer in women and screening mammography's ability to reduce mortality from this disease, there remains suboptimal utilization in the community. The different guidelines for screening presented by respected organizations has created confusion for patients and referring clinicians and the eventual underutilization of screening mammography. As experts in the value of early detection, breast radiologists are well suited to take on the role of screening advocates. Using specific action steps and examples, we create a template for a radiologist to utilize in the promotion of screening among the breast imaging team, clinicians, administrators, and the community at large. By deliberately filling the role of screening mammography advocate, one can satisfy the mandate for radiologists to bring increased value to the health care team while contributing to community health and patient satisfaction.

Enhancing Quality Using the Inspection Program (EQUIP): A Primer for Radiologists.

The new Enhancing Quality Using the Inspection Program (EQUIP) law places more responsibility for quality assurance on the interpreting radiologists and the lead interpreting physician (LIP). Compliance with the law will require addressing three specific questions related to quality assurance and clinical image corrective action, continued compliance, and ensuring LIP oversight. This process enables the radiologist to exemplify added value through physician leadership, team integration, and improved patient care.

Identifying Barriers to Building a Diverse Physician Workforce: A National Survey of the ACR Membership.

PURPOSE: The aim of this study was to identify potential barriers to building a diverse workforce in radiology and radiation oncology by conducting a national survey of physicians in these fields and studying their reported career experiences. METHODS: An electronic survey of ACR members (February 27, 2018, to April 26, 2018) was conducted in which physicians' attitudes about their work environment, relationships, and culture were queried. The aim was to determine if responses differed by gender or race/ethnicity. In total, 900 invitations were issued; women were oversampled with the goal of equal representation. Descriptive summaries (proportions of yes or no responses) were calculated per item, per subgroup of interest. Logistic regression analysis was used to identify significant associations between gender- and item-specific responses; it was not used in the race/ethnicity analysis because of the small sizes of many subgroups. RESULTS: The response rate was 51.2% (461 of 900). In total, 51.0% of respondents identified as women (235 of 461); the 9.5% (44 of 461) who identified as black or African American, Hispanic, or American Indian or Alaska Native were considered underrepresented minorities. Respondents' mean age was 40.2 ± 10.4 years. Subgroups varied most in their reporting of unfair or disrespectful treatment. Women were significantly more likely than men to report such treatment attributable to gender (50.6% versus 5.4%; odds ratio, 18.00; 95% confidence interval, 9.29-34.86; P < .001), and 27.9% of underrepresented minorities compared with 2.6% of white non-Hispanic respondents reported such treatment attributable to race/ethnicity. CONCLUSIONS: Women and underrepresented minorities disproportionately experience unfair or disrespectful treatment in the workplace. Addressing this problem is likely to be critically important for improving workforce diversity.

Preoperative localization of breast lesions: Current techniques.

Image-guided preoperative localization of breast lesions is a common procedure. This article describes several commercially available localization options-wire localization, radioactive seed localization, localization with a radiofrequency reflector, and magnetic seed localization-and outlines the advantages and disadvantages of each. This information may help radiologists initiate conversations at their facilities with surgeons, pathologists, and hospital administration as they seek to add value and provide patient-centered care.

Finding Inspiration for the Next Generation of Breast Radiologists.

Challenges currently facing breast radiologists, including controversial screening mammography guidelines, radiologist burnout, and the perceived threat posed by artificial intelligence could deter potential candidates from pursuing a career in radiology. However, breast radiologists play a fulfilling role by decreasing the effect of breast cancer through both early detection and direct interaction with patients and interdisciplinary clinical colleagues. While perception is that artificial intelligence will threaten the need for radiologists, it is more likely that it will improve image interpretation and efficiency in workflow, thereby further improving patient care. Trainees can be engaged in breast imaging through interactive teaching methods and by role modeling clinical and image interpretation skills.

Musculoskeletal Injuries Affecting Radiologists According to the 2017 ACR Human Resources Commission Workforce Survey.

Practice leaders surveyed in the 2017 ACR Human Resources Commission workforce survey reported that 25% of the radiologists or radiation oncologists they supervised had neck pain, 32% had low back pain, and 16% were dealing with a repetitive stress injury. The prevalence rates of these musculoskeletal ailments among radiologists and radiation oncologists were consistent with those reported in the literature in other populations. However, these prevalence rates may be underestimated because practice leaders, not the radiologists themselves, were surveyed, and the leaders may not be aware of all injuries.

Impact on Clinical Management of After-Hours Emergent or Urgent Breast Ultrasonography in Patients with Clinically Suspected Breast Abscesses.

Newly diagnosed breast abscesses are generally treated as a medical emergency that may necessitate immediate interventional treatment. At our institution, there is no in-house after-hours coverage for breast ultrasonography. We could find no peer-reviewed studies on the cost-effectiveness or clinical management impact of on-call ultrasound technologist coverage for imaging of breast abscesses. The purposes of this study were to determine the incidence of breast abscess in patients with clinical findings highly suggestive of abscess, identify clinical factors associated with breast abscess in such patients, and determine the impact of after-hours emergent or urgent breast ultrasonography on the clinical management of breast abscesses in both outpatients and inpatients. We retrospectively reviewed 100 after-hours breast ultrasound studies performed at our tertiary care center from 2011 to 2015 for evaluation of a suspected breast abscess. Only 26% of our patients with clinically suspected abscess ultimately had a confirmed abscess. Factors associated with breast abscess were a palpable abnormality and a history of breast surgery within the eight weeks before presentation. After-hours diagnosis of an abscess was associated with after-hours clinical intervention. Of the 74 patients in whom after-hours ultrasound imaging showed no evidence of abscess, only three patients underwent after-hours drainage. Our findings support overnight and weekend breast ultrasound coverage in large tertiary care centers.

Exploring the Negative Likelihood Ratio and How It Can Be Used to Minimize False-Positives in Breast Imaging.

OBJECTIVE: This article describes the definition and proposed utilization of negative likelihood ratios (NLRs) as statistical parameters in breast imaging. Examples with calculations are provided using BI-RADS category 4 subcategories. CONCLUSION: By auditing individual performance early and often against American College of Radiology benchmark positive predictive value ranges for the BI-RADS category 4 subcategories, and by fully understanding NLRs and their application in breast imaging, radiologists can minimize false-positive findings and unnecessary biopsies.

Implementing a Multidisciplinary Tumor Board in the Community Practice Setting.

Multidisciplinary tumor boards are an opportunity for radiologists to demonstrate value to referring clinicians, the hospital, and patients. Multidisciplinary tumor boards are commonly utilized in academic institutions, but may not be readily available in community practice. We discuss strategies academic radiologists may employ to assist in the implementation of a multidisciplinary tumor board in the community practice setting. SUMMARY: Strategies to assist in the implementation of a multidisciplinary tumor board in the community practice setting are described.

Implementation of Upright Digital Breast Tomosynthesis-guided Stereotactic Biopsy.

With growing adoption of digital breast tomosynthesis, an increasing number of imaging abnormalities are being identified only by tomosynthesis. Upright digital breast tomosynthesis-guided stereotactic biopsy is a proven method for sampling these abnormalities as well as abnormalities traditionally evaluated using conventional stereotactic biopsy. In this article, we describe the technique of upright digital breast tomosynthesis-guided stereotactic biopsy and outline a systematic operational approach to implementation of this technique in clinical radiology practices.