Facilitating Culturally Competent Breast Imaging Care in South Asian Patients.

South Asians are a rapidly growing subset of the Asian population in the United States. They comprise people from multiple countries with diverse beliefs, languages, and cultural identities and values. The incidence of breast cancer is rising in South Asian women in the United States, with earlier onset and predilection for HER2-enriched tumors. Despite the rising incidence of breast cancer, participation in screening remains lower than other populations. Health care inequities in South Asian women are multifactorial and may be due to traditional health beliefs and practices, language barriers, cultural differences, and lack of overall awareness. Developing a culturally sensitive environment in breast imaging clinic practice can lead to improved patient care and adherence. Given the scarcity of data specific to the South Asian population in United States, there is a need for health service researchers and practice leaders to obtain more high-quality data to understand the needs of South Asian patient populations.

Appropriate Use of Medical Interpreters in the Breast Imaging Clinic.

More than 25 million Americans have limited English-language proficiency (LEP) according to the U.S. Census Bureau. This population experiences challenges accessing health care and is least likely to receive preventive health care, including screening mammogram. In a setting where the breast radiologist does not speak the language of their patient, using certified medical interpreter services is fundamental. Medical interpreter use is associated with improved clinical care and patient satisfaction and can potentially increase adherence to screening mammograms and follow-up in patients with LEP. Title VI of the Civil Rights Act requires interpreter services for patients with LEP who are receiving federal financial assistance. Failure to provide interpretative services when necessary is considered discriminatory and illegal. The use of untrained medical interpreters, including ad hoc interpreters (eg, family, friends, or untrained staff), is associated with more medical errors, violation of confidentiality, and poor health outcomes. Types of medical interpretation services available to address language barriers include in-person interpretation, telephone and video remote interpretation, and qualified bilingual staff. Proper training and certification of medical interpreters is essential to prevent misinterpretations and ensure patient safety. When using an interpreter service, speak to and maintain eye contact with the patient, address the patient directly and seat the interpreter next to or slightly behind the patient, use visual aids whenever possible, and have the patient repeat the information to verify comprehension. Breast radiologists can address disparities in breast cancer screening and treatment by promoting effective communication.

Raising Cultural Awareness and Addressing Barriers to Breast Imaging Care for Black Women.

Health care disparities, which are differences in the attainment of full health potential among population groups, have been documented across medical conditions, clinical settings, and diagnostic and treatment modalities. Deeply rooted health care disparities due to many factors have affected how Black women (BW) view medical care including screening mammography. This article explores health care disparities around breast cancer in BW and how patient distrust, provider biases, race, and social determinants of health continue to have negative effects on breast cancer outcomes in BW, despite medical advances in breast cancer detection and management. In addition, this article addresses the importance of culturally competent care for BW around breast cancer awareness, screening, and treatment, and offers strategies to address disparities and rebuild trust.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers.

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

Culturally Competent Care in the Breast Imaging Clinic: Hispanic/Latino Patients.

Hispanic/Latino people represent 19% of the U.S. population, and this proportion is expected to increase to 26% by 2050. Hispanic/Latino people comprise a diverse ethnic group that includes individuals from all races, religions, languages, cultural identities, and nationalities. Barriers to health care that have created significant disparities in this community include language, low socioeconomic status, and inability to afford health insurance. Health coverage for Hispanic/Latino people has been a longstanding problem in the U.S., stopping many of these patients from seeking preventive care such as screening mammography. Breast cancer is the most common cancer among Hispanic/Latino women in the U.S. and the leading cause of cancer death in this group. Five-year breast cancer survival in Hispanic/Latino women is slightly lower than that in non-Hispanic White women. Some of the factors that account for the ethnic disparities in breast cancer include lower levels of adherence to screening mammography of Hispanic/Latino women as a consequence of inadequate insurance coverage, language barriers, lack of transportation, being unable to leave work, and lack of childcare. By promoting a culturally sensitive clinical environment, breast radiologists can increase patient engagement, utilization of preventive services, treatment adherence rates, and overall health status.

Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists.

RATIONALE AND OBJECTIVES: The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists. MATERIALS AND METHODS: In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed. RESULTS: Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC 'always' or 'most of the time'. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003). CONCLUSION: Radiologists' reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

Upright Tomosynthesis-guided Breast Biopsy: Tips, Tricks, and Troubleshooting.

The advent and implementation of digital breast tomosynthesis (DBT) have had a significant effect on breast cancer detection and image-guided breast procedures. DBT has been shown to improve the visualization of architectural distortions and noncalcified masses. With the incorporation of DBT imaging, biopsy of those findings seen only with DBT is feasible, and the need for localization and surgical excision to determine the pathologic diagnosis is avoided. The additional benefits of reduced procedural time, better localization, and increased technical success support the use of DBT for breast biopsy. DBT-guided biopsy can be performed with the patient prone or upright, depending on the table or unit used. Upright positioning enables improved patient comfort, particularly in patients who have restricted mobility, weight-related limitations, and/or difficulty lying prone for an extended period. Upright DBT-guided breast procedures require a cohesive team approach with overlapping radiologist and technologist responsibilities. Since this is a common breast procedure, the radiologist should be familiar with preprocedural considerations, patient preparations, and use of the biopsy equipment. The basic principles of upright DBT-guided breast biopsy are described in this comprehensive review. The various procedural components, including alternative approaches and techniques, are discussed. Tips and tricks for navigating the biopsy procedure to minimize complications, imaging examples of crucial steps, and supporting diagrams are provided. In addition, the challenges of performing upright DBT-guided biopsy, with troubleshooting techniques to ensure a successful procedure, are reviewed. ©RSNA, 2021.

Characterization of common breast MRI abnormalities: comparison between abbreviated and full MRI protocols.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic performance of abbreviated MRI (AB-MRI) in comparison to a full protocol MRI (FP-MRI) when evaluating common MRI abnormalities of a mass, non-mass enhancement and focus. MATERIALS AND METHODS: This retrospective reader study was Institutional Review Board approved and Health Insurance Portability and Accountability Act (HIPAA) compliant. AB-MRIs were reviewed from May 2018-December 2019 to identify women with an abnormal AB-MRI, FP-MRI within six months of the AB-MRI and an elevated risk for breast cancer. Six breast radiologists initially interpreted and recorded findings from the AB-MRI. Immediately after reviewing the AB-MRI, the same radiologists interpreted and recorded findings from the FP-MRI. Findings were recorded in an electronic data collection form. Cohen's Kappa test was used to calculate agreement. P < 0.05 was considered statistically significant. RESULTS: Of 119 patients who had an AB-MRI, our final study comprised of 32 patients who had 64 breast MRIs (32 AB-MRI and 32 FP-MRI). The amount of fibroglandular tissue for AB-MRI and FP-MRI showed excellent intra-reader agreement [Kappa: 0.89-1.00 (P < 0.0001)]. Substantial to excellent intra-reader agreement [Kappa: 0.74-0.93 (P < 0.0001)] was demonstrated for all 6 readers when identifying abnormalities seen on AB-MRI and FP-MRI. Moderate to excellent intra-reader agreement [Kappa: 0.41-0.87(P < 0.0001)] was demonstrated between the AB-MRI and FP-MRI for the final BI-RADS assessment. CONCLUSION: AB-MRI has acceptable intra-reader agreement with FP-MRI when characterizing common MRI abnormalities such as a mass, non-mass enhancement and focus suggesting that subsequent FP-MRI may not be needed.

Analysis of 612 Benign Papillomas Diagnosed at Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated With Upgrade, and a Proposal for Selective Surgical Excision.

BACKGROUND. Despite numerous published studies, management of benign papillomas without atypia remains controversial. OBJECTIVE. The purpose of this study was to determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. METHODS. This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between December 1, 2000, and December 31, 2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. RESULTS. The study included 612 benign papillomas in 543 women (mean age, 54.5 ± 12.1 [SD] years); 466 papillomas were excised, and 146 underwent imaging or clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p < .05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for 60 years and older vs 0.7% for younger than 60 years), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥ 10 mm vs 0.6% if < 10 mm). Three of 14 upgraded papillomas were associated with four or more metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age 60 years old and older, size 10 mm or larger, and presence of four or more metachronous or concurrent peripheral papillomas achieved an AUC of 0.91, sensitivity of 79%, and spec-ificity of 89% for upgrade. Selective surgery based on presence of any of these five factors, although excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would have spared 294 of 612 lesions from routine excision and identified all 14 upgraded lesions. CONCLUSION. Benign nonatypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the five criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. CLINICAL IMPACT. The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.

Upgrade Rate of Pure Flat Epithelial Atypia Diagnosed at Core Needle Biopsy: A Systematic Review and Meta-Analysis.

Purpose: To perform a systematic review and meta-analysis to calculate the pooled upgrade rate of pure flat epithelial atypia (FEA) diagnosed at core needle biopsy (CNB). Materials and Methods: A PubMed and Embase database search was performed in December 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality and publication bias were assessed. The upgrade rate of pure FEA to cancer, invasive carcinoma, and ductal carcinoma in situ (DCIS), as well as the co-occurrence rate of atypical ductal hyperplasia (ADH), with 95% CIs were calculated. A random effect model was used to integrate the proportions and their corresponding 95% CI. Study heterogeneity was calculated using τ2 and I 2 . Results: A total of 2482 cases of pure FEA across 42 studies (mean age range, 46-59 years) met inclusion criteria to be analyzed. Significant study heterogeneity was identified (τ2 = 0.001, I 2 = 67%). The pooled upgrade rates reported for pure FEA were 5% (95% CI: 3%, 6%) for breast cancer, 1% (95% CI: 0%, 2%) for invasive carcinoma, and 2% (95% CI: 1%, 3%) for DCIS. When more than 90% of calcifications were removed at CNB, the pooled upgrade rate was 0% (95% CI: 0%, 2%). The pooled co-occurrence rate of ADH at surgical excision was 17% (95% CI: 12%, 21%). Study quality was medium to high with a risk of publication bias (P < .01). Conclusion: Pure FEA diagnosed at CNB should be surgically excised due to the pooled upgrade rate of 5% for breast cancer. If more than 90% of the targeted calcifications are removed by CNB for pure FEA, close imaging follow-up is recommended.Keywords: Biopsy/Needle Aspiration, Breast, MammographySupplemental material is available for this article.© RSNA, 2021.

Diagnostic accuracy of MRI textural analysis in the classification of breast tumors.

OBJECTIVE: To investigate whether textural analysis (TA) of MRI heterogeneity may play a role in the clinical assessment and classification of breast tumors. MATERIALS AND METHODS: For this retrospective study, patients with breast masses ≥1 cm on contrast-enhanced MRI were obtained in 69 women (mean age: 51 years; range 21-78 years) with 77 masses (38 benign, 39 malignant) from 2006 to 2018. The selected single slice sagittal peak post-contrast T1-weighted image was analyzed with commercially available TA software [TexRAD Ltd., UK]. Eight histogram TA parameters were evaluated at various spatial scaling factors (SSF) including mean pixel intensity, standard deviation of the pixel histogram (SD), entropy, mean of the positive pixels (MPP), skewness, kurtosis, sigma, and Tx_sigma. Additional statistical tests were used to determine their predictiveness. RESULTS: Entropy showed a significant difference between benign and malignant tumors at all textural scales (p < 0.0001) and kurtosis was significant at SSF = 0-5 (p = 0.0026-0.0241). The single best predictor was entropy at SSF = 4 with AUC = 0.80, giving a sensitivity of 95% and specificity of 53%. An AUC of 0.91 was found using a model combining entropy with sigma, which yielded better performance with a sensitivity of 92% and specificity of 79%. CONCLUSION: TA of breast masses has the potential to assist radiologists in categorizing tumors as benign or malignant on MRI. Measurements of entropy, kurtosis, and entropy combined with sigma may provide the best predictability.

Screening Mammogram Results in the Digital Age: Video Messaging - A Pilot Study.

OBJECTIVE: To assess patients' preferences for receiving screening mammogram results via a video message from their radiologist versus the traditional methods. METHODS: The Institutional Review Board approved this prospective study which enrolled participants from March to May 2019, after written consent was obtained. Two breast radiologists prerecorded video results for normal and abnormal screening mammograms. Women 40 years and older presenting for a screening mammogram who had a prior mammogram and no clinical symptoms were invited to participate in the study. After their mammogram, participants were assigned to obtain results via video message or by traditional methods such as a mailed letter or phone call. Participants then completed an online survey asking questions regarding the method of results delivery. RESULTS: Around 80/94 participants ranging in age from 40 to 76 years old responded (85% response rate), of which 73% (58/80) preferred a video message from the radiologist for their mammogram results (p = 0.029). When analyzed by age, the video results were most liked by patients 40-60 years old. When analyzed by education level, participants with a Master's or Bachelor's degree liked receiving their results by video. DISCUSSION: Our study suggests that patients in the screening mammography setting may prefer a video message from their radiologist to the traditional methods of delivery, including mailed letters and receiving results from their primary care provider. Video results could potentially be utilized in the delivery of other results of standardized medical tests as a method to offer more timely delivery of results and a personal connection.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient.

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Intimate Partner Violence and the Role of Breast Imaging Centers.

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient's upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

Textural Characteristics of Biopsy-proven Metastatic Axillary Nodes on Preoperative Breast MRI in Breast Cancer Patients: A Feasibility Study.

OBJECTIVE: To determine the diagnostic accuracy of MRI textural analysis (TA) to differentiate malignant from benign axillary lymph nodes in patients with breast cancer. METHODS: This was an institutional review board-approved retrospective study of axillary lymph nodes in women with breast cancer that underwent ultrasound-guided biopsy and contrast-enhanced (CE) breast MRI from January 2015 to December 2018. TA of axillary lymph nodes was performed on 3D dynamic CE T1-weighted fat-suppressed, 3D delayed CE T1-weighted fat-suppressed, and T2-weighted fat-suppressed MRI sequences. Quantitative parameters used to measure TA were compared with pathologic diagnoses. Areas under the curve (AUC) were calculated using receiver operating characteristic curve analysis to distinguish between malignant and benign lymph nodes. RESULTS: Twenty-three biopsy-proven malignant lymph nodes and 24 benign lymph nodes were analyzed. The delayed CE T1-weighted fat-suppressed sequence had the greatest ability to differentiate malignant from benign outcome at all spatial scaling factors, with the highest AUC (0.84-0.93), sensitivity (0.78 [18/23] to 0.87 [20/23]), and specificity (0.76 [18/24] to 0.88 [21/24]). Kurtosis on the 3D delayed CE T1-weighted fat-suppressed sequence was the most prominent TA parameter differentiating malignant from benign lymph nodes (P < 0.0001). CONCLUSION: This study suggests that MRI TA could be helpful in distinguishing malignant from benign axillary lymph nodes. Kurtosis has the greatest potential on 3D delayed CE T1-weighted fat-suppressed sequences to distinguish malignant and benign lymph nodes.

A comparison of full-field digital mammograms versus 2D synthesized mammograms for detection of microcalcifications on screening.

OBJECTIVES: To compare the observer agreement of microcalcification detection on synthetic 2D images to full field digital mammography (FFDM) at screening and determine if calcifications can be detected to the same degree and given the same BI-RADS assessment. MATERIAL AND METHODS: Two-experienced radiologists retrospectively reviewed synthetic 2D images and FFDM, in separate sessions, to detect microcalcifications and provide a BIRADS assessment. A third experienced breast radiologist reviewed the cases that were disagreed upon and gave a final assessment. Between March 2016-December 2016, 414 women obtained a screening mammogram with tomosynthesis and acquisition of FFDM. 71 cases had combined FFDM and tomosynthesis images, calcifications visible on FFDM or no calcifications present, which comprised the study group. Synthetic 2D images were constructed from the DBT images. During session 1, all synthetic 2D images for the 71 cases were reviewed. During session 2, all the FFDM images for the 71 cases were reviewed. Tomosynthesis images were not reviewed. The agreement of detection of calcifications and BIRADS assessment between radiologists for FFDM and synthetic 2D images were assessed using Cohen's kappa test. Fisher's exact test was used to detect the differences in calcification identification among various breast densities on FFDM and synthetic 2D images. RESULTS: For the detection of calcifications between synthetic 2D images and FFDM, there was moderate to substantial agreement (p-values < 0.0001) for the two radiologist. For the BIRADS assessments, the agreement between synthetic 2D imaging and FFDM was moderate (p-values < 0.0001). The inter-reader agreement for detection of calcifications was fair for using synthetic 2D and moderate for using FFDM (p-value < 0.0001). The final inter-reader agreement between FFDM and synthetic 2D images for the detection of calcifications was moderate (p-values < 0.0001) with the addition of the third reader. For the final BI-RADS assessment, there was moderate agreement between synthetic 2D imaging and FFDM (p-value < 0.0001). The two readers did not demonstrate a significant difference in the detection of microcalcifications for those who were dense or non-dense (p-value range 0.076-0.302). CONCLUSION: Radiologist interpreting synthetic 2D imaging and FFDM have similar frequency for detection of calcifications and BIRADS assessment. A synthetic 2D mammogram may be a sufficient replacement for FFDM at screening.