Biopsy Marker Standardization: What's in a Name?

OBJECTIVE. The purposes of this study were to compile mammographic images in various projections showing commercially available breast biopsy site markers and to provide a standardized nomenclature and marker guide to improve physician communication and patient care. MATERIALS AND METHODS. A retrospective review of all breast biopsy markers encountered at one institution was conducted from January 2012 to January 2018. Markers placed at the facility and those placed at outside institutions with the patient subsequently referred to the study institution were included. Additional drawings and photographs and biopsy marker information were compiled from manufacturers and the literature. Intrinsic properties, features, pitfalls, and biopsy marker mimics were recorded from the institution's experience and the literature. RESULTS. Thirty-eight different biopsy marker shapes available from six manufacturers were identified, and mammograms of 37 were compiled and organized by manufacturer. Nomenclature was compiled on the basis of the manufacturer names of each marker. Potential pitfalls and mimics were identified. Manufacturer-reported marker material composition and carrier properties were summarized, including decreased marker migration, enhanced ultrasound visibility, and varying MRI susceptibility. CONCLUSION. Variability in the appearance and nomenclature of breast biopsy site markers may contribute to misinterpretation, miscommunication, and possibly removal of the incorrect lesion. A comprehensive guide to breast biopsy marker nomenclature is clinically useful, and standardization is necessary.

Factors Contributing to Disproportionate Burnout in Women Breast Imaging Radiologists: A Review.

Physician burnout continues to increase in prevalence and disproportionately affects women physicians. Breast imaging is a woman-dominated subspeciality, and therefore, worsening burnout among women physicians may have significant repercussions on the future of the breast imaging profession. Systemic and organizational factors have been shown to be the greatest contributors to burnout beyond individual factors. Based on the Mayo Model, we review the evidence regarding the 7 major organizational contributors to physician burnout and their potential disproportionate impacts on women breast radiologists. The major organizational factors discussed are work-life integration, control and flexibility, workload and job demands, efficiency and resources, finding meaning in work, social support and community at work, and organizational culture and values. We also propose potential strategies for institutions and practices to mitigate burnout in women breast imaging radiologists. Many of these strategies could also benefit men breast imaging radiologists, who are at risk for burnout as well.

To scan or not to scan: effect of scanning the axilla of all patients undergoing diagnostic breast ultrasound.

BACKGROUND: Breast ultrasonography is a useful modality in patients undergoing diagnostic and screening breast imaging. However, breast ultrasound has a high false positive rate and can be time-consuming to perform. PURPOSE: The purpose of this study was to evaluate the clinical impact of incidental axillary findings found on diagnostic breast ultrasounds at a single multi-site institution that has a standard protocol of scanning the axilla for all breast ultrasound exams. METHODS: All diagnostic breast ultrasounds were retrospectively reviewed from January 2017 to September 2019. Follow-up imaging, relevant clinical history, and pathology results were also reviewed. All positive axillary findings were divided into incidental or non-incidental findings depending on whether there was a direct clinical indication to scan the axilla. Descriptive statistics were performed with a 5% level of significance. RESULTS: Of the 19,695 diagnostic ultrasounds performed during this timeframe, there were 91 (0.5%) incidental axillary findings given a BIRADS category 3 or 4, and none of these findings resulted in the diagnosis of an occult breast cancer. One biopsy-proven SLL/CLL lymphoma was diagnosed that was otherwise clinically occult. CONCLUSION: Routine axillary scanning in all patients undergoing a diagnostic breast ultrasound at a large multi-site institution yields a low rate of incidental findings and has minimal impact on detection of cancer.

Ongoing Impact of COVID-19 on Breast Radiologists' Wellness.

OBJECTIVE: Assess the ongoing impact of COVID-19 on mental well-being of breast radiologists nationwide two years after the start of the pandemic and compared to early in the pandemic. METHODS: A 27-question survey was distributed from December 2021 to January 2022 to physician members of the Society of Breast Imaging. Psychological distress and anxiety scores were calculated, and factors associated with them were identified with a multivariate logistic model. RESULTS: A total of 550 surveys were completed (23% response rate); the mean respondent age was 50 +/- 10 years. Fifty percent (265/526) of respondents reported two or more psychological distress symptoms, down from 58% in 2020 (P = 0.002), whereas 70% (362/526) of respondents reported increased anxiety, down from 82% in 2020 (P < 0.001). As in 2020, reporting financial strain and childcare adversely affecting job ability were associated with worse psychological distress scores (OR 3.6, 95% CI: 1.6-8.3, P = 0.02 and OR 6.0, 95% CI: 2.5-14.4, P = 0.002, respectively). Less time spent consulting, educating, and discussing results with patients was associated with higher psychological distress (OR 5.3, 95% CI: 2.1-13.2, P = 0.036) and anxiety (OR 6.4, 95% CI: 2.3-17.5, P < 0.001). Diminished research collaboration was associated with higher anxiety (OR 1.8, 95% CI: 1.1-2.9, P = 0.019). CONCLUSION: The COVID-19 pandemic continues to cause mental health symptoms in breast radiologists, especially for those with pandemic-specific childcare needs and financial distress. Pandemic-related decreased opportunities to connect with patients and colleagues negatively impacts radiologists' mental health.

Lung Cancer Screening Among Mammography Patients: Knowledge, Eligibility, Participation, and Interest.

OBJECTIVE: To determine lung cancer screening eligibility, knowledge, and interest and to quantify the effect of the expanded 2021 lung cancer screening eligibility criteria among women presenting for screening mammography, a group with demonstrable interest in cancer screening. METHODS: A single-page survey was distributed to patients presenting for screening mammography, from January-March 2020 and June 2020-January 2021, at 2 academic medical centers on the East and West Coasts. The population served by the East Coast institution has greater poverty, greater ethnic/racial diversity, and lower education levels. Survey questions included age, smoking history, lung cancer screening knowledge, participation, and interest. Lung cancer screening eligibility was determined for both 2013 and 2021 USPSTF guidelines. Descriptive statistics were calculated, and data were compared between groups using the Chi-square test, Mann-Whitney nonparametric test, and the 2-sample t test. RESULTS: 5512 surveys were completed; 33% (1824) of women reported a history of smoking-30% (1656) former smokers and 3% (156) current smokers. Among women with a smoking history, 7% (127/1824) were eligible for lung cancer screening using 2013% and 11% (207/1824) using the 2021 USPSTF criteria. Interest in lung cancer screening was high (73%; 151/207) among eligible women using 2021 USPSTF criteria, but only 42% (87/207) had heard of lung cancer screening and only 28% (57/207) had received prior LDCT screening. CONCLUSION: Eligible screening mammography patients reported high levels of interest in lung cancer screening but low levels of knowledge and participation. Linking mammography and LDCT appointments may improve lung cancer screening participation.

Fear of the Unknown: The Benefits of a Patient Educational Handout on Breast Biopsy Markers.

OBJECTIVE: To determine whether providing a biopsy marker informational handout to patients improves patient knowledge and comfort with receiving a marker. METHODS: In this IRB-exempt prospective study, a patient educational handout on breast biopsy markers was developed. A questionnaire was created with four questions asking patients to self-evaluate their knowledge of biopsy markers and their comfort level with marker placement before and after reading the handout. Technologists distributed the educational handouts to patients presenting for a percutaneous breast biopsy under any modality from December 11, 2020, to April 23, 2021. Data from the completed questionnaires were entered into a database. Statistical analyses included paired t-test and Wilcoxon analyses. RESULTS: In total, 141 completed surveys were included in the analysis. The mean scores prior to reading the handout for knowledge and comfort were 2.59 and 3.40, respectively. After reading the handout, there was a significant increase in mean scores for knowledge and comfort (4.26 and 4.20, respectively) (P < 0.001). There was a 64% increase vs 23% increase for knowledge and comfort, respectively. CONCLUSION: Patient-assessed knowledge of biopsy markers increased significantly after reading our educational handout. Patient-assessed comfort with biopsy marker placement also increased significantly after reading the educational handout, though to a lesser degree than knowledge. Although not included in our study, use of an educational handout may impact patient acceptance of marker placement. Future directions may include quantitatively assessing the effect of the handout on time to consent for a biopsy or influence on acceptance of marker placement.

Breast Imaging for Transgender Individuals: Assessment of Current Practice and Needs.

PURPOSE: The aim of this study was to investigate breast radiologists' practices related to recording sex and gender in the electronic medical record, knowledge and attitudes about breast cancer screening recommendations for transgender individuals, and experience and willingness to enter screening mammography data from transgender patients into databases that document service provision and outcomes of cancer detection protocols. METHODS: A 19-question anonymous survey was distributed by e-mail to all active physician members of the Society of Breast Imaging. Response characteristics were assessed as frequencies and percentages and compared between groups using the Fisher exact test or χ2 test. The degree of agreement between questions was assessed using the McNemar test. RESULTS: Four hundred one radiologists across the United States and Canada responded (response rate 18%). Recording birth-assigned sex distinct from gender identity was reported by 44 of 352 respondents (13%). Depending on geographic region, 38% to 62% of breast radiologists followed screening guidelines for transgender women, and 226 of 349 (65%) did not provide screening recommendations for transgender men. Of 400, 324 (81%) believed that the evidence base for screening transgender individuals is incomplete, and 247 of 352 (70%) were either unsure of or had no Lesbian, Gay, Bisexual, Transgender, Queer competency training. A majority (247 of 401 [62%]) of respondents reported that they would enroll transgender patients in existing or novel national databases. CONCLUSIONS: In the practice of breast imaging, there is a substantial need to record transgender and other gender-nonconforming information. Breast radiologists differ in their practice and knowledge regarding screening of transgender women and men but expressed interest in contributing data to facilitate longitudinal databases needed to inform cancer screening guidelines.

Communicating With Breast Imaging Patients During the COVID-19 Pandemic: Impact on Patient Care and Physician Wellness.

OBJECTIVE: Assess the impact of COVID-19 on patient-breast radiologist interactions and evaluate the relationship between safety measure-constrained communication and physician wellbeing. METHODS: A 41-question survey on the perceived effect of COVID-19 on patient care was distributed from June 2020 to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Non-radiologists and international members were excluded. Anxiety and psychological distress scores were calculated. A multivariable logistic model was used to identify demographic and mental health factors associated with responses. RESULTS: Five hundred twenty-five surveys met inclusion criteria (23% response rate). Diminished ability to fulfill patients' emotional needs was reported by 46% (221/479), a response associated with younger age (OR, 0.8 per decade; P < 0.01), higher anxiety (OR, 2.3; P < 0.01), and higher psychological distress (OR, 2.2; P = 0.04). Personal protective equipment made patient communication more difficult for 88% (422/478), a response associated with younger age (OR, 0.8 per decade; P = 0.008), female gender (OR, 1.9; P < 0.01), and greater anxiety (OR, 2.6; P = 0.001). The inability to provide the same level of care as prior to COVID-19 was reported by 37% (177/481) and was associated with greater anxiety (OR, 3.4; P < 0.001) and psychological distress (OR, 1.7; P = 0.03). CONCLUSION: The majority of breast radiologists reported that COVID-19 has had a negative impact on patient care. This perception was more likely among younger radiologists and those with higher levels of anxiety and psychological distress.

COVID-19 and Breast Radiologist Wellness: Impact of Gender, Financial Loss, and Childcare Need.

PURPOSE: The purpose of this study was to evaluate the emotional and financial impact of coronavirus disease 2019 (COVID-19) on breast radiologists to understand potential consequences on physician wellness and gender disparities in radiology. METHODS: A 41-question survey was distributed from June to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Psychological distress and financial loss scores were calculated on the basis of survey responses and compared across gender and age subgroups. A multivariate logistic model was used to identify factors associated with psychological distress scores. RESULTS: A total of 628 surveys were completed (18% response rate); the mean respondent age was 52 ± 10 years, and 79% were women. Anxiety was reported by 68% of respondents, followed by sadness (41%), sleep problems (36%), anger (25%), and depression (23%). A higher psychological distress score correlated with female gender (odds ratio [OR], 1.9; P = .001), younger age (OR, 0.8 per SD; P = .005), and a higher financial loss score (OR, 1.4; P < .0001). Participants whose practices had not initiated wellness efforts specific to COVID-19 (54%) had higher psychological distress scores (OR, 1.4; P = .03). Of those with children at home, 38% reported increased childcare needs, higher in women than men (40% versus 29%, P < .001). Thirty-seven percent reported that childcare needs had adversely affected their jobs, which correlated with higher psychological distress scores (OR, 2.2-3.3; P < .05). CONCLUSIONS: Psychological distress was highest among younger and female respondents and those with greater pandemic-specific childcare needs and financial loss. Practice-initiated COVID-19-specific wellness efforts were associated with decreased psychological distress. Policies are needed to mitigate pandemic-specific burnout and worsening gender disparities.

Impact of COVID-19 on Breast Imaging Practice Operations and Recovery Efforts: A North American Study.

OBJECTIVE: To assess the impact of the COVID-19 pandemic on breast imaging facilities' operations and recovery efforts across North America. METHODS: A survey on breast imaging facilities' operations and strategies for recovery during the COVID-19 pandemic was distributed to the membership of the Society of Breast Imaging and National Consortium of Breast Centers from June 4, 2020, to July 14, 2020. A descriptive summary of responses was performed. Comparisons were made between demographic variables of respondents and questions of interest using a Pearson chi-square test. RESULTS: There were 473 survey respondents (response rate of 13%). The majority of respondents (70%; 332/473) reported 80%-100% breast imaging volume reduction, with 94% (447/473) reporting postponement of screening mammography. The majority of respondents (97%; 457/473) continued to perform biopsies. There were regional differences in safety measures taken for staff (P = 0.004), with practices in the West more likely reporting no changes in the work environment compared to other regions. The most common changes to patients' experience included spacing out of furniture in waiting rooms (94%; 445/473), limiting visitors (91%; 430/473), and spacing out appointments (83%). A significantly higher proportion of practices in the Northeast (95%; 104/109) initiated patient scheduling changes compared to other regions (P = 0.004). CONCLUSION: COVID-19 had an acute impact on breast imaging facilities. Although common national operational patterns emerged, geographic variability was notable in particular in recovery efforts. These findings may inform future best practices for delivering breast imaging care amid the ongoing and geographically shifting COVID-19 pandemic.

Effectiveness of Lung-RADS in Reducing False-Positive Results in a Diverse, Underserved, Urban Lung Cancer Screening Cohort.

PURPOSE: The Lung CT Screening Reporting and Data SystemTM (Lung-RADSTM) was created to standardize lung cancer screening CT reporting and recommendations but has not been well validated prospectively in clinical practice. The aim of this study was to determine the effectiveness of lung cancer screening using Lung-RADS in a diverse, underserved, academic clinical screening program, focusing on whether Lung-RADS would successfully reduce the 23.3% false-positive rate found in the National Lung Screening Trial. METHODS: Institutional review board approval was obtained to study the clinical lung cancer screening cohort. Low-dose CT results were prospectively assigned a Lung-RADS or equivalent score. The proportion of examinations in each Lung-RADS category and the corresponding lung cancer rate, subsequent imaging, interventions, mortality, and compliance were tracked. The National Death Index was queried for follow-up losses. RESULTS: The cohort comprised 1,181 patients with 2,270 person-years of follow-up from December 2012 to December 2016. The mean age was 64 ± 16.2 years, with 51% women, 63% nonwhite, 71% current smokers, 69% overweight and obese, and multiple comorbidities. The Lung-RADS false-positive rate was 10.4% (95% confidence interval, 8.8%-12.3%). Baseline CT results were negative in 87% (n = 1,031): for Lung-RADS 1, the lung cancer rate was 0.2%, and for Lung-RADS 2, the cancer rate was 0.5%. Positive baseline examinations were Lung-RADS 3 in 10% (n = 119), 4a in 1.2% (n = 14), and 4b in 1.5% (n = 18). Corresponding cancer rates were 3.4%, 43%, and 83%, respectively. Lung cancer prevalence was 2.1%. Mortality was 40% in patients with lung cancer versus 2.5% in the remaining cohort (P < .001). Fifty-four percent of patients were overdue for first annual examinations. Eighty-four percent of patients (n = 989) had follow-up verified via electronic records or personal contact, and the remainder had vital status ascertained via the National Death Index. CONCLUSIONS: Lung cancer screening using Lung-RADS was effective in reducing the false-positive rate compared with the National Lung Screening Trial in a diverse and underserved urban population.

Computed tomography screening for lung cancer: preliminary results in a diverse urban population.

PURPOSE: The purpose of this study was to describe the baseline characteristics and results of the initial 18 months of our clinical computed tomography (CT) lung cancer screening program in an ethnically diverse, poor, predominantly overweight, and obese population, which differs dramatically from the National Lung Screening Trial population. MATERIALS AND METHODS: All patients had a physician referral for CT lung cancer screening and met National Lung Screening Trial eligibility criteria. Infrastructure developed for the program included a standardized results report [Bronx score of 1 to 5 (modeled on BI-RADS)] for the electronic medical record and a dedicated bilingual screening coordinator. If the patient's insurance did not cover CT screening, a fee of $75 was charged. RESULTS: A total of 320 patients [54% (174) men, mean age 64 y] underwent initial CT lung cancer screening from December 18, 2012 to July 3, 2014. The median pack-years was 47, and 68% (218) were current smokers. Twenty-six percent (84) were white, and 70% (223) were overweight (101) or obese (122). The lung cancer prevalence was 2.2% (7/320). Seventy-eight percent (7/9) of patients with CT findings positive for lung cancer (score 5a, 5b) had proven lung cancer; 1 had stage 1 (1B) disease, and 6 had stage IIA or higher disease. The false-positive rate for a Bronx score ≥3 was 19% (60). Medicare and Medicaid insure 80% of the institution's overall population but only 38% (121) of the CT screening patients. CONCLUSIONS: CT screening is feasible in a diverse inner-city population with the support of a robust infrastructure. Further study is needed to determine whether CT screening will confer a mortality benefit in this population.

Differentiating shunt-responsive normal pressure hydrocephalus from Alzheimer disease and normal aging: pilot study using automated MRI brain tissue segmentation.

Evidence suggests that normal pressure hydrocephalus (NPH) is underdiagnosed in day to day radiologic practice, and differentiating NPH from cerebral atrophy due to other neurodegenerative diseases and normal aging remains a challenge. To better characterize NPH, we test the hypothesis that a prediction model based on automated MRI brain tissue segmentation can help differentiate shunt-responsive NPH patients from cerebral atrophy due to Alzheimer disease (AD) and normal aging. Brain segmentation into gray and white matter (GM, WM), and intracranial cerebrospinal fluid was derived from pre-shunt T1-weighted MRI of 15 shunt-responsive NPH patients (9 men, 72.6 ± 8.0 years-old), 17 AD patients (10 men, 72.1 ± 11.0 years-old) chosen as a representative of cerebral atrophy in this age group; and 18 matched healthy elderly controls (HC, 7 men, 69.7 ± 7.0 years old). A multinomial prediction model was generated based on brain tissue volume distributions. GM decrease of 33% relative to HC characterized AD (P < 0.005). High preoperative ventricular and near normal GM volumes characterized NPH. A multinomial regression model based on gender, GM and ventricular volume had 96.3% accuracy differentiating NPH from AD and HC. In conclusion, automated MRI brain tissue segmentation differentiates shunt-responsive NPH with high accuracy from atrophy due to AD and normal aging. This method may improve diagnosis of NPH and improve our ability to distinguish normal from pathologic aging.

A novel nutrition medicine education model: the Boston University experience.

Most deaths in the United States are preventable and related to nutrition. Although physicians are expected to counsel their patients about nutrition-related health conditions, a recent survey reported minimal improvements in nutrition medicine education in US medical schools in the past decade. Starting in 2006, we have developed an educational plan using a novel student-centered model of nutrition medicine education at Boston University School of Medicine that focuses on medical student-mentored extracurricular activities to develop, evaluate, and sustain nutrition medicine education. The medical school uses a team-based approach focusing on case-based learning in the classroom, practice-based learning in the clinical setting, extracurricular activities, and a virtual curriculum to improve medical students' knowledge, attitudes, and practice skills across their 4-y period of training. We have been using objectives from the NIH National Academy Awards guide and tools from the Association of American Medical Colleges to detect new areas of nutrition medicine taught at the medical school. Although we were only able to identify 20.5 h of teaching in the preclerkship years, we observed that most preclerkship nutrition medicine objectives were covered during the course of the 4-y teaching period, and extracurricular activities provided new opportunities for student leadership and partnership with other health professionals. These observations are very encouraging as new assessment tools are being developed. Future plans include further evaluation and dissemination of lessons learned using this model to improve public health wellness with support from academia, government, industry, and foundations.

Elevated amygdala responses to emotional faces in youths with chronic irritability or bipolar disorder.

A major controversy in child psychiatry is whether bipolar disorder (BD) presents in children as severe, non-episodic irritability (operationalized here as severe mood dysregulation, SMD), rather than with manic episodes as in adults. Both classic, episodic BD and SMD are severe mood disorders characterized by deficits in processing emotional stimuli. Neuroimaging techniques can be used to test whether the pathophysiology mediating these deficits are similar across the two phenotypes. Amygdala dysfunction during face emotion processing is well-documented in BD, but little is known about amygdala dysfunction in chronically irritable youth. We compared neural activation in SMD (n=19), BD (n=19), and healthy volunteer (HV; n=15) youths during an implicit face-emotion processing task with angry, fearful and neutral expressions. In the right amygdala, both SMD and BD exhibited greater activity across all expressions than HV. However, SMD and BD differed from each other and HV in posterior cingulate cortex, posterior insula, and inferior parietal lobe. In these regions, only SMD showed deactivation in response to fearful expressions, whereas only BD showed deactivation in response to angry expressions. Thus, during implicit face emotion processing, youth with BD and those with SMD exhibit similar amygdala dysfunction but different abnormalities in regions involved in information monitoring and integration.

Enhancement of ischemic wound healing by inducement of local angiogenesis.

OBJECTIVE: To determine if monocytes activated toward an angiogenic phenotype can be used to improve ischemic tissue healing in a rat skin flap model. STUDY DESIGN: Prospective experimental study on Wistar rats. METHODS: A caudally based 9 x 3 cm dorsal skin/panniculus carnosus flap was raised in 15 rats. The animals were divided into three groups: the monocyte group (N = 5) received subcutaneous topical application of 0.1-0.2 cc of i-Monogrid, a collagen gel containing M2 angiogenic monocytes; control group 1 (N = 5) received application of cell-free collagen; and control group 2 (N = 5) received no treatment. Skin flaps were stapled in place and observed for wound ischemia and necrosis of the skin flap. One week postoperatively, skin and underlying muscle were harvested for histologic analyses. RESULTS: No macroscopic differences in wound healing or microscopic differences in skin viability were observed. However, the monocyte group showed significantly greater vascular improvement than C1 (P = .047, chi = 3.96), and a trend toward greater vascular improvement than C2 (P = .103, chi = 2.67). CONCLUSIONS: Delivery of activated pro-angiogenic monocytes to an ischemic skin flap tended to improve histologic evidence of vascularity without corresponding microscopic or gross evidence of improved flap survival. These results are encouraging regarding the use of monocytes as a potential method of improving vascularization of ischemic tissue.