Barriers and facilitators to breast cancer screening among high-risk women: a qualitative study.

PURPOSE: Women with greater than 20-25% lifetime breast cancer risk are recommended to have breast cancer screening with annual mammogram and supplemental breast MRI. However, few women follow these screening recommendations. The objective of this study was to identify barriers and facilitators of screening among women at high risk for breast cancer, guided by the Health Services Utilization Model (HSUM). METHODS: Unaffected high-risk women (N=63) completed semi-structured qualitative interviews exploring their experiences with breast cancer screening. Interviews were audio recorded, transcribed verbatim, and analyzed using a combined deductive and inductive approach. RESULTS: Most participants (84%) had received a screening mammogram; fewer (33%) had received a screening breast MRI. Only 14% had received neither screening. In line with the HSUM, qualitative analysis identified predisposing factors, enabling factors, and need factors associated with receipt of breast cancer screening. Enabling factors - including financial burden, logistic barriers, social support, and care coordination - were most frequently discussed. Predisposing factors included knowledge, health beliefs, and self-advocacy. Need factors included healthcare provider recommendation, family history of breast cancer, and personal medical history. Although HSUM themes were consistent for both mammography and breast MRI, participants did highlight several important differences in barriers and facilitators between the two screening modalities. CONCLUSION: Barriers and enabling factors associated with supplemental screening for high-risk women represent possible intervention targets. Future research is needed to develop and test multilevel interventions targeting these factors, with the ultimate goal of increasing access to supplemental screening for high-risk women.

Strategies for Identifying and Recruiting Women at High Risk for Breast Cancer for Research Outside of Clinical Settings: Observational Study.

BACKGROUND: Research is needed to understand and address barriers to risk management for women at high (≥20% lifetime) risk for breast cancer, but recruiting this population for research studies is challenging. OBJECTIVE: This paper compares a variety of recruitment strategies used for a cross-sectional, observational study of high-risk women. METHODS: Eligible participants were assigned female at birth, aged 25-85 years, English-speaking, living in the United States, and at high risk for breast cancer as defined by the American College of Radiology. Individuals were excluded if they had a personal history of breast cancer, prior bilateral mastectomy, medical contraindications for magnetic resonance imaging, or were not up-to-date on screening mammography per American College of Radiology guidelines. Participants were recruited from August 2020 to January 2021 using the following mechanisms: targeted Facebook advertisements, Twitter posts, ResearchMatch (a web-based research recruitment database), community partner promotions, paper flyers, and community outreach events. Interested individuals were directed to a secure website with eligibility screening questions. Participants self-reported method of recruitment during the eligibility screening. For each recruitment strategy, we calculated the rate of eligible respondents and completed surveys, costs per eligible participant, and participant demographics. RESULTS: We received 1566 unique responses to the eligibility screener. Participants most often reported recruitment via Facebook advertisements (724/1566, 46%) and ResearchMatch (646/1566, 41%). Community partner promotions resulted in the highest proportion of eligible respondents (24/46, 52%), while ResearchMatch had the lowest proportion of eligible respondents (73/646, 11%). Word of mouth was the most cost-effective recruitment strategy (US $4.66 per completed survey response) and paper flyers were the least cost-effective (US $1448.13 per completed survey response). The demographic characteristics of eligible respondents varied by recruitment strategy: Twitter posts and community outreach events resulted in the highest proportion of Hispanic or Latina women (1/4, 25% and 2/6, 33%, respectively), and community partner promotions resulted in the highest proportion of non-Hispanic Black women (4/24, 17%). CONCLUSIONS: Although recruitment strategies varied in their yield of study participants, results overall support the feasibility of identifying and recruiting women at high risk for breast cancer outside of clinical settings. Researchers must balance the associated costs and participant yield of various recruitment strategies in planning future studies focused on high-risk women.

Self-reported barriers to screening breast MRI among women at high risk for breast cancer.

BACKGROUND: Annual screening breast MRI is recommended for women at high (≥ 20% lifetime) breast cancer risk, but is underutilized. Guided by the Health Services Utilization Model (HSUM), we assessed factors associated with screening breast MRI among high-risk women. METHODS: From August 2020-January 2021, we recruited an online convenience sample of high-risk women ages 25-85 (N = 232). High-risk was defined as: pathogenic genetic mutation in self or first-degree relative; history of lobular carcinoma in situ; history of thoracic radiation; or estimated lifetime risk ≥ 20%. Participants self-reported predisposing factors (breast cancer knowledge, health locus of control), enabling factors (health insurance type, social support), need factors (perceived risk, screening-supportive social norms, provider recommendation), and prior receipt of screening breast MRI. Multivariable logistic regression analysis with backward selection identified HSUM factors associated with receipt of screening breast MRI. RESULTS: About half (51%) of participants had received a provider recommendation for screening breast MRI; only 32% had ever received a breast MRI. Breast cancer knowledge (OR = 1.15, 95% CI = 1.04-1.27) and screening-supportive social norms (OR = 2.21, 95% CI = 1.64-2.97) were positively related to breast MRI receipt. No other HSUM variables were associated with breast MRI receipt (all p's > 0.1). CONCLUSIONS: High-risk women reported low uptake of screening breast MRI, indicating a gap in guideline-concordant care. Breast cancer knowledge and screening-supportive social norms are two key areas to target in future interventions. Data were collected during the COVID-19 pandemic and generalizability of results is unclear. Future studies with larger, more heterogeneous samples are needed to replicate these findings.

NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

Quantitative Measures of Background Parenchymal Enhancement Predict Breast Cancer Risk.

BACKGROUND. Higher categories of background parenchymal enhancement (BPE) increase breast cancer risk. However, current clinical BPE categorization is subjective. OBJECTIVE. Using a semiautomated segmentation algorithm, we calculated quantitative BPE measures and investigated the utility of individual features and feature pairs in significantly predicting subsequent breast cancer risk compared with radiologist-assigned BPE category. METHODS. In this retrospective case-control study, we identified 95 women at high risk of breast cancer but without a personal history of breast cancer who underwent breast MRI. Of these women, 19 subsequently developed breast cancer and were included as cases. Each case was age matched to four control patients (76 control patients total). Sociodemographic characteristics were compared between the cases and matched control patients using the Mann-Whitney U test. From each dynamic contrast-enhanced MRI examination, quantitative fibroglandular tissue and BPE measures were computed by averaging enhancing voxels above enhancement ratio thresholds (0-100%), totaling the enhancing volume above thresholds (BPE volume in cm3), and estimating the percentage of enhancing tissue above thresholds relative to total breast volume (BPE%) on each gadolinium-enhanced phase. For the 91 imaging features generated, we compared predictive performance using conditional logistic regression with 80:20 hold-out cross validation and ROC curve analysis. ROC AUC was the figure of merit. Sensitivity, specificity, PPV, and NPV were also computed. All feature pairs were exhaustively searched to identify those with the highest AUC and Youden index. A DeLong test was used to compare predictive performance (AUCs). RESULTS. Women subsequently diagnosed with breast cancer were more likely to have mild, moderate, or marked BPE (odds ratio, 3.0; 95% CI, 0.9-10.0; p = .07). According to ROC curve analysis, a BPE category threshold greater than minimal resulted in a maximized AUC (0.62) in distinguishing cases from control patients. Compared with BPE category, the first gadolinium-enhanced (phase 1) BPE% at the 30% and 40% enhancement ratio thresholds yielded significantly higher AUC values of 0.85 (p = .0007) and 0.84 (p = .0004), respectively. Feature combinations showed similar AUC values with improved sensitivity. CONCLUSION. Preliminary data indicate that quantitative BPE measures may outperform radiologist-assigned category in breast cancer risk prediction. CLINICAL IMPACT. Future risk prediction models that incorporate quantitative measures warrant additional investigation.

Distribution of Estimated Lifetime Breast Cancer Risk Among Women Undergoing Screening Mammography.

OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.

Performance of Screening Breast MRI After Negative Full-Field Digital Mammography Versus After Negative Digital Breast Tomosynthesis in Women at Higher Than Average Risk for Breast Cancer.

OBJECTIVE: The objective of our study was to compare the supplemental cancer yield and performance of breast MRI in women at higher-than-average risk for breast cancer after negative 2D full-field digital mammography (FFDM) or negative digital breast tomosynthesis (DBT). MATERIALS AND METHODS: Retrospective review identified 4418 screening breast MRI examinations: 2291 were performed from January 2010 through January 2012 of patients with a negative FFDM examination in the 12 months before MRI (FFDM group), and 2127 were performed from January 2013 through January 2015 of patients with a negative DBT examination in the 12 months before MRI (DBT group). Screening indications included genetic predisposition, personal history of breast cancer or high-risk lesion, prior chest irradiation, family history, or other risk factors conferring a lifetime risk of greater than 20%. Supplemental cancer detection rate (CDR), abnormal interpretation rate (AIR), and positive predictive values (PPVs) were estimated with 95% exact CIs. Logistic regression analysis, adjusting for differences in patient demographics, was used to compare metrics. RESULTS: There was no significant difference in the CDR of MRI in the FFDM group versus the DBT group (11 vs 16 cancers per 1000 examinations, respectively; odds ratio, 1.4; 95% CI, 0.4-1.2; p = 0.23). The AIR, PPV1, PPV2, and PPV3 were 7.4%, 15%, 23%, and 28% for the FFDM group and 7.3%, 22%, 33%, and 35% for the DBT group, with no statistical differences. Of the cancers detected in both groups, the majority were invasive, less than 1 cm, and node-negative. CONCLUSION: In women at higher-than-average risk of breast cancer screened with DBT, the supplemental CDR of MRI is similar to that of MRI after FFDM screening, with most cancers being invasive, subcentimeter, and node-negative.

Breast Cancer Screening and Diagnosis, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis have been developed to facilitate clinical decision making. This manuscript discusses the diagnostic evaluation of individuals with suspected breast cancer due to either abnormal imaging and/or physical findings. For breast cancer screening recommendations, please see the full guidelines on NCCN.org.

Utility of Breast MRI for Further Evaluation of Equivocal Findings on Digital Breast Tomosynthesis.

OBJECTIVE: The purpose of this study is to evaluate the utility of MRI as a problem-solving tool for equivocal findings on diagnostic digital mammography (DM) and digital breast tomosynthesis (DBT). MATERIALS AND METHODS: Breast MRI examinations performed from March 2011 to November 2014 were retrospectively reviewed to identify those examinations that were performed to further assess equivocal findings on combined DM and DBT (DM/DBT) examinations. All patients underwent diagnostic ultrasound in conjunction with their DM/DBT examination. Imaging reports were retrospectively reviewed for BI-RADS findings and assessments of diagnostic DM/DBT and diagnostic MRI examinations. A review of the electronic medical records provided information on demographic data, cancer diagnoses, and pathologic findings. Differences in the positive predictive values and negative predictive values of DM/DBT and MRI were compared using a generalized estimating equation for correlated binary data. RESULTS: Of 5330 MRI examinations performed during the study, 67 (1%) were performed for evaluation of an equivocal finding, including 27 asymmetries (40%), 16 focal asymmetries (24%), five masses (7%), and 19 architectural distortion (28%). MRI correlates were identified in 22 of 67 examinations (33%). Biopsies yielded a cancer diagnosis for five of 67 patients (7%). For MRI, the positive predictive value and negative predictive value were 19% and 98%, respectively, whereas for DM/DBT they were 6% and 90%, respectively (p = 0.009 and p = 0.059, respectively). The frequency of recommendations for breast MRI to evaluate equivocal findings decreased exponentially in the 3 years after DBT implementation. CONCLUSION: As clinical implementation of DBT becomes increasingly widespread, breast radiologists need an algorithm for addressing the small number of inconclusive findings that remain equivocal despite thorough DM/DBT and ultrasound examinations. Breast MRI is a useful adjunctive tool for these selected cases.

Screening for Breast Cancer in Women Age 75 Years and Older.

OBJECTIVE: Older women undergoing regular mammography experience significant reductions in breast cancer mortality, except in women with severe comorbidities or limited life expectancy. Optimizing screening strategies requires informed discussions of benefits and risks given each woman's health status. CONCLUSION: This article will review the benefits and risks of screening mammography in women older than 75 years within the context of life expectancy and comorbidities and summarize the current recommendations from professional organizations for screening mammography in older women.

Screening Mammography: Patient Perceptions and Preferences Regarding Communication of Estimated Breast Cancer Risk.

OBJECTIVE: Many models exist to estimate a woman's risk of development of breast cancer. At screening mammography, many imaging centers collect data required for these models to identify women who may benefit from supplemental screening and referral for cancer risk assessment. The purpose of this study was to discern perceptions and preferences of screening mammography patients regarding communication of estimated breast cancer risk. SUBJECTS AND METHODS: An anonymous survey was distributed to screening and surveillance mammography patients between April and June 2015. Survey questions were designed to assess patient preferences regarding the receipt and complexity of risk estimate communication, including hypothetical scenarios with and without > 20% estimated risk of breast cancer. The McNemar test and the Wilcoxon signed rank test were used with p ≤ 0.05 considered statistically significant. RESULTS: The survey was distributed to 1061 screening and surveillance mammography patients, and 503 patients responded (response rate, 47%). Although 86% (431/503) of patients expressed interest in learning their estimated risk, only 8% (38/503) had undergone formal risk assessment. The preferred method (241 respondents [26%]) of communication of risk < 20% was a mailed letter accompanying annual mammogram results. For risk > 20%, patients preferred oral communication and were 10-fold as likely to choose only oral communication (p < 0.000001). For risk < 20% and > 20%, patients preferred to learn their estimated risk in great detail (69% and 85%), although women were significantly more likely to choose greater detail for risk > 20% (p < 0.00001). CONCLUSION: Screening mammography patients expressed interest in learning their estimated risk of breast cancer regardless of their level of hypothetical risk.

Extramammary Findings on Breast MR Examinations: Frequency, Clinical Relevance, and Patient Outcomes.

PURPOSE: To evaluate the frequency of extramammary findings on breast magnetic resonance (MR) images, recommendations for further imaging evaluation of each finding, and the subsequent effect on patient outcomes and health care expenditures. MATERIALS AND METHODS: Institutional review board approval was acquired for this HIPAA-compliant study. Informed consent was waived. Review of the institutional database identified 2324 breast MR examinations performed in women from January 1, 2010, to December 31, 2010. Breast MR imaging reports were reviewed for extramammary findings. Extramammary findings were categorized by using the computed tomography (CT) colonography reporting and data system (C-RADS). The electronic medical record was reviewed for each patient with a C-RADS category E3 and E4 finding to assess clinical relevance and pathologic outcome. If an E3 or E4 finding was previously described and evaluated, the finding was downgraded and assigned a final C-RADS E2 category. The cost of additional imaging was estimated by using the Medicare physician fee schedule. Statistical significance was assessed by using χ(2) statistics. A P value less than .05 indicated statistical significance, and 95% exact confidence intervals (CIs) were constructed. RESULTS: Extramammary findings were identified in 391 of 2324 breast MR examinations (16.8%), which included 105 patients (4.5%) with E3 or E4 findings. Of the 2324 patients, 86 patients (3.7% [95% CI: 3.0%, 4.5%]) were recommended to undergo further imaging. After undergoing evaluation for additional imaging, a clinically important finding was found in nine patients (0.4% [95% CI: 0.2%, 0.7%]). Most frequently, hepatic lesions were the indication for additional imaging. Abdominal MR examinations accounted for 55% of costs related to additional imaging. Averaged across the entire cohort, further imaging evaluation and follow-up of incidental findings contributed an additional $16 to each breast MR imaging performed. CONCLUSION: Additional imaging evaluation for E3 and E4 extramammary findings at breast MR imaging can identify clinically important disease without substantially increasing cost. .

Prospective analysis of an interprofessional team training program using high-fidelity simulation of contrast reactions.

OBJECTIVE: Successful management of a contrast reaction requires prompt recognition and treatment and effective team dynamics among radiologists, technologists, and nurses. A radiology department implemented a simulation program in which teams of nurses, technologists, and physicians managed simulated contrast reactions. The purpose of this study was to evaluate whether simulation improved the participants' abilities to manage a contrast reaction and work in a team during an emergency. SUBJECTS AND METHODS: Physicians, nurses, and technologists worked in inter-professional teams to manage two high-fidelity simulated adverse contrast reactions. Participants completed surveys before and after the simulation that included knowledge-based questions about the appropriate management of contrast reactions. Surveys also included questions for assessing participants' perceptions of their ability to manage adverse contrast reactions, measured with a 6-point Likert scale. Before and after comparisons were made with the McNemar test with a Bonferroni correction requiring p ≤ 0.003 for significance. For the other analyses, p ≤ 0.05 was considered significant. RESULTS: After completion of the simulation exercises, participants had significant improvement in knowledge (p < 0.001). After the simulation, participants reported significant improvement in their ability to manage an anaphylactoid reaction and their ability to work in a team (p < 0.00001). Participants requested repeat simulation exercises every 6-12 months. CONCLUSION: Simulation exercises improved the self-reported ability of radiology personnel to manage contrast reactions and work in a team during an emergency. Simulation should be incorporated into future educational initiatives to improve patient safety in radiology practices.

Patient outcomes in canceled MRI-guided breast biopsies.

OBJECTIVE: The reported frequency of aborted MRI-guided breast biopsies ranges from 8% to 17%, usually secondary to nonvisualization at attempted biopsy. Our study examines the frequency of MRI-guided breast biopsies aborted because of lesion nonvisualization and the subsequent risk of malignancy. MATERIALS AND METHODS: We identified 350 patients and 445 lesions scheduled for MRI-guided biopsy between January 1, 2007, and December 31, 2009. Medical records and imaging studies were reviewed to ascertain patient demographics, lesion and imaging characteristics, and subsequent pathology results. Chi-square statistics were calculated for patient level analyses. RESULTS: MRI-guided biopsies were aborted in 13% (56/445) of lesions and 15% (53/350; 95% CI, 11.6-19.3%) of patients because of nonvisualization of the biopsy target at the time of attempted biopsy. Of these 53 patients, 50 patients had follow-up data available. Malignancy was subsequently diagnosed in five of those 50 patients (10%; 95% CI, 3.3-21.8%), three with invasive ductal carcinomas and two with ductal carcinoma in situ. The mean time to malignant diagnosis from the date of aborted biopsy was 2.6 months (range, 1.1-6.9 months). CONCLUSION: Informed consent for MRI-guided breast biopsies should include discussion of biopsy cancellation because of nonvisualization of the target lesion. The low yet significant risk of malignancy in patients subsequent to an aborted MRI-guided breast biopsy warrants short-term follow-up MRI after a canceled biopsy.

ACR Appropriateness Criteria® Female Breast Cancer Screening: 2023 Update.

Early detection of breast cancer from regular screening substantially reduces breast cancer mortality and morbidity. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are the recommended method for breast cancer screening in all risk categories. In addition to the recommendation of mammography and digital breast tomosynthesis in high-risk patients, screening with breast MRI is recommended. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Current Practices in Anticoagulation Management for Patients Undergoing Percutaneous Image-guided Breast Procedures.

Objective: Given variability in how practices manage patients on antithrombotic medications, we undertook this study to understand the current practice of antithrombotic management for patients undergoing percutaneous breast and axillary procedures. Methods: A 20-item survey with multiple-choice and write-in options was emailed to 2094 active North American members of the Society of Breast Imaging (SBI) in March 2021. Data were collected anonymously and analyzed quantitatively, with free-text responses categorized by themes. Results: Three-hundred twenty-six of 2094 members (15.6%) completed the survey. Eighty-seven percent (274/313) reported having a policy for managing antithrombotic medications. Fifty-nine percent (185/312) reported routinely withholding medications before biopsy, more commonly in the Northeast and South (P = 0.08). Withholding of medications did not vary by lesion location (182/308, 59%, breast vs 181/308, 58.7%, axillary; P = 0.81). Respondents were statistically more likely to withhold medications if using a vacuum-assisted device for all classes of antithrombotic medications (P < 0.001). Up to 50.2% (100/199) on warfarin and 33.6% (66/196) on direct oral anticoagulants had medications withheld more stringently than guidelines suggest. Conclusion: Based on a survey of SBI members, breast imaging practices vary widely in antithrombotic management for image-guided breast and axillary procedures. Of the 60% who withhold antithrombotic medications, a minority comply with recommended withhold guidelines, placing at least some patients at potential risk for thrombotic events. Breast imaging radiologists should weigh the risks and benefits of withholding these medications, and if they elect to withhold should closely follow evidence-based guidelines to minimize the risks of this practice.

ACR Appropriateness Criteria® Breast Implant Evaluation: 2023 Update.

This document discusses the appropriate initial imaging in both asymptomatic and symptomatic patients with breast implants. For asymptomatic patients with saline implants, no imaging is recommended. If concern for rupture exists, ultrasound is usually appropriate though saline rupture is often clinically evident. The FDA recently recommended patients have an initial ultrasound or MRI examination 5 to 6 years after initial silicone implant surgery and then every 2 to 3 years thereafter. In a patient with unexplained axillary adenopathy with current or prior silicone breast implants, ultrasound and/or mammography are usually appropriate, depending on age. In a patient with concern for silicone implant rupture, ultrasound or MRI without contrast is usually appropriate. In the setting of a patient with breast implants and possible implant-associated anaplastic large cell lymphoma, ultrasound is usually appropriate as the initial imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.