Yield of MR-directed US for MRI-detected breast findings: how often can we avoid MR biopsy?

PURPOSE: To evaluate the yield of MR-directed ultrasound for MRI detected breast findings. METHODS: This retrospective study included 857 consecutive patients who had a breast MRI between January 2017-December 2020 and received a BI-RADS 4 assessment. Only exams recommended for MR-directed ultrasound were included in the study, yielding 765 patients. Findings were characterized by presence or absence of a sonographic correlate. Utilizing the electronic medical record, for those with a sonographic correlate, the size, location, and morphology were noted. Imaging guided (Ultrasound and MRI) pathology results as well as excisional pathology results were recorded. A multivariable logistical regression analysis was used to investigate the clinical utility of MR-directed ultrasound. RESULTS: There were 1262 MRI-detected BI-RADS category 4 findings in 765 patients. Of the 1262 findings, MR-directed ultrasound was performed on 852 (68 %). Of these, 291/852 (34 %) had an ultrasound correlate, including 143/291 (49 %) benign lesions, 81/291 (28 %) malignant lesions, 16/291 (5 %) with high-risk pathology and 51/291 (18 %) unknown due to lost to follow-up. Of those findings with ultrasound correlates, 173/291 (59 %) represented masses, 69/291 (24 %) were regions of non-mass enhancement, 22/291 (7.6 %) were foci and 27/291 (9.3 %) fell into the category of other which included lymph node, cysts, and scar tissue. Masses were significantly more likely to be identified on MR-directed ultrasound (p < 0.0001) compared to foci. CONCLUSION: The yield of MR-directed ultrasound is significantly higher for masses, than foci and non-mass enhancement, which should be taken into consideration when recommending an MR-directed ultrasound.

Breast Imaging Fellowship Virtual Interviews: The Program Director's Perspective.

OBJECTIVE: To evaluate breast imaging fellowship program directors' perspectives on the virtual interview process. METHODS: A 20-question survey constructed by members of the Fellowship Match Committee of the Society of Breast Imaging was distributed to all 99 breast imaging program directors registered with the Society. An initial e-mail with a link to the survey was distributed on September 9, 2022, and the survey was closed on October 1, 2022. Results were compiled and a descriptive statistical analysis was performed utilizing Microsoft Excel. RESULTS: There were 63 total responses (63/99, 64% response rate). There was a wide distribution in both the number of applications received and the number of interviews each program offered. Just under a fifth (12/63, 19%) of programs received 1 to 5 applications, whereas a quarter (16/63, 25%) received over 40 applications. In contrast, over a quarter (17/63, 27%) of programs interviewed 1 to 5 applicants, and only a small number (3/63, 5%) interviewed over 40 applicants. When reporting what worked best with the virtual interview process, the responses fell into the following 4 categories: efficiency, flexibility, virtual format, or other. When reporting what did not work well, the most common response (14/37, 38%) was conveying the atmosphere of the program in the virtual setting. CONCLUSION: This study provides an assessment of the virtual interview experience from the perspective of breast imaging fellowship programs, which may be useful in optimizing future interview experiences for programs and applicants.

Thriving In and Out of the Reading Room: A Faculty Development Workshop.

RATIONALE AND OBJECTIVES: Given the immense time and energy radiologists dedicate to their profession, the experience at work should be a major contributor to a meaningful and fulfilling life. In pursuit of this vision, our department launched a novel faculty development workshop entitled "Thriving In and Out of the Reading Room: What They Didn't Teach Us in Training." We report on the design, implementation and initial outcomes of this faculty development workshop. MATERIALS AND METHODS: The workshop drew upon positive psychology research and the PERMA model of well-being, which encompasses five key elements: Positive emotion, Engagement, Relationships, Meaning, and Achievement. These elements have been shown to enhance work satisfaction and foster resilience. Using interactive, small group exercises, the workshop provided strategies for incorporating PERMA elements into daily life. At the conclusion of each workshop, an anonymous voluntary electronic survey was distributed to participants. RESULTS: The final version of the workshop was offered to 58 faculty over eight sessions between September 2022 and May 2023. Survey results indicate that participants found the workshop to be highly valuable and practical. They also found the workshop to promote camaraderie and peer learning. Developing the workshop internally allowed us to customize it to our faculty's unique experiences and engage a large number of participants. CONCLUSION: The workshop shows promise in improving job satisfaction and addressing burnout among academic radiologists.

Bleeding Events After Image-Guided Breast Biopsies: Comparison of Patients Temporarily Discontinuing Versus Maintaining Antithrombotic Therapy During Biopsy.

BACKGROUND. Antithrombic (AT) therapy is commonly temporarily discontinued before breast core needle biopsy (CNB), introducing risks of thrombotic events and diagnostic delay. OBJECTIVE. The purpose of this article was to compare the frequency of postbiopsy bleeding events among patients without AT use, patients temporarily discontinuing AT therapy, and patients maintaining AT therapy during breast CNB. METHODS. This retrospective study included 5302 patients (median age, 52 years) who underwent image-guided breast or axillary CNB between January 1, 2014, and December 31, 2019. From January 1, 2014, to December 31, 2016, patients temporarily discontinued all AT therapy for 5 days before CNB; from January 1, 2017, to December 31, 2019, patients maintained AT therapy during CNB. Immediate postbiopsy mammograms were reviewed for imaging-apparent hematoma. Patients were called 24-48 hours after biopsy and asked regarding palpable hematoma and breast bruise. The EMR was reviewed for clinically significant postbiopsy hematoma (i.e., hematoma requiring drainage, primary care or emergency department visit for persistent symptoms, or hospital admission). Bleeding events were compared among groups, including Firth bias-reduced multivariable logistic regression analysis. RESULTS. During CNB, 4665 patients were not receiving AT therapy, 423 temporarily discontinued AT therapy, and 214 maintained AT therapy. Imaging-apparent hematoma occurred in 3% of patients without AT use, 6% of patients discontinuing AT therapy, and 7% of patients maintaining AT therapy (p = .60 [discontinuing vs maintaining]). Palpable hematoma occurred in 2% of patients without AT use, 4% of patients maintaining AT therapy, and 4% of patients discontinuing AT therapy (p = .92 [discontinuing vs maintaining]). Breast bruise occurred in 2% of patients without AT use, 1% of patients discontinuing AT therapy, and 6% of patients maintaining AT therapy (p < .001 [discontinuing vs maintaining]). In multivariable analysis adjusting for age, biopsy imaging modality, needle gauge, number of biopsy samples, and pathologic result, discontinued AT therapy (using maintained AT therapy as reference) was not a significant independent predictor of imaging-apparent hematoma (p = .23) or palpable hematoma (p = .91) but independently predicted decreased risk of bruise (OR = 0.11, p < .001). No patient developed clinically significant postbiopsy hematoma. CONCLUSION. Frequencies of imaging-apparent and palpable hematoma were not significantly different between patients temporarily discontinuing versus maintaining AT therapy. CLINICAL IMPACT. The findings support the safety of continuing AT therapy during CNB. Patients who maintain AT therapy should be counseled regarding risk of bruise.

Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain.

With the shift of the healthcare system toward patient-centered, value-based care, the role of the breast radiologist is essential and increasingly multifaceted. Beyond sole image interpreters, breast radiologists serve as subject matter experts within multidisciplinary care teams, acting as advocates and initiators into the healthcare system and providing patient-centered care through effective communication and patient education. These vital roles are well demonstrated through the imaging evaluation and management of the most common breast symptom that affects the majority of the patient population-mastalgia. By leveraging the opportunities provided during the evaluation of the symptomatic breast to optimize patient communication and education, as well as integration of care delivery, breast radiologists add significant value to patient care and ultimately improve patient outcomes.

State of Communication Training During the Breast Imaging Fellowship Year.

OBJECTIVE: The purpose of this study was to survey breast imaging fellowship programs nationally on the state of communication skills training during fellowship training. METHODS: In this IRB-exempt study, fellowship program director members of the Society of Breast Imaging (SBI) were anonymously surveyed on current provision and types of communication skills training in their fellowship curricula. RESULTS: A six-question survey was sent to all 95 SBI member fellowship program directors with a response rate of 56% (53/95). Although direct fellow patient-centered communication interactions are practiced across all respondent training programs, formal communication skills training was offered in a minority of programs with 32% (17/53) providing formal communication in the form of a didactic lecture and 17% (9/53) engaging fellows in a simulation communication skills workshop. Of the 53 programs, 12 (22%) reported no formal communication skills training of any kind, while a majority (44/53, 83%) of programs provide regular feedback based on observed fellow-patient communication interactions. CONCLUSION: Despite nearly uniform practice of engaging breast imaging fellows in direct patient-centered interaction at the onset of the fellowship training year, the majority of fellowship programs do not provide any formal communication skills training curricula at any point during fellowship training. To equip future breast radiologists with the skills to provide value in an increasingly patient-centered field, dedicated formal communication curricula ought to be incorporated consistently into breast imaging fellowship training programs.

Impact of the COVID-19 breast cancer screening hiatus on clinical stage and racial disparities in New York City.

BACKGROUND: The impact of the COVID-19 mammography screening hiatus as well as of post-hiatus efforts promoting restoration of elective healthcare on breast cancer detection patterns and stage distribution is unknown. METHODS: Newly diagnosed breast cancer patients (2019-2021) at the New York Presbyterian (NYP) Hospital Network were analyzed. Chi-square and student's t-test compared characteristics of patients presenting before and after the screening hiatus. RESULTS: A total of 2137 patients were analyzed. Frequency of screen-detected and early-stage breast cancer declined post-hiatus (59.7%), but returned to baseline (69.3%). Frequency of screen-detected breast cancer was lowest for African American (AA) (57.5%) and Medicaid patients pre-hiatus (57.2%), and this disparity was reduced post-hiatus (65.3% for AA and 63.2% for Medicaid). CONCLUSIONS: The return to baseline levels of screen-detected cancer, particularly among AA and Medicaid patients suggest that large-scale breast health education campaigns may be effective in resuming screening practices and in mitigating disparities.

Virtual Interviews for Breast Imaging Fellowship During the COVID-19 Pandemic: Perspectives of Program Directors and Applicants.

OBJECTIVE: To compare in-person and virtual breast fellowship interview experiences from the perspective of fellowship program directors (PDs) and applicants. METHODS: Three separate voluntary, anonymous, e-mail delivered surveys were developed for PDs, in-person interview applicants in 2019-2020, and virtual interview applicants in 2020-2021. PD and applicant survey responses regarding the two interview cycles were compared. RESULTS: The response rate was 56% (53/95) for PDs, 19% (23/123) for in-person applicants, and 38% (49/129) for virtual applicants. PDs reported significantly lower cost for virtual compared to in-person interviews (P < 0.001). They reported no significant difference in number of applications received, number of applicants interviewed, applicant pool geographic regions, number of interview days offered, or format of interviews. Most PDs (31/53, 58%) felt the virtual format still allowed them to get to know the applicants well. Cost was significantly higher for in-person compared to virtual applicants (P < 0.001). More in-person applicants (11/23, 48%) listed cost as a barrier compared to virtual applicants (7/49, 14%) (P = 0.002). Virtual and in-person applicants reported a similar number of program applications, but virtual applicants completed more interviews (P = 0.012). Both groups preferred scheduled time to speak with the current fellows and a one-on-one interview format with two to four faculty members. Most applicants (36/49, 73%) felt the virtual format still allowed them to get to know each program well. CONCLUSION: Virtual interviews provide a reasonable alternative to in-person interviews for breast imaging fellowship applicants, with decreased cost being the main advantage.

The American College of Radiology/Society of Breast Imaging Updated Fellowship Training Curriculum for Breast Imaging.

Since the publication of the most recent breast imaging resident and fellowship curriculum in 2013, there have been widespread changes to the field of breast imaging. Screen-film mammography has been nearly completely replaced, and there has been widespread adoption of breast MRI and digital breast tomosynthesis. Fellowship training programs are increasingly one year in length, which accommodates the rapidly evolving subspecialized field of breast imaging. Recent surveys have identified deficits in nonclinical training related to patient communication and practice audits. This updated fellowship curriculum focuses on four discrete skill sets: clinical, noninterpretive, collaborative, and scholarly. Updates to the clinical curriculum include familiarity with new and emerging imaging technologies and biopsy techniques, as well as a more comprehensive understanding of breast pathology and appropriate follow-up and/or treatment recommendations. There is an increased focus on noninterpretive skills related to the practice audit and quality control. A formal communication curriculum tailored toward discussions with patients is highly recommended. The collaborative value of multidisciplinary care and the benefits of mentorship are emphasized. Finally, scholarly activities including both the opportunity for teaching and research, as well as dedicated lectures and journal clubs, will establish a platform for lifelong learning. This updated curriculum, which has been approved by the Executive Committee of the American College of Radiology and the Society of Breast Imaging Board of Directors, is designed to develop well-rounded fellowship graduates who are positioned to be breast imaging leaders within their future practices.

Lessons learned: A single academic department's unique approach to preventing physician burnout.

Physician burnout is a recognized problem within medicine and its prevalence appears to be increasing. The symptoms include three major components; exhaustion, depersonalization and feeling a lack of accomplishment. The presence of burnout can have major professional and personal consequences. While there has been much commentary on the impact of burnout, little has been published addressing ways to prevent and resolve the issue. Our department has taken a novel and individualized approach to lower burnout. This includes allowing faculty to personalize their schedules as demonstrated by the perspectives of four breast imaging faculty. We as physicians are as diverse as the patient population we treat which needs to be recognized when addressing solutions to burnout. We propose that most practices and departments can find meaningful ways to allow physicians to increase their sense of autonomy through flexibility and control in scheduling. Having leadership open to unique and sometimes unconventional approaches enables a mutually beneficial culture of respect, productivity, and wellness.

Effect of a communication lecture tutorial on breast imaging trainees' confidence with challenging breast imaging patient interactions.

PURPOSE: The aim of the study was to evaluate the effect of a one-hour lecture based communication curriculum on breast imaging trainees' confidence in communicating with patients in a challenging communication setting such as delivering bad news or radiologic error disclosure. METHODS: 12 breast imaging trainees from an academic fellowship program completed questionnaires before and after a communication tutorial. A four breast imaging specific scenario questionnaire assessed confidence by asking the trainees to rank agreement with statements related to their attitude in those specific settings. 12-month follow-up questionnaire was sent to the graduating fellows assessing their -overall confidence in patient communication, the contribution of the curriculum to their self-perceived communication skill and their likelihood in disclosing a radiologic error to a patient. RESULTS: All trainees completed the pre and post lecture questionnaire. After the communication tutorial, all trainees reported increased confidence in communicating with patients in a variety of challenging settings with pre lecture survey mean confidence score of 38/98 and post lecture survey mean score of 85.3/98, P = 0.003. Three of eight trainees who completed the 12-month follow up questionnaire reported confidence in their communication skills and reported that the tutorial significantly contributed to their communication skill development. All three agreed that they would be likely to disclose a medical error should they encounter it in their future career. CONCLUSIONS: A limited resource one-hour lecture communication tutorial provides effective communication training for breast imaging fellows and is a promising part of a breast imaging curriculum.

Performance of 2D Synthetic Mammography Versus Digital Mammography in the Detection of Microcalcifications at Screening.

OBJECTIVE. The purpose of this study is to compare the performance of 2D synthetic mammography (SM) to that of full-field digital mammography (FFDM) in the detection of microcalcifications and to evaluate radiologists' preference between the two imaging modalities for assessing calcifications. MATERIALS AND METHODS. A fully crossed, mode-balanced, paired-case (n = 160), retrospective, multireader (n = 3) performance study was implemented to compare screening mammograms acquired with digital breast tomosynthesis and both FFDM and SM between 2015 and 2017. The study cohort included 70 patients with mammograms recalled for microcalcifications (35 with malignant findings and 35 with benign findings) and was supplemented with 90 patients with mammograms with negative findings. In separate sessions, readers interpreted SM or FFDM images by recording a BI-RADS assessment and the probability of malignancy. In a final session that included 70 mammograms with microcalcifications, readers recorded their subjective assessment of microcalcification conspicuity and diagnostic confidence. RESULTS. There was no difference in diagnostic accuracy as assessed by comparing the likelihood of malignancy based on the AUC of plotted ROCs, with AUCs of 91% (95% CI, 83-97%) and 88% (95% CI, 79-95%) observed for SM and FFDM, respectively (p = 0.392), and with noninferiority of SM compared with FFDM (p = 0.011). No significant difference was observed between SM and FFDM in terms of sensitivity (77% vs 73%, respectively; p = 0.366) or negative predictive value (84% vs 82%, respectively; p = 0.598). The specificity and positive predictive value of SM were lower than those of FFDM (91% vs 98%, respectively [p = 0.034], and 87% vs 96%, respectively [p = 0.034]). All readers found calcifications to be more conspicuous on SM (p < 0.0001); however, no significant difference in subjective diagnostic confidence was seen. CONCLUSION. SM is noninferior to FFDM in the detection of microcalcifications. Despite the increased conspicuity of microcalcifications on SM, the subjective diagnostic confidence in the two modalities is comparable.

Assessing the Positive Predictive Value of Architectural Distortion Detected with Digital Breast Tomosynthesis in BI-RADS 4 Cases.

OBJECTIVE: The purpose of this study was to evaluate the positive predictive value of biopsy (PPV3) of architectural distortion (AD) detected on digital breast tomosynthesis (DBT) in BI-RADS 4 cases, where suspicion for malignancy remains broad. METHODS: This Institutional Review Board-approved, retrospective study included screening and diagnostic mammograms performed from August 2015 to December 2017 with DBT and digital mammography (DM) revealing suspicious AD with a BI-RADS 4 assessment. Medical records were reviewed for clinical data, imaging, and pathology results. Malignancy rate was assessed by lesion visibility on DM and DBT. Multivariate analysis was performed to assess the odds ratio (OR) of malignancy. RESULTS: A total of 63/179 cases were malignant, yielding a PPV3 of 35%. No significant difference in PPV3 was found by race, personal or family history of breast cancer, presence of microcalcifications, or mammogram type. Architectural distortion was more likely to be malignant when an US correlate was present (PPV3 49% vs 19%; P < 0.0001). Multivariate analysis demonstrated a 3-fold increased OR for malignancy with an US correlate present (P = 0.005). Lesion visibility analysis revealed a higher PPV3 for AD visible on DM-DBT compared with DBT alone (44% vs 26%; P = 0.01) and when an US correlate was present (DM-DBT 54% vs 30%, P = 0.02; DBT-only 43% vs 11%, P < 0.001). CONCLUSIONS: Tomosynthesis-detected BI-RADS 4 AD are malignant in 35% of cases and are more likely to be malignant if an US correlate is present and if visible on both DM and DBT.

Breast Imaging Fellowship Match: Applicants' Perspectives of Years Two and Three.

OBJECTIVE: The purpose of this study is to summarize the results of a survey distributed by the Society of Breast Imaging (SBI) to assess applicants' experience with the 2018 and 2019 Breast Imaging Fellowship Match process. METHODS: In this institutional review board-exempt study, the SBI issued an anonymous survey to all matched applicants in an attempt to gauge their experience with the 2018 and 2019 Match process. RESULTS: The survey was sent to all 2018 and 2019 matched applicants and 105/236 (45%) responses were received. The majority (75%, 79/105) of respondents reported a positive experience with the Match, with at least a 4/5 rating, and only 3% (5/105) reported a rating below 3/5. There was some improvement in 2019, with 86% (24/28) of respondents reporting at least a 4/5 rating compared to 71% (55/77) in 2018. No respondent reported a score below a 3/5 rating in 2019. The most commonly cited issues with the Match were the timing of the Match process, the need for a universal application, and the burden of travel. Location and program reputation were the two most important factors contributing to the final rank order of programs. CONCLUSION: The great majority of applicants felt that the Match created a positive experience. Planned areas of improvement include the implementation of a universal application, the transition to virtual interviews, and a condensed timeline. These measures are likely to increase applicant satisfaction and provide a fair and efficient experience for future breast radiologists.

Accuracy of Synthetic 2D Mammography Compared With Conventional 2D Digital Mammography Obtained With 3D Tomosynthesis.

OBJECTIVE. The purpose of this study was to compare the diagnostic performance of synthetic 2D imaging generated from 3D tomosynthesis (DBT) with traditional 2D full-field digital mammography (FFDM) by use of the most up-to-date software algorithm in an urban academic radiology practice. MATERIALS AND METHODS. The records of patients undergoing screening mammography with DBT, synthetic 2D imaging, and FFDM between August 13, 2014, and January 31, 2016, were retrospectively collected. The cohort included all biopsy-proven breast cancers detected with screening mammography during the study period (n = 89) and 100 cases of negative or benign (BI-RADS category 1 or 2) findings after 365 days of follow-up. In separate sessions, three readers blinded to outcome reviewed DBT plus synthetic 2D or DBT plus FFDM screening mammograms and assigned a BI-RADS category and probability of malignancy to each case. The diagnostic performance of each modality was assessed by calculating sensitivity and specificity. Reader performance was assessed by ROC analysis to estimate the AUC of the likelihood of malignancy. RESULTS. No statistically significant difference was found in diagnostic accuracy (sensitivity, specificity, positive predictive value, or negative predictive value) between DBT plus synthetic 2D mammography and DBT plus FFDM. There was no statistically significant difference between the AUC of DBT plus synthetic 2D mammography and the AUC of DBT plus FFDM for any reader. CONCLUSION. DBT plus synthetic 2D mammography performs as well as and not worse than DBT plus FFDM in measures of diagnostic accuracy and may be a viable alternative for decreasing radiation dose without sacrificing diagnostic performance.

Breast Imaging Fellowship Match: Program Directors' Perspectives in Year Two.

OBJECTIVE: The purpose of this study was to summarize the results of a survey distributed by the Society of Breast Imaging to assess Breast Imaging programs' experience with the second year of the Breast Imaging Fellowship Match process. METHODS: In July 2018, the Society of Breast Imaging sent out an anonymous 11-question survey to all Breast Imaging programs in attempts to gauge their experience with the previous Match cycle. The survey included dichotomous questions and Likert-scaled questions. Follow-up to several questions allowed for unstructured free text responses. In this institutional review board-exempt study, responses were then summarized and categorized into appropriate categories. RESULTS: The survey was sent to 88 program coordinators and 90 program directors of the 89 existing programs. In total, 66 responses from program directors were received, representing 74.2% of the existing programs. The majority (68%) of programs reported a positive experience with participation in the Match (at least 4/5 stars). The most commonly cited issues with the Match were interview dates/timeline, programs participating outside of the Match, and need for a universal application. Eighty-four percent of programs stated that they were planning on participating in the Match for the upcoming application cycle, with 11% undecided and 5% stating they were not planning on participating. CONCLUSIONS: Despite recognized areas for improvement, the great majority of programs felt that the Match is an improvement over the prior application process and that it significantly improved the experience for the applicants.

Evaluation of Palpable Breast Abnormalities.

A palpable breast abnormality is one of the most common presenting clinical breast complaints. Although the majority of palpable abnormalities are benign, they are among the most common presenting symptoms of breast cancer, and those breast cancers detected symptomatically tend to have poorer prognosis than their screen-detected counterparts. Clinical breast examination is a vital part of the workup of palpable abnormalities. However, as physical exam features of most masses are not reliable for categorization of malignancy, imaging evaluation is necessary. Choice of imaging modality, which includes diagnostic mammography and breast ultrasound, is dependent upon patient age. Ultrasound is the primary imaging modality for evaluation of palpable masses in women younger than 30 years of age because of its high negative predictive value and sensitivity and lack of ionizing radiation. For women aged 30-39 years, ultrasound or mammography can be performed as the initial imaging evaluation, with ultrasound maintaining a high sensitivity in women younger than 40 years old. Mammography, often followed by ultrasound, is the recommended imaging evaluation sequence for women aged 40 and older. Utilization of advanced imaging modalities for evaluation of the palpable area of concern is not supported by evidence.