Integration and usability of a digital cancer risk stratification tool to optimize identification of patients at risk for hereditary cancers: A pilot study.

BACKGROUND: Patients with a personal or family history of cancer may have elevated risk of developing future cancers, which often remains unrecognized due to lapses in screening. This pilot study assessed the usability and clinical outcomes of a cancer risk stratification tool in a gynecologic oncology clinic. METHODS: New gynecologic oncology patients were prompted to complete a commercially developed personal and family history-based risk stratification tool to assess eligibility for genetic testing using National Comprehensive Cancer Network criteria and estimated lifetime breast cancer risk using the Tyrer-Cuzick model. After use of the risk stratification tool, usability was assessed via completion rate and the System Usability Scale, and health literacy was assessed using the BRIEF Health Literacy Screening Tool. RESULTS: 130 patients were prompted to complete the risk stratification tool; 93 (72%) completed the tool. Race and ethnicity and insurance type were not associated with tool completion. The median System Usability Scale score was 83 out of 100 (interquartile range, 60-95). Health literacy positively correlated with perceived usability. Public insurance and race or ethnicity other than non-Hispanic White was associated with lower perceived usability. Sixty (65%) patients met eligibility criteria for genetic testing, and 21 (38% of 56 eligible patients) were candidates for enhanced breast cancer screening based on an estimated lifetime breast cancer risk of ≥20%. CONCLUSIONS: A majority of patients completed the digital cancer risk stratification tool. Older age, lower health literacy, public insurance, and race or ethnicity other than non-Hispanic White were associated with lower perceived tool usability.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review.

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

Disparities in genetic testing for breast cancer among black and Hispanic women in the United States.

Women from racial and ethnic minorities are at a higher risk for developing breast cancer. Despite significant advancements in breast cancer screening, treatment, and overall survival rates, disparities persist among Black and Hispanic women. These disparities manifest as breast cancer at an earlier age with worse prognosis, lower rates of genetic screening, higher rates of advanced-stage diagnosis, and higher rates of breast cancer mortality compared to Caucasian women. The underutilization of available resources, such as genetic testing, counseling, and risk assessment tools, by Black and Hispanic women is one of many reasons contributing to these disparities. This review aims to explore the racial disparities that exist in genetic testing among Black and Hispanic women. Barriers that contribute to racial disparities include limited access to resources, insufficient knowledge and awareness, inconsistent care management, and slow progression of incorporation of genetic data and information from women of racial/ethnic minorities into risk assessment models and genetic databases. These barriers continue to impede rates of genetic testing and counseling among Black and Hispanic mothers. Consequently, it is imperative to address these barriers to promote early risk assessment, genetic testing and counseling, early detection rates, and ultimately, lower mortality rates among women belonging to racial and ethnic minorities.

Assessing breast arterial calcification in mammograms and its implications for atherosclerotic cardiovascular disease risk.

PURPOSE: Breast arterial calcifications (BAC) are incidentally observed on mammograms, yet their implications remain unclear. We investigated lifestyle, reproductive, and cardiovascular determinants of BAC in women undergoing mammography screening. Further, we investigated the relationship between BAC, coronary arterial calcifications (CAC) and estimated 10-year atherosclerotic cardiovascular (ASCVD) risk. METHODS: In this cross-sectional study, we obtained reproductive history and CVD risk factors from 215 women aged 18 or older who underwent mammography and cardiac computed tomographic angiography (CCTA) within a 2-year period between 2007 and 2017 at hospital. BAC was categorized as binary (present/absent) and semi-quantitatively (mild, moderate, severe). CAC was determined using the Agatston method and recorded as binary (present/absent). Adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated, accounting for age as a confounding factor. ASCVD risk over a 10-year period was calculated using the Pooled Cohort Risk Equations. RESULTS: Older age, systolic and diastolic blood pressures, higher parity, and younger age at first birth (≤28 years) were significantly associated with greater odds of BAC. Women with both BAC and CAC had the highest estimated 10-year risk of ASCVD (13.30 %). Those with only BAC (8.80 %), only CAC (5.80 %), and no BAC or CAC (4.40 %) had lower estimated 10-year risks of ASCVD. No association was detected between presence of BAC and CAC. CONCLUSIONS: These findings support the hypothesis that BAC on a screening mammogram may help to identify women at potentially increased risk of future cardiovascular disease without additional cost and radiation exposure.

The Association Between Food Security and Mammography Screening: Cross-Sectional Survey Results From the National Health Interview Survey.

OBJECTIVE: There are limited data about food insecurity within the cancer screening setting. To inform the potential need for food insecurity interventions, our study evaluated the association between food security and mammographic screening among eligible participants. METHODS: Female respondents aged 40 to 74 years in the 2019 National Health Interview Survey without history of breast cancer were included. Food insecurity was assessed using the Six-Item Food Security Scale developed by the National Center for Health Statistics. The proportion of patients who reported mammographic screening within the last year was estimated, stratified by food security. Multiple variable logistic regression analyses evaluated the association between food security and mammography screening, adjusted for potential confounders. All analyses were performed accounting for complex survey design features. RESULTS: In all, 8,956 weighted survey respondents met inclusion criteria; 90.1% were classified as having high or marginal food security, of whom 56.6% reported screening; 6.1% were classified with low food security, of whom 42.1% reported screening; and 3.8% were classified with very low food security, of whom 43.1% reported screening. In our unadjusted analyses, participants with low food security (P < .001) and very low food security (P < .001) were less likely to report screening within the last year. In our adjusted analyses, participants with food insecurity (P = .009) were less likely to report screening. DISCUSSION: In a nationally representative cross-sectional survey, participants with food insecurity were less likely to report mammography screening. Radiology practices should consider screening patients for food insecurity and social determinants of health. Evidence-based food insecurity interventions may increase adherence to mammography screening.

Screening mammography for women in their 40s: a retrospective study of the potential impact of the U.S. Preventive Service Task Force's 2009 breast cancer screening recommendations.

OBJECTIVE: The objective of our study was to review screening mammography examinations performed at our institution from 2007 through 2010 with the primary endpoint of determining the incidence of breast cancer and associated histologic and prognostic features in women in their 40s. MATERIALS AND METHODS: Patients who presented for screening mammography who ultimately (i.e., after additional imaging, including diagnostic mammographic views and ultrasound) received a BI-RADS assessment of a category 4 or 5 for a suspicious abnormality were followed retrospectively through completion of care and were analyzed with respect to pathology results after biopsy, treatment, and family history. RESULTS: During the study period, 43,351 screening mammography examinations were performed; 1227 biopsies were recommended on the basis of those studies and yielded 205 breast cancers (cancer detection rate of 4.7 per 1000 screening examinations). These screening examinations included 14,528 (33.5%) screening examinations of patients in their 40s; 413 biopsies were recommended and yielded 39 breast cancers (39/205 = 19%) (cancer detection rate of 2.7 per 1000 screening examinations). More than 50% (21/39) of the cancers in women in their 40s were invasive. Only 8% (3/39) of the women in their 40s with screening-detected breast cancer had a first-degree relative with breast cancer. CONCLUSION: From 2007 through 2010, patients in their 40s accounted for one third of the population undergoing screening mammography and for nearly 20% of the screening-detected breast cancers--more than half of which were invasive. This information should be a useful contribution to counseling women in this age group when discussing whether or not to pursue regular screening mammography.

Emergent complications of assisted reproduction: expecting the unexpected.

With the increasing popularity of assisted reproductive technology (ART), radiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome (OHSS), ovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy. Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Heterotopic pregnancy refers to simultaneous intrauterine and ectopic pregnancies and has an incidence of 1%-3% in ART patients. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed. Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely diagnosis and help avert potentially fatal consequences.

Supporting underrepresented minority students and advancing educational and health equity: Travelers Summer Research Fellowship (TSRF) program radiology panel.

OBJECTIVE: The COVID-19 pandemic has highlighted the racial disparities in health outcomes within our nation. This is especially relevant in the field of radiology where the lack of minority representation is particularly striking. The purpose of this paper is to describe a pipeline program designed to support underrepresented minority (URM) students and provide a model to bridge URMs to careers in medicine hence cultivating health equity. METHODS: We designed a radiology pipeline program within The Travelers Summer Research Fellowship Program (TSRF) to give underrepresented students an opportunity to engage with radiologists. Participants experience a rich inquiry-based curriculum and completed pre- and post-intervention surveys that measured motivational factors for medical education and interest level in medical careers. RESULTS: 29 undergraduate students participated in the 2021 TSRF Program. The data comparing the pre- and post-surveys demonstrated that the TSRF program played a positive role in sparking interest in radiology, debunking misperceptions about radiologists, and boosting participant confidence regarding medical school applications. DISCUSSION: We created an interactive curriculum for URM students to cultivate a new generation of radiologists that will reflect and better meet the needs of the populations they are serving thereby mitigating the current health disparities in our nation.

Chatbot Artificial Intelligence for Genetic Cancer Risk Assessment and Counseling: A Systematic Review and Meta-Analysis.

PURPOSE: Most individuals with a hereditary cancer syndrome are unaware of their genetic status to underutilization of hereditary cancer risk assessment. Chatbots, or programs that use artificial intelligence to simulate conversation, have emerged as a promising tool in health care and, more recently, as a potential tool for genetic cancer risk assessment and counseling. Here, we evaluated the existing literature on the use of chatbots in genetic cancer risk assessment and counseling. METHODS: A systematic review was conducted using key electronic databases to identify studies which use chatbots for genetic cancer risk assessment and counseling. Eligible studies were further subjected to meta-analysis. RESULTS: Seven studies met inclusion criteria, evaluating five distinct chatbots. Three studies evaluated a chatbot that could perform genetic cancer risk assessment, one study evaluated a chatbot that offered patient counseling, and three studies included both functions. The pooled estimated completion rate for the genetic cancer risk assessment was 36.7% (95% CI, 14.8 to 65.9). Two studies included comprehensive patient characteristics, and none involved a comparison group. Chatbots varied as to the involvement of a health care provider in the process of risk assessment and counseling. CONCLUSION: Chatbots have been used to streamline genetic cancer risk assessment and counseling and hold promise for reducing barriers to genetic services. Data regarding user and nonuser characteristics are lacking, as are data regarding comparative effectiveness to usual care. Future research may consider the impact of chatbots on equitable access to genetic services.

Barriers to breast cancer screening are worsened amidst COVID-19 pandemic: A review.

Disparities in screening mammography and barriers to accessing breast cancer screening are most prevalent among racial/ethnic minority and low-income women. The significant breast cancer mortality rates experienced in both Hispanic and African American populations are found to be connected to delayed screening. For these women to follow the screening guidelines outlined by the American College of Radiology and Society of Breast Imaging, they must successfully navigate existing barriers to screening. These barriers include differential access to care, language barriers, and lack of medical insurance. The COVID-19 Pandemic has worsened the barriers to breast cancer screening faced by these groups of women. These barriers need to be addressed or they may further exacerbate disparities.

Hiding in plain sight: How incorporating honest discussion of racial and social (in)justice into medical education can inspire change.

The carnage wrought by systemic racism through social, judicial, and health injustices compels us to work towards a system that is fair and just for patients and colleagues. The evidence that change is necessary in medicine is hiding in plain sight in literature, oral histories, medical records, and news media. Notwithstanding this evidence, changing a system 400 years in the making will require a major paradigm shift. One of the many ways our department sought to catalyze such a shift was through media consumption, reflection, and discussion. Reading and studying literature and humanities in medicine can awaken our consciousness by making medicine an embodied practice that considers the totality of patients' lives in ways that a disembodied, purely scientific approach cannot. Thus, we started a Racial and Social Justice Book Club to normalize discussions about racial and social (in)justice and examine everything through an anti-racist lens. Herein, we describe our experiences in the inaugural year of the Book Club, a space to lend credence and dignity to the voices, experiences, and stories of folks who have long been marginalized by power structures in America, including medicine.

Metastatic melanoma in the breast and axilla: A case report.

Metastatic melanoma of the breast is rare, and demonstrates nonspecific imaging findings which may overlap with both benign and malignant pathology.1-3 Immunohistochemical stains are important to confirm the diagnosis, particularly combining S100, a sensitive marker for melanoma, with more specific tumor markers such as Melan-A and HMB-45, and lack of cytokeratin staining.4-7 We present a case of a 64-year-old female who presented for diagnostic imaging of a palpable abnormality in her right breast, with medical history notable for previously excised cutaneous melanoma, recent COVID-19 vaccination, and significant family history of breast cancer. Diagnostic mammogram of the right breast demonstrated a circumscribed mass in the lower inner quadrant corresponding to the area of palpable concern, as well as an additional non-palpable circumscribed mass in the lower inner quadrant. Targeted right breast ultrasound demonstrated corresponding circumscribed cystic versus solid masses as well as a morphologically abnormal right axillary lymph node. Pathologic results after tissue sampling of the two right breast masses and right axillary lymph node all yielded metastatic melanoma.

The Design and Preliminary Experience with a Virtual Diversity Visiting Student Acting Internship in Radiology for Underrepresented Minority Medical Students.

OBJECTIVE: Benefits of a diverse physician workforce are numerous and the impact of a lack of diversity has been highlighted with the COVID-19 pandemic. Despite the commitment of professional societies such as the American College of Radiology to diversity in Radiology, the field and its residency training programs remain the least diverse. With COVID-19 related suspension of in-person medical student rotations, our Department of Radiology redesigned and implemented a virtual radiology internship for underrepresented minority (URM) medical students. METHODS: A four-week virtual radiology internship was designed to provide clinical exposure to radiology and to allow students to gain an understanding of what a career in radiology entails. Course design included videoconference patient care sessions, didactic lectures, online modules, mentoring, and extra-clinical curriculum. Feedback from students was collected using online surveys assessing pre- and postcourse attitudes and understanding of a career in radiology and the students' perceived aptitude for such a career, as well as course component evaluation. RESULTS: Three participants were enrolled in the inaugural clerkship. All noted exceptional educational course content and ample opportunities to build connections with faculty and residents-with mentoring seen as the highlight of the course. All indicated a significant shift in perception of the field and in declaring interest in pursuing a career in radiology. CONCLUSION: Virtual radiology internship for URM students is a feasible paradigm to address potential impediments to diversification of the specialty by both engaging interested URM medical students in a career in radiology and arming them with the tools for a successful application to radiology residency.

Extranodal multifocal Rosai-Dorfman disease of the breast: A case report.

We report a case of a 49-year-old female diagnosed with extranodal multifocal Rosai-Dorfman disease (RDD) of the breast using mammography and ultrasound. RDD is a rare non-Langerhans cell benign proliferative disorder of histiocytes that usually involves the lymph nodes, but may involve extranodal sites. We review the clinical presentation as well as imaging features of this rare disease on multiple modalities and the importance of recognizing the diagnosis in order to direct treatment.

Paraneoplastic limbic encephalitis as initial presentation of testicular neoplasm: A case report.

Paraneoplastic limbic encephalitis (PLE) is an immunopathologic syndrome associated with malignancy and represents a rare remote outcome of tumor on the nervous system. We report a case of PLE caused by a regressed testicular germ cell tumor in an otherwise healthy young man, who presented with acute-onset confusion, memory impairment and anterograde amnesia. Prompt recognition of PLE is critical as it allows early treatment of both the primary tumor and PLE-related neurologic impairments, which can be severe and irreversible if treatment is delayed. Complete tumor treatment response offers the best chance for neurologic recovery in patients with PLE. To our knowledge, this is the second reported case of PLE with radiologic-pathologic correlation in the setting of a regressed testicular germ cell tumor.

Unilateral axillary Adenopathy in the setting of COVID-19 vaccine.

With the recent U.S. Food and Drug Administration (FDA)-approval and rollout of the Pfizer-BioNTech and Moderna COVID-19 vaccines, it is important for radiologists to consider recent COVID-19 vaccination history as a possible differential diagnosis for patients with unilateral axillary adenopathy. Hyperplastic axillary nodes can be seen on sonography after any vaccination but are more common after a vaccine that evokes a strong immune response, such as the COVID-19 vaccine. As the differential of unilateral axillary adenopathy includes breast malignancy, it is crucial to both thoroughly evaluate the breast for primary malignancy and to elicit history of recent vaccination. As COVID-19 vaccines will soon be available to a larger patient population, radiologists should be familiar with the imaging features of COVID-19 vaccine induced hyperplastic adenopathy and its inclusion in a differential for unilateral axillary adenopathy. Short-term follow-up for unilateral axillary adenopathy in the setting of recent COVID-19 vaccination is an appropriate recommendation, in lieu of immediately performing potentially unnecessary and costly axillary lymph node biopsies.

Unilateral axillary adenopathy in the setting of COVID-19 vaccine: Follow-up.

With the Pfizer-BioNTech, Moderna, and now Johnson and Johnson COVID-19 vaccines readily available to the general population, the appearance of vaccine-induced axillary adenopathy on imaging has become more prevalent. We are presenting follow up to the first reported four cases of vaccine induced unilateral axillary adenopathy on imaging to our knowledge, which demonstrate expected self-resolving adenopathy. Our hope is that by providing this follow-up and reviewing current management guidelines, clinicians as well as patients will appreciate that this is an expected, benign, and self-resolving finding. In addition, we hope to quell any vaccine hesitancy brought about by recent mainstream media attention to this topic and ultimately empower patients to receive both the COVID-19 vaccine and undergo routine screening mammography, as both are vital to their health.

Breast Cancer Disparities Through the Lens of the COVID-19 Pandemic.

Purpose of Review: The emergency medicine and critical care needs of the COVID-19 pandemic forced a sudden and dramatic disruption of cancer screening and treatment programs in the USA during the winter and spring of 2020. This review commentary addresses the impact of the pandemic on racial/ethnic minorities such as African Americans and Hispanic-Latina Americans, with a focus on factors related to breast cancer. Recent Findings: African Americans and Hispanic-Latina Americans experienced disproportionately higher morbidity and mortality from COVID-19; many of the same socioeconomic and tumor biology/genetic factors that explain breast cancer disparities are likely to account for COVID-19 outcome disparities. Summary: The breast cancer clinical and research community should partner with public health experts to ensure participation of diverse patients in COVID-19 treatment trials and vaccine programs and to overcome COVID-19-related breast health management delays that are likely to have been magnified among African Americans and Hispanic-Latina Americans.