Diagnostic Imaging brings you daily coverage of SBI/ACR 2021 virtual annual meeting.

SBI/ACR 2021: April 9 - April 11, 2021

When it comes to breast cancer, imaging and preventive efforts go hand-in-hand. This year, through its Honorary Fellow Award, the Society of Breast Imaging recognized a provider who collaborates closely with imaging colleagues to bring the best level of care to women facing or receiving a breast cancer diagnosis.

Therese Bevers, M.D., is professor of clinical cancer prevention and medical director of the Cancer Prevention Center and prevention outreach programs at MD Anderson Cancer Center. In addition to overseeing the first comprehensive clinical cancer prevention service program that opened in 1996, she concentrates her efforts of breast cancer prevention, screening, and diagnosis.

For additional Society of Breast Imaging conference coverage, click 

 spoke with Bevers about what she sees as the main priorities in the fields surrounding breast cancer, as well as the main challenges that exist and what the future brings with imaging.

 How did you become interested in breast cancer prevention and screening? What was in your background or your education that led you to want that to be your focus?

Therese Bevers, M.D.
MD Anderson Cancer Center

 Interestingly, my background and my board certification is in family medicine. Prevention is a big component of primary care, and I eventually went into preventive medicine as a field of practice. Then, I was hired by MD Anderson to run the newly opened Cancer Prevention Center in 1996. That's when I really focused my career on cancer prevention, screening, and diagnosis. The natural area for me was breast cancer prevention and screening and diagnosis. I quickly became involved in the breast cancer prevention trial, which was the trial of tamoxifen versus placebo, that showed that tamoxifen reduced the risk of developing breast cancer by one-half. That just naturally led to expanding my career in the field of breast cancer prevention, screening, and diagnosis. I don't do any treatment – my background is primary care. Although, I have become a specialist in the field of preventive medicine and cancer diagnosis.

 What do you consider to be your most significant contributions to the field surrounding breast cancer?

 I think my biggest contribution has been in a leadership role largely through the National Comprehensive Cancer Network (NCCN), but through other entities, as well. That's my biggest area where I have led the breast cancer screening and diagnosis guideline panel that talks about how we should screen women at average and increased risk, and how we make the right diagnosis. Then, I also chaired the breast cancer risk reduction guideline panel, which talks about how to reduce a woman's risk of developing breast cancer, not only through tamoxifen and Raloxifene and aromatase inhibitors, but also through healthy lifestyle changes and for very high-risk women through prophylactic mastectomy.

I feel that my biggest contribution has been through that arena because I feel that as far as breast cancer risk reduction, I have helped to lead practice-changing guidelines there in the field of breast cancer screening. I, along with SBI and the American College of Radiology, have really endorsed, strongly supported, and being very vocal about the importance of beginning annual mammograms at age 40. The U.S. Preventive Services Task Force really recommends biennial or every other year mammograms beginning at age 50. I think if COVID-19 does nothing else, it shows us the error of going to every other year. Many women have not gotten their screening during COVID-19. So, some of their intervals have stretched out two years, and we are seeing more advanced diagnosis of breast cancer. I feel very strongly that the data supports getting an annual mammogram beginning at age 40.

So, the SBI and ACR are very vocal about that, along with my co-chair of the NCCN panel. Having said that, I would like to note that I think it is the members, many members of SBI, who have really taught me all that I know about screening mammography and the data supporting annual beginning at age 40.

What are the most significant challenges you see facing efforts for breast cancer prevention, screening, and detection?

 For screening, it's that there are a number of different recommendations out there that just simply confuse women. Women don't know what to do, and when you don't know what to do, many people take the action of not doing anything. That concerns me, and I wish that we had a more unified voice for breast cancer screening, unfortunately, we don't.

I am very blessed in the institution that I work in that I get to work literally across the hallway from our breast imagers. I get to have daily one-on-one interactions with them about the symptoms a woman presents with the clinical findings that I identify and what their imaging findings are. We get to approach it collaboratively. Unfortunately, in the real world, out in the community, that doesn't get to happen often. That’s the biggest challenges for many clinicians who are trying to do the best that they can for women in making appropriate recommendations and making an accurate diagnosis. They just don't have that one-on-one collaboration with their breast imager.

What do you see as the main priorities in the field today or 5-to-10 years out?

Looking at new ways of screening for breast cancer, we have seen huge advances. I remember when I started at MD Anderson, there was a huge film library dedicated just to mammograms and breast imaging studies. Now, that film library has gone to the wayside and we have digital images. We now have expanded into tomosynthesis – in street lingo called 3D mammography – where we're actually getting images of the breast in slices like a CT scan would do. One other modality that has come since I started practicing 25 years ago is being able to offer women breast MRI if they're at high risk of developing breast cancer. That wasn't something we offered when I started in the field in 1996. But, now, it's codified in the NCCN and American Cancer Society recommendations for women at increased risk of breast cancer.

We’ve already made great strides that helped us to improve imaging. But, there are so many new modalities out there that are coming down the pipe. Areas I think that we will see continue to grow, at least in the field of imaging, would be contrast enhanced mammography where not only do we get the images, but we get functional information if contrast is injected. Is there a role for molecular breast imaging in screening? Maybe, maybe not. It has a higher dose of radiation. So, that's a bit of a concern. Certainly, it is an opportunity in the diagnosis of breast cancer because it gives functional information, especially for women that can't do MRI whether due to claustrophobia or body habitus. we're seeing more and more imaging modalities.

There's a lot of interest in identifying the Holy Grail of tumor markers in the blood that would identify women at risk for developing breast cancer or women that actually have breast cancer. If we had a tumor marker in the blood or saliva or whatever body fluid that we use, that allows us to move away from mobile mammography vans and brick-and-mortar buildings out to maybe a mall or a health fair where we could draw blood or get the saliva specimen. Then, we could circle back to that woman and say, “Hey, you're okay,” or the next woman and say, “We're a little concerned with what we saw. We need to get you in now for the imaging and do a workup to see if there is actually something going on.”

For you, in your career, what’s on the horizon? What is your next endeavor or area of focus?

I intend to continue with NCCN and leading those two guideline panels. I think there's a lot of opportunity. I have seen our NCCN and breast cancer screening and diagnosis guideline panel grow from a few pages to now close to 30 pages, We encompass not just the straightforward screening of average risk women and the diagnosis of just breast masses and nipple discharge, etc., but to encompassing more rare conditions like anaplastic large cell lymphoma (LCL), breast implant associated LCL, as well as breast cancer in men and breast pain imaging in the pregnant and lactating woman. That’s a big interest for me – being able to take what experts know and what the data has shown and being able to put it in a recommendation or a guideline such that community physicians can easily access it and say, “Ah, I should do that. I didn't think of that.”

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Articles

MD Anderson Cancer Center medical director shares her thoughts the priorities and challenges facing breast cancer detection and screening.

For SBI Awardee: Face-to-Face Collaborations, a Challenge; New Modalities, Exciting Possibilities

Lung cancer remains the leading cause of cancer death in the United States, with more than half of all cases (57 percent) being diagnosed at a late stage with an average five-year survival rate of 22.6 percent

 However, there are signs of progress, with the rate of new cases going down 9 percent nationally and an increase in the five-year survival rate by 13.1 percent over the past five years

. This is likely due to reduced smoking rates, increased radon testing, more stringent air pollution regulations, and improvements in treatment

. However, the implementation of lung cancer screening to detect the deadly disease at an earlier stage has undoubtedly played a role in these gains, as well.

In 2011, the National Lung Screening Trial reported a 20-percent relative reduction in lung cancer amongst adults who smoked heavily and received low-dose CT (LDCT) annual screening compared to those who received annual chest radiographs

. Based on this evidence, the United States Preventive Services Task Force recommended annual lung cancer screening (LCS) with LDCT for high-risk adults (defined as 55-to-80-year-old persons who have a 30-plus pack year smoking history and quit less than 15 years ago).

Insurance companies and Medicare/Medicaid began to cover LCS in 2014-2015. Despite these guidelines and financial reimbursement, patient and physician uptake to the guideline has been slow. Less than 4 percent of eligible adults received screenings in 2015, and that figure had a marginal increase to 5.7 percent in 2020

. However even with the lagging adoption, early diagnosis rates have increased 33 percent over the past five years

. Of all cases, 23 percent are caught at an early stage, which has a much higher five-year survival rate at 59 percent

Why have the rates for LCS with LDCT remained low? There are many potential factors at play, such as healthcare providers not collecting a sufficiently detailed smoking history to identify eligible patients, smokers being a demographic with a predisposition to have less contact with primary care providers (PCP), PCPs not recommending screening due to lack of time and other priorities, lack of insurance incentivization, high rate of false positives on LDCT, perhaps even the perception that smoking is a lifestyle choice and that resources should not be spent on this population.

Cancer Screening Challenges in the Face of COVID-19

As for the argument of the unacceptable number of false positives, there is, indeed, a 20-percent rate of over-diagnosis of lung cancer, which is consistent with the rate of over-diagnosis in breast cancer

. However, it also prevents one death for every 250 screens, which far exceeds the number needed to treat (NNT) of 2,000 for screening mammography

. According to one meta-analysis of annual LCS with LDCT, all-cause mortality was not reduced in a significant manner, which is reassuring that the increased amount of screening and over-diagnosis of lung cancer did not increase other causes of mortality

What can we do to increase adherence to this useful screening tool? Many possible obstacles can be targeted, such as using clinical navigators to assist patients in following up appropriately, implementing algorithms to better identify eligible patients by using existing electronic health care data. There are two reports that attempted to increase it in two different manners, one more clinically, one involving more of the community.

In the first scenario, within the Kaiser Northern California system, they implemented a reporting system in 2015 that standardized radiology reports of pulmonary findings with tags. Tags that were indicative of lung cancer were automatically forwarded to a coordinator who sent a list of cases to a triage physician. The physician, then, either sent the case to a multidisciplinary committee or the patient's primary care physician (PCP) with management recommendations.

For additional columns by Mina Makary, M.D., click

The committee was composed of a care coordinator, pulmonologist, thoracic surgeon, and often a radiologist and oncologist, and the group met weekly to discuss cases. They would, then, either manage the case or send recommendations to the PCP. From the data that was collected pre- and post-implementation from nearly 100,000 patients, they found that lung cancer was detected at the early stage 26 percent of the time pre-intervention, and 30 percent of the time post-intervention. 

The intervention was associated with a 24-percent increase in odds of early-stage lung cancer diagnosis within 120 days, with a quicker time to surgical intervention (46 days vs 41 days) without biopsies. It appears that standardization of the radiologic reporting coupled with the multi-disciplinary committee increased the rate of detection of early-stage cancer which ultimately leads to improved long-term outcomes

The other instance is the state Kentucky which has one of the highest LCS rates in the country. Kentucky has expanded the Medicaid program, which removes the need for preauthorization for LCS. The government supports the cause with the governor publicly committing to reduce lung cancer mortality. In 2013, the Kentucky Lung Cancer Education Awareness Detection Survivorship Collaborative was created and implemented two LCS projects.

The first one educated hundreds of PCPs on lung cancer prevention, early detection, treatment, and survivorship. The second project gave feedback to LCS programs on how to best deliver screening and engage healthcare providers. Due to this combined effort from the community with government support, Kentucky has the third highest screening rate in the nation, leading to more lung cancer survivors. They have provided a framework for other states with high lung cancer burdens to follow

As evidence continues to grow that LDCT is an effective tool at increasing lung cancer survivorship – and awareness increases amongst the public – LCS rates will likely increase in the following years. However, there is still much work to be done to achieve the rates that would benefit the most vulnerable populations. 

As demonstrated by these two cases, there are issues that can be improved at every level of the system – educating patients about the benefits of annual LDCT, promoting the value of LCS to PCPs, standardization of lung cancer findings and templates within an electronic medical record, improved coordination of care, and further research into how to refine screening populations and screening modalities. With widespread adoption by healthcare providers, this intervention will surely improve both the longevity and quality-of-life for increased numbers of at-risk individuals who receive the diagnosis of lung cancer.

State of Lung Cancer 2020 Report (Rep.). (2020, November 17). Retrieved https://www.lung.org/getmedia/381ca407-a4e9-4069-b24b-195811f29a00/solc-2020-report-final.pdf

Stacey A Fedewa, PhD, Ella A Kazerooni, MD, MS, Jamie L Studts, PhD, Robert A Smith, PhD, Priti Bandi, PhD, Ann Goding Sauer, MSPH, Megan Cotter, MPH, Helmneh M Sineshaw, MD, MPH, Ahmedin Jemal, DVM, PhD, Gerard A Silvestri, MD, MS, State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States, JNCI: Journal of the National Cancer Institute, 2020;, djaa170, https://doi.org/10.1093/jnci/djaa170

Urbania, T. H., Dusendang, J. R., Herrinton, L. J., Alexeeff, S., Corley, D. A., Ely, S., . . . Sakoda, L. C. (2020). Standardized reporting and management of suspicious findings on chest ct imaging is associated with improved lung cancer diagnosis in an observational study. Chest, 158(5), 2211-2220. doi:10.1016/j.chest.2020.05.595

Gøtzsche, P. C., & Nielsen, M. (2006). Screening for breast cancer with mammography. The Cochrane database of systematic reviews, (4), CD001877. https://doi.org/10.1002/14651858.CD001877.pub2

Ebell, M. H., Bentivegna, M., &amp; Hulme, C. (2020). Cancer-Specific mortality, all-cause mortality, and overdiagnosis in lung cancer Screening Trials: A meta-analysis. The Annals of Family Medicine, 18(6), 545-552. doi:10.1370/afm.2582

Two interventions to increase lung cancer screening rates from the clinical and community perspectives. 

Lung Cancer Screening: Challenges and Opportunities

The days of relying on the radiology report to be your main communication with patients are gone. As the push for radiologists to become more active members of the patient care team continues to gain strength, its incumbent upon you and your trainees to learn how to effectively communicate with your referring providers, as well as patients.

a five-member team of experts laid out several tips for improving your communication skills – techniques that can benefit you as the healthcare climate tips further to value-based care.

“Communication requires the formulation of a message which is then shared with, and ultimately interpreted by, the receiving party. Importantly, absent or ineffective communication can lead to wasted time, increased healthcare expenditures, increased patient anxiety, and patient harm,” said the team led by Judah Burns, M.D., director of the diagnostic residency program at Montefiore Medical Center. “Effective communication, on the other hand, has been shown to improve health outcomes.”

But, despite efforts from the American Board of Radiology, the American College of Radiology (ACR), and the Accreditation Council for Graduate Medical Education, radiology residents are not getting the communication guidance they need, the team said.

To help trainees – and practicing providers – communicate better with patients, the team offered several suggestions:

Keep your reports clear and concise, using clinically relevant information. For example, if you don’t see anything alarming, say the results are “normal” rather than “unremarkable.” Structured reports, disease-specific reports, and templates can help clarify any uncertainty.

“From a patient’s perspective, conclusions and summary recommendations are the most impactful and notable sections of the written report,” they said. “These portions of the report should be most carefully considered to avoid simple repetition of findings, and to make reports actionable and understandable.”

Radiologists are often thought of as being removed from or not as invested in a patient’s care. To dispel that thought, include patient-specific information that shows you are an integrated member of the healthcare team. Remember to be respectful and non-judgmental in your tone when discussing sensitive topics, such as alcohol use or body habitus.

Using these templates can help trainees better learn how to organize their patient communications, giving patients easily understandable, organ-specific information that can help guide their future healthcare decisions. It can also help them develop greater clarity in their communications.

“Communicating uncertainty in radiological imaging is a critical reporting element,” the team said. “Clarifying the nature and extent of potential uncertainty allows physicians and patients to understand the degree of confidence and conveys diagnostic certainty in clinical decision-making.”

When possible, use pictures, tables, graphs, and images with hyperlinks to help illustrate findings.

“From the patient’s perspective, enhanced reporting is akin to story-telling. In many cases, a picture is more visually descriptive or impactful than a detailed or nuanced narrative,” they said. “The radiologist must aim to communicate important findings using written and illustrative tools in a manner that is precise, impactful, and relatable, maintaining focus on using those tools that help to best convey and contextualize imaging results.”

Communication Critical to Providers Adhering to Follow-Up Recommendations

Patient portals are growing in popularity with the number of patients using them rising from 35 percent in 2006 to 51 percent in 2016. But, giving patients direct access to images is still somewhat controversial as it can lead to confusion. It could be possible to mitigate this problem by including a summary statement in the report that provide context, such as letting a patient know that while images are available immediately, the care team needs time to interpret the results and will contact them for a discussion. If you choose, you can also include your contact information, as well as information for web consultations.

Participating in clinical imaging rounds or embedding reading rooms in clinical areas are two good ways to bolster the amount of face-to-face time radiologist trainees have to perfect their oral communication skills. In addition, attending multi-disciplinary meetings or participating in virtual consults can also be helpful. It would also be a good idea to increase training in telehealth consultations.

Encourage your trainees to make eye contact, nod their heads, and gesture – it’s a way to deepen the discussion and show patients that their radiologist is actively engaged.

“Particularly in brief interactions, such as those commonly occurring during radiologist consultations, the opportunity to establish and maintain relationships is limited,” the team said. “Effective non-verbal communication can decrease patient anxiety, reinforce patient discussions, and improve patient accordance with medication and follow-up recommendations.”

 Approach these situations carefully. Don’t use jargon – instead, focus on using simple terms. Be sure to be an active listener, and choose a supporting environment and atmosphere for relaying bad news.

By actively engaging in more patient interactions, the team said, radiology residents have more opportunities to identify barriers to care and existing health disparities. It provides them with the knowledge needed to combat any potential internal biases. Mastering these skills is critical, the team said, for trainees to be able to offer the highest level of care possible.

“Radiology trainees must gain skills in all forms of communication to fully engage with their patients,” they concluded. “Residency and fellowship programs and teaching faculty must model effective, professional communication in all forms and seek constant improvements in the work and clinical learning environments.”

Clear communication with referring providers and patients is critical. Following these steps can help.

8 Tips to Improve Radiologist Communication

What is your diagnosis of this condition as seen on CT?

 3D CT volume render demonstrates deformity and expansile appearance of multiple bones of the skull and mandible in this image.

 Fibrous dysplasia is a condition where normal bone and marrow are replaced with fibrous tissue growing/expanding such that the bone is weak and expands resulting in extensive deformity, higher risk of fracture, impairment of biomechanics, and symptoms of pain.

Image IQ Quiz: What's the Diagnosis?

Risk assessment can be a complicated topic when it comes to determining the likelihood an individual woman will develop breast cancer during her life. But, incorporating it into your practice can help you deliver a higher level of patient care, according to an industry expert.

In a Friday session, during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Bethany Niell, M.D., Ph.D., section chief of breast imaging at H. Lee Moffitt Cancer Center in Tampa, outlined what you should consider when trying to integrate risk-assessment into what you already do.

For more Society of Breast Imaging conference coverage, click 

According to existing data, one in 11 women will develop breast cancer before age 45. If practices can begin risk-based assessment at an early enough age, it may be possible to impact the delivery and efficacy of care, she said. There are several things you need to consider to be successful, however.

 Before proceeding with risk assessment, figure out what you want to focus on, Niell advised. Do you want to concentrate on early detection and supplemental screening, risk-reduction strategies, or genetic counseling? You could do any or all of these.

“Consider it conducting a first pass to identify elevated-risk women who may benefit from formal risk assessment by a high-risk specialist,” she said.

 When selecting a risk assessment model, choose one based upon whether you are looking to determine risk of developing breast cancer or risk of having a genetic mutation. Some models can provide both assessments, but Niell offered these suggestions.

While most models are designed to compensate for some level of incomplete data entry, do your best to collect and input the highest quality data you can, she said.

“I cannot emphasize enough that if you are going to perform risk assessment in your practice, collect high quality data,” she said. “Do not expect any of the models to provide you and your patients with accurate risk calculations if you are not inputting complete data.”

Up to 6 percent of women who undergo screening mammograms have a life-time risk of developing breast cancer of more than 20 percent. Because different model will identify high-risk groups in different ways, always use more than two models to assess your patients, she said, and refer women who are determined to be high risk for further evaluation.

With so many patients, taking additional time to conduct and evaluate risk assessment can slow down your workflow. Instead, automate every step of the process. It both decreases the chance of error and alleviates some of your workload. Establish a system that auto-populates the risk estimates directly into the radiology report so that it can be easily reviewed by the referring provider.

Although the average American can read at around an 8th-grade level, 20 percent read at a 5th-grade level or below, she said. Be careful to simply your communications as most medical material is written at roughly a 10th-grade level.

“When drafting documents for your patients, remember to target a 5th or 6th grade reading level,” Niell recommended. “There are online tools you can use to help you revise your initial drafts.”

It’s a good idea to have communications designed for patients of both average and elevated risk that are easy-to-read and that can guide patients through their next steps. Be sure you gather input from your patients and referring providers as their thoughts can be helpful on how best to word your communications.

Knowing how your patients prefer to receive their information about risk can also be useful, she said. In a survey of patients in her practice, women of average risk were amenable to written communication informing them. However, high-risk patients preferred verbal communication, making the role of the breast imaging navigator valuable.

Ultimately, she advised, your patients are likely to respond positively to risk-based assessment if you offer it.

“Patients want breast cancer risk assessment but are not receiving it,” she said. “Please consider performing a ‘first-pass’ risk assessment in your breast imaging practice with subsequent referrals for formal risk assessment.”

Patients want to know their risk. But, before you provide it, consider these factors to successfully integrate it into your practice.



Adding Breast Cancer Risk Assessment to Your Practice Benefits Patients

The American College of Radiology (ACR) announced the launch of its ACR National Clinical Imaging Research Registry™ (ANCIRR™) on Monday.

This initiative brings together six current and eight planned registries that will collect and organize both images and clinical data from a variety of practice settings. The goal is creating large data sets that will help researchers with investigations that impact multiple care settings, geographic locations, and populations.

“The ACR National Clinical Imaging Research Registry™ (

) is the future of radiology research registries, said Howard B. Fleishon, M.D., MMM, FACR, chair of the ACR Board of Chancellors. “The ANCIRR can democratize healthcare research by enabling radiologists who have never taken part in research studies to make vital contributions to patient care advancement.”

ANCIRR’s focus differs from the National Radiology Data Registry (NRDR®) that concentrates on enabling practice quality improvement through site feedback and peer benchmarking.

This innovation, which is driven by the ACR Center for Research and Innovation and ACR Informatics, is critical, ACR leaders said, because observational studies borne out of registries are becoming increasingly important in research and the development of randomized clinical trials and retrospective studies, moving the fields of medicine forward.

“The ANCIRR provides seamless data and image collection through the ACR TRIAD and ACR Connect suite of tools to support clinical research, quality improvement initiatives, artificial intelligence development and evaluation, regulatory submissions, and other new technologies,” said Christoph Wald, M.D., Ph.D., MBA, FACR, chair of the ACR Informatics Commission.

The ACR is well positioned to pursue and reach this goal, said Pamela K. Woodard, M.D., FACR, chair of the ACR Research Commission.

“The ACR has a unique ability to create curated, integrated diagnostic datasets of multi-institutional data,” she said. “This ability to leverage electronic health records can fulfill the promise of digital data, aid health equity efforts and lead to more targeted patient care.”

Work for the ANCIRR is ongoing. The COVID-19 Imaging Research Registry (CIRR), the newest of the six current registries, is now operating. It will be a primary data collection pathway for the National Institute of Biomedical Imaging and Bioengineering-funded Medical Imaging and Data Resource Center which has the potential to become the largest world-wide COVID-19 medical imaging archive. In addition, CIRR provides COVID-19 images to the Society of Critical Care Medicine VIRUS COVID-19 Registry and the National Heart, Lung, and Blood Institute PETAL Clinical Trials Network.

Registry brings together images and clinical data from multiple practice settings to help answer questions and produce results.

 ACR Launches Clinical Imaging Research Registry™

In this week’s preview, here are some highlights of what you can expect to see coming soon:

The Society of Breast Imaging and the American College of Radiology held their 2021 Virtual Annual Meeting over the weekend. There were plenty of sessions, touching on using risk assessment in practice, reimbursement, mergers and acquisition, as well as important news on breast imaging research and utilization. Look for our continuing coverage of the conference throughout the week.

For more SBI/ACR 2021 Virtual Annual Meeting coverage

As conversations around lung cancer screening and the need to increase its utilization have swirled recently, so have discussions about ways to encourage more people to come in and get scanned. This week, Editorial Board member Mina Makary, M.D., from The Ohio State Wexner Medical Center takes a look at some approaches institutions have used to positively impact their lung cancer screening rates and what their outcomes were. Look for his column in the coming days.

The struggle for effective communication between radiologist and patient has existed for decades. With little face-to-face contact between parties, it has historically been challenging for providers to have an active part in patient care outside reading their images. Recent years, however, have seen a push toward better communication between the two. In an article later this week, 

will explore the evidence-based strategies laid out for direct communication between radiologist and patient in an article published in 

For additional coverage of radiologist and patient communication

Here's what to expect this week on Diagnostic Imaging.

Diagnostic Imaging's A Look Ahead: April 12, 2021, to April 18, 2021

In the middle of my morning routine this past week, I had a standard interaction with the household pooch. She was sitting nearby, our eyes met, I said something, and she approached with tail wagging to receive some scratches from me. Both of us were gratified for our minimal efforts: Her approach and tail-wagging indicated her appreciation of me, and my verbalization/scratching did the same in reverse.

The thought stuck with me as my workday ensued: We humans don’t show our appreciation for one another all that much, outside of family and friends. Downright miserly with our positive feedback, when it comes to work environments.

It could be that, for most folks, work is a relatively joyless affair. If you’d prefer to be somewhere other than you are, doing something else, it might take all of your motivation just to attend to your responsibilities. There might be little psychic energy left to distribute positivity to those around you. Folks doing what they’re supposed to be? Well, that’s what they’re getting paid for; you’re not wasting your meager reserves to coddle them.

Immersed in a culture of non-appreciation, one adapts. If I find that, day in and day out, I’m getting my job done, and nobody ever says a positive “boo” to me, I’m probably going to return that indifference to everyone with whom I interact. Especially if I think I’ve gone above and beyond—getting more done or doing it with higher quality. If it seems to me I’ve been doing 110 percent and everyone else is in the 90 percent-to-100 percent range, I might go beyond indifference, to resentment.

I also think some folks are wary, consciously or otherwise, of expressing positivity about others in their work environment. Why risk praising a subordinate if you might have to take them down a peg or two later on? And, if you express approval of a peer or a superior, might they take it the wrong way? Who are you, to comment on their performance?

As understandable as all of this might be, it’s maladaptive. In a column of yesteryear, I wrote about the too-often-wrong focus of quality assurance (QA) programs: Detecting, tracking, and remediating errors, but rarely if ever focusing on work that was particularly well done. In psychological terms, business-as-usual QA is “aversive conditioning.” It’s been shown to shape behavior, but not as well as “positive reinforcement.” In other words, catching somebody being good works better than punishing them for being bad.

Being stingy with appreciation risks “negative reinforcement,” which is not the same as aversive conditioning. Negative reinforcement means taking away something desirable in response to unwanted behavior. For instance, withholding an end-of-year bonus from someone who previously got bonused. It shapes behavior most effectively if the reinforced individual knows 

they’re no longer receiving something…but even if no such connection is spelled out to them, they might come to their own conclusions. (“I’ve busted my hump since day one, and nobody seems to notice. Think I’ll take it a bit easier from now on.”)

I’ll emphasize that positive reinforcement does not need to be a big deal: A financial bonus, a promotion, even an “Employee of the Month” certificate…such things can of course be strong motivators…but, much like with my doggo, simple words, even gestures go a long way.

Perfect example: One of the human resources folks in my current rad group takes the opportunity to say something positive in most interactions, even if sometimes in jest. I can’t speak for anybody else there, but to me she’s always a spot of sunshine. Small wonder that she’s usually the point-person for recruitment.

Changing the culture of a group to be freer with verbal encouragement is no small project; heck, even getting one person to alter their behavior can be tough. Leadership and other senior members of the team can make it happen more easily/naturally if they exemplify the proactive-positive approach.

Since I imagine more than a few readers aren’t in such lofty positions to enact change, and might remain relatively starved of positive regard in their workplaces for the visible future, allow me to tell you what you should probably already be hearing. Not all might apply to your particular circumstances…but, when in doubt, be generous to yourself:

Thanks for your part in clearing the worklist every day!

Good job fielding those calls from referrers/techs/patients, answering their questions, addressing their concerns! Always easy to get in touch with you.

Other members of the team really appreciate that you’ve made yourself available for consultations—both in and outside of your subspecialty.

Hey, those are some nice suggestions you’ve made to leadership! It’s great to see interest from members of the team.

Scheduling wants you to know: They really appreciate your flexibility and reliability. You pitch in when they need help with coverage, and never have unexpected absences for them to fill in a hurry.

Thanks for always being on top of your CME and other credentialing requirements!

Just wanted to acknowledge your timely responses to messages and attentiveness when following up on issues. Way too many people respond late or not at all…you could teach them a thing or two.

Great diagnostic catch on that case the other day! A lot of rads would have missed it.

You’ve got a broad comfort-zone with the types of studies you read. “Plug and play” rads like you who can fill just about any spot in the schedule are priceless!

It’s been great having you on the team for [X amount of time]; I hope we continue to make you feel welcome!

Follow Editorial Board member Eric Postal, M.D., on Twitter, 

Positive acknowledgement can go a long way.

Nicely done!

Breast imaging radiologists are in the best position to give patients bad news associated with their exams.

From the patient’s perspective, radiologists do the best job in delivering upsetting information, said Colleen McNally, a fourth-year medical student at Georgetown University School of Medicine. She presented her poster and the results of her survey during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting.

“The results of this survey show that breast imaging radiologists are in the best position to deliver bad news with regards to understanding the disease process timing, honesty, and empathy,” she said. “Breast imaging radiologists often deliver bad news to patients, such as the need for imaging work up and biopsy or discussing breast cancer results.”

Despite these results, she said, there is still a need for structured educational models designed to teach providers about “breaking bad news.” The overall goal should be improving communication skills, the patient’s experience, and ultimately, bolstering their ability to cope with a cancer diagnosis.

For her study, McNally delivered a cross-sectional prospective survey via email to patients who had breast cancer diagnosed by image-guided biopsy between May 1, 2019, and April 30, 2020. She asked about the type of provider who delivered the news to the patient, the method of communication, the presence of trainees in the room, the time and day of the week, whether a warning shot was given prior to results, and personal preferences on who should deliver cancer news. In addition, she gathered details about patients age and demographics, as well as if the patient had access to a patient portal.

A total of 105 patients were surveyed, and 43 (40 percent) responded. Of that group, 21 patients (49 percent) received their cancer diagnosis from the procedure radiologist (15 via telephone and six in person), and 21 others (49 percent) were told by other specialists. Only one patient found out via the patient portal.

Based on her analysis, radiologists performed well – 85 percent of respondents said the radiologist was completely honest and did provide a warning shot.

“[These] respondents felt the radiologist was empathetic and considerate of their feelings during [the] delivery of cancer diagnosis,” she said.

In fact, 54 percent said a radiologist was their preference because not only did imagers have had good communication skills and a greater understanding of their imaging, but they also provided results faster. Still, 46 percent of patients did prefer to hear the news from their own physician, mainly because of a long-term existing relationship.

Patients indicated breast imaging radiologists expressed more empathy over the diagnosis and had more understanding of their scans than other providers.



For Breaking News about Cancer Diagnoses, Patients Prefer Breast Imagers

Clinical breast exams and breast self-exams are valuable tools in the fight for breast cancer detection even though they have unclear guidelines.

In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Nicole Huang, a fourth-year medical student at the University of Texas Medical Branch, revealed findings that show both clinical and self-exams successfully identify breast cancers even if not all exams are equivalent.



“There is no significant difference between clinical breast exams and breast self-exams in identifying cancer or positive ultrasound findings,” she said. “Self-breast exams detect cancers. Clinical breast exams are not all equal.”

In fact, she said, based on her findings, clinical breast exams performed by medical doctors, especially female health specialists, are typically more effective than those performed by mid-level providers.

To reach this conclusion, she conducted a retrospective cross-sectional study, reviewing electronic medical records from 462 women who were seen for breast lumps in 2019. She focused on detection of cancer and positive ultrasound findings.

Based on her analysis, 69 of 462 breast masses had positive ultrasound findings, and 26 were ultimately diagnosed as cancer. Of those malignancies, 96 percent were detected via a patient-identified lump, as were 81 percent of ultrasound findings. Medical doctors identified 100 percent of cancers and 92.3 percent of positive ultrasound findings.

Specifically, 25 of 26 breast cancers were initially detected by patients, and only one of 26 was found via clinical breast exam. Still, the evaluation showed that there was no statistically significant difference between clinical breast exams or breast self-exams in identifying cancer or positive ultrasound findings, she said.

Although these tests are controversial, they are highly effective in identifying lumps that lead to breast cancer diagnoses.

Clinical- and Self- Breast Exams Are Vital for Breast Cancer Detection

Low-dose CT (LDCT) isn’t just for lung cancer screening. Data gathered from the scans can also help predict a patient’s five-year risk of death from cardiovascular disease.

investigators from The Netherlands detailed how implementing a deep learning algorithm that is fueled with information captured during a low-dose CT exam for lung cancer screening can offer valuable details about calcification in the heart and the aorta.

Using LDCT in this way is a two-for-one opportunity to screen patients for both potentially deadly conditions. The scan is used to detect lung cancer in high-risk individuals, including heavy smokers, but for those individuals, cardiovascular disease actually surpasses lung cancer as the leading cause of death. By picking up these areas of calcification that are linked to plaque build-up, the scan can give providers a strong predictor of heart attacks, stroke, and mortality from cardiovascular disease.

Given the recent recommendation update from the U.S Preventive Services Task Force that opened up LDCT lung cancer screening to high-risk individuals ages 50-to-80 who have at least a 20-pack year smoking history, it is possible that providers will be able to pick up on cardiovascular disease mortality risk in an even wider population of patients, the team said.

In the past, data pulled from CT images has been used in conjunction with other risk factors, such as cholesterol levels, blood pressure, and self-reported history of illness. But, for this study, the team, led by Bob D. de Vos, Ph.D., from Amsterdam University Medical Center and the Image Sciences Institute at the University Medical Center Utrecht, drew upon deep learning to create an automated method that can quickly predict five-year cardiovascular disease mortality without putting a heavier work burden on providers.

“We have shown that five-year cardiovascular disease mortality can be predicted for lung screening participants in less than half a second, using only site-specific calcium scores automatically derived from lung screening low-dose CT,” the team said. “Hence, the proposed image-based analysis could aid in identification of lung screening participants at risk for cardiovascular disease mortality, without relying on self-reported participant data.”

Figure 2: Projections of all aligned chest CT scans show feasibility of slab-based quantification of calcium, resulting in an average image. For alignment, only translation, rotation, and scaling were allowed, resulting in a blurry image, because not all anatomy is exactly the same across participants. From left to right, the center axial, sagittal, and coronal sections are shown. Note that field of view is similar to cardiac CT, which is a consequence of image alignment by the used automatic calcium scoring method. Image alignment allowed the determination of calcification distributions into slabs as a proxy measure for proximal and distal calcifications, of which the borders are indicated by the horizontal lines.

For the study, they pulled data from LDCT scans conducted between August 2002 and April 2004 on 4,451 participants with an average age of 61 who were part of the National Lung Screening Trial. Using those details, the team trained their deep learning method to quantify six types of vascular calcification: thoracic aorta calcification (TAC), aortic and mitral valve calcification, coronary artery calcification (CAC) of the left main, the left anterior descending, and the right coronary artery. After training, they tested their method on data gleaned from 1,113 participants.

The team compared the methods with semi-automatic baseline prediction using self-reported participant characteristics, such as age, smoking history, and history of illness. According to their analysis, the prediction model using calcium scores performed better than the baseline model.

Specifically, the prediction model that used calcium scores reached a C statistic of 0.74 while the baseline model that relied on only participant characteristics achieved 0.69. The model had the best results, they said, when all variables were combined – a 0.76 C statistic.

“The analysis shows we found predictors that are typically not described in a literature, possibly because we performed analysis in lung cancer screening participants we are already at high risk of cardiovascular disease from a history of heaving smoking and the presence of extensive arterial calcification,” de Vos explained.

The method works in two stages, he said, first using deep learning to pinpoint the amount and location of arterial calcification in the coronary arteries and aorta. The second stage relies on a more conventional statistical approach to mortality prediction and identifies features that are most predictive of five-year mortality.

Incorporating the deep learning method into lung cancer screening would be simple, de Vos said, because it requires no special equipment and does not tack on any exam time. And, the benefits to providers and patients could be immense.

“The method uses only image information, it is fully automatic, and it is fast. The method obtains calcium scores in a complete chest CT in less than half a second. This means that the method should be easy to implement to routine patient work ups and screening,” he said. “Lung screening studies show that heavy smokers die from cardiovascular disease as much as from lung cancer. But, we also see that some people with very high calcium scores survive, while others with low scores do suffer from major cardiac events.”

Their results point to a need for additional research that can more specifically point to calcifications that are dangerous. To date, they have developed several automatic scoring methods that can use varied types of data, but they are continuing on with development. Now, de Vos said, they are concentrating on creating a calcium-scoring method that can use low-quality data, such as data affected by cardiac motion, low image resolution, and high noise level, to detect arterial calcification.

“We developed a method, for example, that can detect coronary calcification even when the lesions are below the clinically used threshold,” he said. “This way, we hope to increase the reproducibility of calcium scoring and enable more accurate prediction.”

But, for now, he said, their work has shown that it is possible to achieve real-time mortality prediction with lung screening chest CT by using only data from automatic deep learning-quantified arterial calcium.

A low-dose CT for lung cancer screening can also predict a five-year cardiovascular disease risk of death when using a deep learning algorithm.

Add Predicting Heart Disease Mortality Risk to LDCT Capabilities

Take a look at this CTA -- what's your diagnosis?

Focal narrowing of the descending aorta distal to the great vessels as visualized on this sagittal view of the aorta on CTA.

CTA and MRA can enable clear cross-sectional visualization of the aortic coarctation. One can also look for collateralization of vessels most commonly involving the subclavian artery to internal mammary artery to intercostal arteries and, then, to the aorta, distal to the coarctation. Rib notching can be seen. Treatment can surgical or balloon angioplasty.

What's the diagnosis for this image captured with CTA?

Image IQ Quiz: What's the Diagnosis for this CTA?

59-Year-Old Patient Presents with Abdominal Pain

Small bowel obstruction secondary to adhesions

Large bowel obstruction secondary to malignancy

- Complication of chronic cholecystitis with formation of cholecystoenteric fistula
- Gallstone passage through fistula, which ultimately becomes impacted within the small bowel (most commonly at ileocecal valve).
- Uncommon cause of small bowel obstruction

What is your diagnosis for this 59-year-old patient who presents with abdominal pain?

Add Predicting Heart Disease Mortality Risk to LDCT Capabilities

Image IQ Quiz: What's the Diagnosis for this CTA?

Image IQ Quiz: 59-Year-Old Patient Presents with Abdominal Pain