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ECR 2021: March 3 - March 7, 2021

For women with the BRCA 1 and 2 mutations who are pregnant or lactating, providers vary in how they recommend the use of screening breast MRI and screening mammography.

In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Sophia O’Brien, M.D., a radiology resident from the Hospital of the University of Pennsylvania detailed the differing policies breast imagers follow for annual screening with these women.

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Currently, the American College of Radiology recommends women with these genetic mutations begin annual screening breast MRI starting between ages 25 and 30 and annual screening mammography starting at age 30.

To evaluate the utilization of and attitudes toward the use of these screening services, O’Brien surveyed Society of Breast Imaging members twice during May 2020, asking about practice information, utilization, and timing of imaging during pregnancy and lactation. She also queried members about their perceptions over false positive and false negative rates with breast MRI during lactation.

All total, 218 Society members responded, of which 19 percent reported having an institutional standardized policy for screening women with these genetic mutations during lactation. Academic-institution based providers who read more than 10 breast MRIs a day were more likely to have such a policy.

Views on how to implement the policy, however, varied. More than half of providers – 59 percent – recommended continuing screening breast MRI with a lactating patient. But, 57 percent indicated it could occur at any time while 38 percent recommended some delay. In addition, 39 percent recommended postponing until after the patient was no longer breast-feeding, and 64 percent of that group supported waiting for 1 month-to-3 months.

When it came to breast MRI in lactating women, half of respondents said they believed the exam has higher false positive and false negative rates than in women who were not lactating – 51 percent each.

Perspectives over screening mammography were a bit clearer.

“Despite ACR recommendations to consider screening mammography in pregnant high-risk women, most respondents do not perform this study,” she said.

In fact, only 32 percent of survey respondents supported continuing the exam during pregnancy with 67 percent recommended going through with the exam during lactation.

Although most providers indicated they support screening breast MRI during lactation, the variability of timing created a lack of clarity on what might be best, O’Brien said.

“Further research into the optimal timing of screening breast MRI during lactation, as well as education of breast imagers regarding ACR mammography guidelines in pregnancy, is needed,” she said.

Articles

Despite recommendations from the American College of Radiology, most providers opt to delay screening in these women.

Most Breast Imagers Postpone Breast Cancer Screenings in Pregnant or Lactating Women with BRCA 1 or 2

Fewer than 40 percent of American Indian women adhere to regular screening mammography, a proportion vastly lower than the U.S. population of women from all races.

In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Nicole Honey, a medical student from the University of Michigan Medical School revealed that only 38.7 percent of American Indian women were mammography adherent. And, reaching even this level could be difficult without the use of mobile mammography units.

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“This American Indian population is far below recommended rates of screening at recommended intervals,” she said in her poster, noting that, existing data shows 72.8 percent of women of all races have undergone screening mammography within the last two years. “Without mobile mammography, screening may be less.”

Honey based her research on the performance of an Indian Health Service mobile mammography unit that traveled more than 4,500 miles to provide screening services to 22 predominantly rural Indian Health Services clinics across four states between 2013 and 2017. She compared the adherence of American Indian women to screening data from the American College of Radiology National Mammography Database (NMD).

She defined adherence for both groups as a previous mammogram within 9 months to 27 months before the mobile mammography visit. Non-adherence was no previous mammogram or a prior scan from more than 27 months.

For the study, she included 1,616 American Indian women between ages 42 and 87, as well as 2,509,826 women between ages 42 and 80 from the NMD. According to her analysis, 625 American Indian women (38.7 percent) were adherent compared to the 1,481,021 women (59 percent) included in the NMD. Consequently, the non-adherence rate among American Indian women was 1.5 times that of NMD patients – 61.3 percent versus 41 percent, respectively.

In addition, she found that, among non-adherent women, more American Indian women than NMD women – 43.7 percent and 21.7 percent, respectively – had a prior mammogram more than 27 months before the study. Baseline mammogram rates were similar for both groups – 34.5 percent and 32.1 percent.

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The screening mammography non-adherence rate among American Indian women is 1.5 times that of the overall population.

Mobile Mammography May Be Critical for Screenings in American Indian Women

Ten years after Connecticut passed the first breast density notification law, approximately three-quarters of women with dense breasts now opt to undergo supplemental whole-breast ultrasound screening.

In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Liane Philpotts, M.D., FACR, professor of radiology and biomedical imaging at Yale School of Medicine, outlined her department’s experience with breast density laws.

Currently 38 states have breast density notification laws, and a federal law is anticipated soon. Her department started offering screening whole-breast ultrasound (WBUS) in 2009 with the state first passed the law.

“Our policy has been to inform women of density (as per Connecticut law) and offer, but not explicitly recommend WBUS, leaving it to the patient and provider to decide,” said Philpotts, who is also section chief of breast imaging.

To help practices in the early stages of adopting supplemental screening, her team assessed the percentage of women with dense breasts who have opted to undergo supplemental WBUS.

By searching an electronic breast imaging database, Philpotts team identified women with dense breast tissue who had screening mammography performed at either a main academic tertiary hospital or three outpatient satellite offices. They also identified women who underwent bilateral WBUS after a normal, same-day screening mammogram. They compared the number of patients from July 1 to July 31 of each year between 2010 and 2019.

Based on her team’s analysis, screening mammography volume increased 3.5 times across practice sites over the decade. The first year, only 18 percent of women underwent WBUS, but the increase was steady on a year-by-year basis, growing to 28 percent by year two and climbing all the way to 75 percent each year of the past few years, she said.

These results show that the dense breast notification laws could be having some positive impact, she said.

“While initial uptake was low, after a few years, the majority of women with dense breasts undergoing mammography also undergo WBUS,” she said. “This suggest the acceptance of the supplemental screening test is high among both providers and women.”

After a decade, roughly 75 percent of women with dense breasts seen in one department now undergo screening whole-breast ultrasound as a supplemental imaging service.

10 Years Later: Dense Breast Notification Letters Result in Higher Supplemental Ultrasound Screening

Ultrasound should not be offered up for pediatric patients who experience breast pain without an accompanying palpable mass, new research indicates.

In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Lauren K. Hinojosa, M.D., a diagnostic radiology resident at the University of Texas Southwestern Medical Center provided evidence that pointed to a minimized role for ultrasound.

“Pediatricians should be advised to offer reassurance rather than imaging in cases of breast pain without a palpable mass,” she said. “Pediatric breast pain should not contribute to a recommendation for biopsy following breast ultrasound.”

In a retrospective study, she examined radiology reports and medical records from 310 patients under age 18 – 271 females and 39 males – who underwent breast ultrasound for breast pain between Jan. 2, 1010, and Dec. 31, 2017. The average age was 13, and 41 percent reported right-sided pain, 39 percent presented with left-sided pain, and 19 percent had bilateral discomfort.

Most patients – 65 percent – reported focal pain, and the duration of pain varied. Roughly 23 percent had experienced pain for less than a week, 13 percent between one-to-three weeks, 21 percent between one-to-six months, and 6 percent reporting between one-to-three years.

What to Know About Pediatric Breast Ultrasound

While 196 patients (63 percent) had a palpable mass, 146 cases (47 percent) showed no sonographic correlate to the symptoms. In addition, 146 cases had benign correlates with the most common being asymmetric breast bud and benign-appearing mass. However, 18 cases (6 percent) did have a sonographic mass that could not be categorized as benign, six of which went to biopsy which revealed benign pathology, she said.

Based on these results, Hinojosa said, ultrasound did not uncover any malignancy, and biopsies in the 2 percent of cases sent for further evaluation yielded the same results.

It is important to note, she said, that no formal guidelines for managing imaging findings on pediatric breast ultrasound exist, and BI-RADS classifications are likely to over-state malignancy risk in this population. Consequently, she reiterated the need for reassurance with patients over pursuing imaging.



Pediatric breast ultrasound use should be minimized for patients with breast pain but not a palpable mass.



For Pediatric Breast Pain -- Choose Reassurance, Not Imaging

Using pre-operative MRI can help providers identify which patients could be at increased risk for post-operative ischemic complications following nipple-sparing mastectomy (NSM), according to newly presented research.

During the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Natalie Ultey, a medical student from Georgetown University School of Medicine, shared details of how using these images can help with patient counseling and surgical planning.

“Nipple sparing mastectomy is a growing surgical option for patients undergoing mastectomy in both the oncologic and prophylactic setting,” she said. “Nipple sparing mastectomy is associated with improved patient satisfaction and has a similar low recurrence rate compared to skin-sparing mastectomy.”

However, between 5.9 percent and 15 percent of patients who undergo NSM experience ischemia and nipple necrosis. To determine whether pre-operative imaging could alert providers to which patients might develop these problems, Utley conducted a retrospective review on women who underwent pre-operative breast MRI and mammography before NSM between 2015 and 2020. Most of the patients included – 68.8 percent – were white, and 16.8 percent were African American.

For the study, she reviewed records from 125 patients who underwent 220 mastectomies – 33.2 percent for invasive cancer, 30 for ductal carcinoma in situ, and 53.2 percent for prophylactic reasons. Within this group, 10 cases of nipple necrosis (4.5 percent) developed in eight patients. In addition, 21 patients experienced 28 cases of post-operative ischemia (12.7 percent) with 19 cases (8.6 percent that occurred in 14 patients being considered major ischemia that required surgical intervention.

Most cases of ischemic complications were identified in patients who had a mild background of parenchymal enhancement (23.9 percent) – and additional 20 percent with minimal background parenchymal enhancement also experienced the complication. Patients with marked background parenchymal enhancement experienced major ischemia. Additionally, 80 percent of nipple necrosis cases occurred in patients with mild background parenchymal enhancement.

Her analysis also showed that all nipple necrosis and major ischemia presented in patients with scattered and hetereogenous fibroglandular tissue. Necrosis cases also developed in patients with minimal and mild nipple enhancement compared to the ipsilateral background parenchymal enhancement of MRI.

The record review also showed that African American women were disproportionately affected by these problems – they accounted for 50 percent of nipple necrosis cases, as well as 36.8 percent of major ischemic complications.

“There is a correlation between the pre-operative breast MRI imaging features of background parenchymal enhancement and the fibroglandular tissue and both post-operative major ischemic changes and nipple necrosis,” Utley concluded.

Images can pinpoint which women are at risk for ischemia and nipple necrosis.  

Pre-Operative Breast MRI Can Help Identify Patients Likely to Experience Nipple-Sparing Mastectomy Risks

Recent research has shed light on the low utilization rate for low-dose CT lung cancer screening, but there’s been little investigation into what might drive adherence to annual screening and what might keep people away.

 on March 30, investigators from the University of Colorado Anschutz Medical Campus took a deep dive into insurance claims and found that age, geographic location, and type of insurance coverage can keep at-risk patients from getting screened on a yearly basis.

“The State of Lung Cancer”: Single-Digit Low-Dose CT Screening and Significant Outcomes Disparities

“Quantifying population-based adherence rates and understanding factors associated with annual adherence is a critical first step in improving screening adherence and ultimately reducing lung cancer death,” said the team led by Stephen P. Malkoski, M.D., Ph.D., associate clinical professor of medicine, pulmonary sciences, and critical care.

Even though current data shows that survival rates for lung cancer detected at earlier stages is 55 percent, reports of real-world screening compliance outside of clinical trials show between 37 percent and 66 percent adherence, the team said. This is the first study to examine insurance claims data to identify factors that influence adherence rates.

For retrospective their study, Malkoski’s team evaluated 9,056 claims records from the Colorado All Payer Claims Dataset of people who had undergone screening with low-dose CT. Of the group 3,072 were adherent patients, 3,570 were non-adherent patients, and 2,414 patients couldn’t be classified. The team defined adherence as a second screening claim filed within 10 months-to-18 months of the initial claim.

Overall, when using the 18-month definition, they found 46-percent adherence. It increased to 53 percent if any second claim timeframe was considered adherence. Of the patients who came in for a second screening, 50 percent continued their adherence.

More specifically, the team determined that patients between ages 55 and 64, as well as those between ages 75 and 79 had a 20-percent adherence reduction.

USPSTF Updates Recommendation for LDCT Lung Cancer Screening

“Reduced adherence among older individuals is likely explained by multiple recommendations to stop [lung cancer screening] as individuals reach their mid-70s, and an increasing proportion of patients who may have a shorter life expectancy and hence derive less screening benefit,” they said. “Younger individuals are less likely to receive preventive services than individuals over 65 and may have competing time priorities and misperceptions about screening cost.”

If patients lived in rural areas, Malkoski’s team found they had a 44-percent drop in adherence compared to urban residents, despite having higher rates of smoking. In addition, individuals with Medicare fee-for-service and Medicaid had a 45-percent adherence reduction over those with Medicare Advantage.

The team also found that outpatients who had no co-morbidities were slightly more likely to adhere to annual screening.

“That the association between adherence and healthcare utilization was most pronounced in individuals with no co-morbidities may suggest that healthcare utilization alone is associated with higher adherence to preventive services,” they explained.

No association was found between adherence and gender.

These results could be used to pinpoint populations that could benefit from specific interventions designed to increase adherence and maximize the benefit of lung cancer screening efforts. These interventions, which have been successful with breast, colon, cervical, and prostate cancer screening adherence, could include dedicated program coordinators, patient reminders, and mobile screening for rural residents.

Results show screening adherence is low among patients who could benefit most from scans.

Age, Location, and Insurance Influence Lung Cancer Screening Adherence

It’s possible to capture the same quality images with MRI for some painful knee conditions in half the time, according to new research.

According to a study from Johns Hopkins University School of Medicine, published in 

a 5-minute MRI protocol is equivalent to a 10-minute one. These findings could make patient care faster and more effective, reducing the time patients are in discomfort.

“Rapid knee MRI using combined simultaneous multi-slice (SMS) technique and parallel imaging (PI) acceleration can add value through reduced acquisition time but requires validation of clinical efficacy,” said the team of investigators led by Filippo Del Grande, M.D.

A parallel imaging acquisition protocol or multi-slice acquisition captured at the same time are typical methods providers use to image and diagnose knee conditions with MRI in less time. But, is 10-minute scan short enough? Del Grande’s team wondered it were possible to cut that time in half.

MRI Knee Protocol Halves Scan Time, Safeguards Imaging Quality

For their study, they enrolled 252 patients between April 2018 and October 2019 and performed knee MRI scans using either a standard two-fold parallel turbo spin-echo 10-minute scan or a four-fold, multi-slice/parallel imaging-accelerated, turbo spin-echo protocol in 5 minutes. Patients were imaged on either a 1.5T scanner (104 patients) or a 3T scanner (148 patients).

The scans were examined by three radiologists who evaluated them for meniscal, tendinous, ligamentous, and osseocartilaginous injuries. Using these assessments, Del Grande’s team compared protocol performance and found no statistically significant differences between the 5-minute and 10-minute protocols, indicating they performed equivalently across knee conditions and magnet strengths.

Specifically, they said, inter-method agreements, measured by kappa coefficient, were good at 1.5T and very good at 3T -- >0.71 and >0.83, respectively. In addition, the diagnostic performances of both the 5-minute and 10-minute protocols were similar for 1.5T, as well as 3T, with areas under the curve of >0.78 and >0.83, respectively.

These results, the team said, demonstrate that combined SMS and PI acceleration for 5-minute, five-sequence 1.5T and 3T knee MRI is clinically feasible.

Outside experts agreed, in an accompanying 

, that these findings indicate rapid knee MRI could be around the corner. Naveen Subhas, M.D., MPH, associate professor of radiology in the Cleveland Clinic’s musculoskeletal division, noted that this technique is the only one currently clinically available that can truncate acquisition times to 5 minutes with the same diagnostic performance and without diminishing image resolution or quality.

“This study brings us one step closer to establishing a new normal: the 5-minute knee MRI,” he said.

Cutting the time for a knee MRI protocol in half can accelerate image capture without compromising image resolution or quality.

A Knee MRI in Half the Time? It’s Possible

Providers can get valuable body composition information from chest CT scans that can lead to a better understanding of overall health for patients with chronic obstructive pulmonary disease (COPD), including their risk of all-cause mortality.

investigators from Johns Hopkins University examined scans from patients with this condition and determined the added detail could lead to earlier intervention and reduced risk.

While CT is typically used to evaluate the lung health of patients with COPD, it could also play a role in evaluating the impact of other associated conditions, such as obesity and sarcopenia, through soft-tissue biomarkers. This could be particularly helpful because obesity has the opposite effect in COPD patients than would be expected – it is associated with lower mortality.

“Chest CT scans have long focused on the lungs or heart,” said study co-author David A. Bluemke, M.D., Ph.D., from the University of Wisconsin School of Medicine and Public Health. “Few prior investigators have evaluated muscle quality, bone density, or degeneration of the spine as an index of overall health. These are readily available and quantifiable in these CT examinations.”

Along with Johns Hopkins School of Medicine colleagues Farhad Pishgar, M.D., MPH, and Shadpour Demehri, M.D., Bluemke, who is also 

 editor, examined chest CT scans to pinpoint associations between soft-tissue markers picked up on images and the all-cause mortality in COPD.

For their study, they included 2,994 participants who were involved in the Multi-Ethnic Study of Atherosclerosis (MESA), a large trial that looks at the role of these biomarkers in predicting outcomes that are relevant to cardiopulmonary diseases. Of the study population, 265 patients had COPD, 49 (18 percent) of whom died during the follow-up period.

In addition, the team determined that having more intermuscular fat, which is linked to diabetes and insulin resistance, was associated with higher mortality rates. However, having more subcutaneous fat tissue was associated with lower all-cause mortality risk. This contrast showed, they said, that fat in the muscles is a more effective predictor of bad outcomes.

“Compared with subcutaneous adipose tissue quantification, intermuscular adipose tissue may be a better marker for predicting all-cause mortality in patients with COPD,” said the team, pointing out that intermuscular adipose tissue accumulation occurs before any loss of muscle volume and the index is less affected by weight fluctuations. “The [intermuscular adipose tissue] index is an indicator of other underlying co-morbidities (e.g., diabetes and hypertension) and may predict the all-cause mortality better.”

Based on these results, the team determined that benefit could come from body composition assessment in patients with COPD who have chest CT scans. Incorporating artificial intelligence algorithms could facilitate automatically adding risk assessment to the imaging report.

“I expect that more studies in the future will begin looking at all information on the CT, rather than just one organ at a time,” Bluemke said. “Clinicians will need thresholds when to intervene when fat or bone abnormalities become severe.”

Outside experts re-iterated that assessment. In an accompanying 

, Nicola Sverzellati, M.D., Ph.D., and Filippo Cademartiri, M.D., Ph.D., from the University of Parma in Italy, agreed that this study’s outcomes point to the efficacy of using soft-tissue markers visualized on chest CT in estimating COPD patient’s mortality risk. The potential exists for chest CT to become an important arrow in the quiver for personalized medicine, they said.

“Whether it is incorporated into routine assessment for patients with COPD will ultimately depend on our ability to demonstrate that this information changes treatment and improves outcomes,” they concluded.

The use of soft-tissue biomarkers identified on chest CT can be a reliable way to accurately assess risk.



Chest CT Accurate in Estimating All-Cause COPD Mortality Risk

What is the diagnosis in this patient who is a 68-year-old male retired cement factory worker with progressive shortness of breath?


 A 68-year-old male retired cement factory worker presented with progressive exertional dyspnea and clubbing. PA and Lateral plain films were obtained.

Multiple diffuse opacities can be seen in the lower lung fields. Lateral view shows diffuse plaques in the lung parenchyma, as well as the pleura. Heart and diaphragmatic contours are poorly defined. Given the patient’s occupational exposure to asbestosis, these findings are most consistent with a diagnosis of asbestosis.

Asbestosis is a diffuse parenchymal lung disease caused by the formation of fibrous plaques in response to exposure to asbestos dust. Though environmental exposure to asbestos is now limited by regulations, there is a 10 year-to-20 year latency from exposure to symptoms so patients continue to present with asbestos-related diseases.

The severity of asbestosis seems to be proportional to the level of exposure and is usually seen in patients with a 10-plus year history of occupational exposure. Asbestos fibers in the lungs induce an inflammatory response that leads to fibrogenesis around the fibers. The process occurs bilaterally in the lower lobes, although in advanced disease, the middle and even upper lobes may be involved.

Clinical symptoms resemble those of other interstitial lung diseases and include:
• Progressive dyspnea
• Inspiritory crackles
• Clubbing
• Cyanosis (rare)
• Reduced diffusion capacity and compliance on pulmonary function tests


On plain radiograph:
• Shaggy heart sign
• “Ground-glass” opacification
• Small nodular opacities
• Ill-defined diaphragmatic contours
• Honeycombing (more severe cases)
• Pleural thickening
• Calcified pleural plaques

CT is more sensitive for detecting asbestosis and is useful in early diagnosis.
• Subpleural curvilinear opacities
• Parenchymal bands projecting in from pleura
• Ground-glass opacification
• Subpleural nodular opacities
• Thickening of interlobular septa
• Pleural plaques


Diagnosis of asbestosis is based on occupational exposure history and radiographic findings of diffuse lung disease. Pleural involvement is common in asbestosis but rare in other diffuse lung diseases. The differential diagnosis includes:

• Interstitial pneumonitis
• Idiopathic pulmonary fibrosis
• Connective tissue disease (sarcoidosis, systemic lupus erythematosis, rheumatoid arthritis)
• Other pneumoconiosis (eg silicosis)
• Pleurodesis
• Multifocal malignancy or calcified metastatic disease

What is the diagnosis in this patient who is a 68-year-old male?

Image IQ Quiz: Patient Presents with Progressive Shortness of Breath

Media coverage of screening tests worldwide is not necessarily balanced, a new study has found. While news reports herald the benefits of these exams, they do not always point out the downsides – the potential for over-diagnosis or conflicts of interest.

In a research letter published this week in 

a team of experts from Australia and the United Kingdom discussed how the media approaches conveying details about screening services. For their analysis, they looked at more than 1,100 medical news stories, nearly half of which were on the use of 3D mammography for breast cancer screening.

Based on their evaluation, the team, led by Mary O’Keefe, Ph.D., from the Institute for Musculoskeletal Health at Sydney Local Health District and the University of Sydney, determined that more than 60 percent of stories, including those from newspapers, television, podcasts, and blogs, only presented the benefits of screening.

These results point to a need for better reporting that can give the public more well rounded information about these tests, including the benefits and harms that can present, the team said.

“Strategies to improve media reporting so that professionals, patients, and the public receive more balanced information about early detection tests are urgently needed,” they said. “Higher quality reporting by journalists could encourage more healthy skepticism toward health options and curb over-diagnosis.”

Specifically, O’Keefe’s team examined 1,173 news stories published between 2016 and 2019. The articles discussed several topics, such as artificial intelligence, biopsy exams, blood biomarker tests, and Apple Watch electrocardiogram, with 579 focusing on 3D mammography. Their analysis showed 63 percent of stories discussed only screening benefits while 27 percent mentioned, but downplayed, potential harms, and 13 percent mentioned over-diagnosis.

The team also found that approximately half of stories incorporated input from sources who had conflicts of interest. However, only 12 percent of stories revealed such conflicts.

 accompanying the study, Tiffany Doherty, Ph.D., and Aaron Carroll, M.D., MS, from the Indiana University School of Medicine, said this lack of balanced reporting can pose particular risk for women between ages 40 and 49 who need routine screening mammography, noting such an exam is not supported by the U.S. Preventive Services Task Force.

But, presenting information about mammography screening can be complicated, they acknowledged.

“The harms include false-positive results, unnecessary biopsies, and over-diagnosis and treatment of breast cancer that would not have become a health threat if left undetected,” they said, pointing about that the exams are still important. “But, they have downsides, as well as upsides, and we do not serve patients and the public well by focusing only on the latter or overstating the former.”

More than 60 percent of news stories, including those discussing screening mammography, only highlight the potential benefits of testing.

Unbalanced Mammography Media Coverage Focuses on Benefits, Downplays Harms

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

Contrast-enhanced mammography (CEM) is an acceptable alternative to breast MRI for women who have breast implants, according to recently presented research.

CEM has already been shown to be an effective diagnostic or screening option for women with an increased breast cancer risk or who have dense breasts and cannot undergo breast MRI. In a poster presentation during the Society of Breast Imaging/American College of Radiology 2021 Annual Meeting, Molly P. Hogan, M.D., assistant attending provider in breast imaging service at Memorial Sloan Kettering Cancer Center, detailed the performance of CEM in women with breast implants.

For more Society of Breast Imaging conference coverage, click here.

“It is feasible to utilize CEM in both a diagnostic and screening capacity in women with breast implants,” she said. “Women who are at increased risk of developing breast cancer or who require extent of disease evaluation, but are unable to undergo MRI evaluation, can consider CEM as a safe alternative.”

To evaluate efficacy, Hogan conducted a retrospective review of 104 women with breast implants who underwent 198 CEM exams (102 bilateral and 96 unilateral) between November 2014 and March 2020. She reviewed electronic medical records and imaging reports for exam indication, technique, and patient characteristics, such as breast density and implant type, and compared those outcomes to results from women without implants.

Of the women who had implants, 93 percent had dense breasts, and 32 had saline implants, 70 had silicone ones, and two women and one saline and one silicone. The vast majority of women (90 percent) had sub-pectoral implants with only 10 percent having retro-glandular implants. Most exams – 88 percent – were for screening due to increased risk, but 5 percent were for palpable abnormalities. The remaining scans were either to assess disease extent following neoadjuvant chemotherapy for a known malignancy or for a six-month follow-up.

According to her analysis, the accuracy of the 174 screening exams did not significantly differ from those conducted in the control group, and 99.5 percent of patients reported no complications.

Ultimately, she said, CEM can successfully be used clinically.

“Contrast enhanced digital mammography is a technically feasible and clinical useful exam in women with breast implants,” she concluded.

CEM performance showed no significant difference between women with or without breast implants, and it produced very few complications.



For Breaking News about Cancer Diagnoses, Patients Prefer Breast Imagers

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

Contrast-Enhanced Mammography Useful in Women with Breast Implants