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.

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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.”

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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

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.

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“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.



Contrast-Enhanced Mammography Useful in Women with Breast Implants

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.

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.

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.

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

The “Safer at Home” order issued early in the COVID-19 pandemic was intended to help stem the spread of the virus, but it also led to the much-discussed, significant drop-off in imaging services.

According to an e-poster that will be presented during the 2021 ARRS Virtual Annual Meeting, this protective order prompted a reduction in radiology ordering, outpatient consultations, and emergency department visits. The results, presented by investigators from Olive View-UCLA Medical Center, point to a 40-percent decline in radiology orders during the that time period.

“There was a disproportionate impact in the outpatient setting, especially on screening and other non-essential imaging,” wrote Evan Raff, M.D., MHA, patient safety officer for the radiology department, “which mirrors the impact that the order has had on clinical services, as reflected in outpatient consult volumes, with larger declines in specialties with high screening rates, including in gastroenterology, optometry/ophthalmology, and gynecology.”

By reviewing radiology orders, indications, and appropriateness for the studies conducted at Los Angeles County’s Department of Health Services system, Raff pinpointed a 40-percent drop that followed the “Safer at Home” order. In addition, he also found a 67-percent drop in outpatient volumes, a 21-percent decline in emergency department volumes, and a 13-percent reduction in inpatient volumes.

From his analysis, dexa and breast imaging felt the greatest impact with volumes that plummeted by 88 percent and 80 percent, respectively. Body CT and interventional radiology fared better – 29 percent and 26 percent declines, respectively.

His evaluation even unearthed a 44-percent decline in emergency department visits that are typically viewed as urgent and essential.

ARRS

Impact felt the most in specialties with high screening rates, least in interventional radiology.

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