Radiology Done Right

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How breast imaging has built a model practice

Excellence in some fields of medicine seems to be born of necessity. When a condition becomes so prevalent that it touches the lives of almost everyone you know in some way, patient demand for quality care raises the bar for better health care practices. That has been the case, many agree, for breast imaging.

For decades, the field has seen dramatic changes in screening techniques and follow-up care, massive surges in advocacy for prevention and treatment, and increased awareness and screening efforts that save thousands of lives annually. Widespread breast health education and funding continue to put radiologists who specialize in breast imaging at the forefront of progressive efforts to partner with other physicians, embrace and utilize technological advances, and build patients’ trust — all while reducing mortality rates.

Breast cancer mortality rates have decreased by nearly 40 percent in the United States since 1990 — due largely to mammography screening.1 “Annual screening beginning at age 40 saves the most lives, and screening is very effective for women who are in their 40s,” says Debra L. Monticciolo, MD, FACR, chair of the ACR Breast Imaging Commission and vice chair for research and section chief of breast imaging at Scott and White Medical Center in Temple, Texas. “Those who suggest that screening should begin later are not placing a high enough value on the years of life lost to breast cancer for women in their 40s.”
Large-scale screening of an undiagnosed population puts breast imagers in a very different position from many others in radiology. “From the get-go, standards for quality had to be high,” says Dana H. Smetherman, MD, section head of breast imaging at Ochsner Medical Center in New Orleans, La. “If you’re going to intervene in an asymptomatic group of people, you must make sure that what you’re doing is going to make a difference. So we are very stringent about our quality standards.”

The Mammography Quality Standards Act (MQSA) in the early 1990s set a very high bar, Smetherman says, for equipment and training for radiologists, technologists, and medical physicists. “I think it set breast imaging a little bit apart in radiology early on,” she says. Since then, breast imagers have been at the forefront of using computer-aided detection — and managing not to be replaced by computers. They were among the first to effectively use a standardized lexicon (the Breast Imaging Reporting and Data System, or BI-RADS®) and structured reporting. They are also among the most patient-facing radiologists and have had tremendous outreach success in working across specialties. They have been able to bolster funding for new and expanded research and screening, notes Monticciolo, at the same time raising patient awareness of the importance of breast health.

Partnering With Patients

Breast imagers at the forefront of patient-facing radiology offer an example of how to enhance physician-patient interaction in everyday practice.2 “We go into this area of radiology understanding that patient contact is part of it,” says Jay A. Baker, MD, FACR, vice chair of clinical operations and chief of the division of breast imaging at Duke University Medical Center in Durham, N.C. “We do things we don’t get paid for, like setting up referrals to surgeons. It can take time for other radiologists to shift their comfort zone in dealing with patients.”

“It’s really important to be cognizant of how we can help patients with imaging and of how they view us,” says Monticciolo. It helps, she says, to put yourself in the patient’s position. Having a patient-centered focus drives quality, not only in interpretation but in the total care to the patient, she insists. “Breast imagers really focus on the patient behind the images. Everything else follows naturally from that.”

For example, Monticciolo says, in her practice, when a woman comes in to have a lump examined and something is found on an ultrasound that warrants a biopsy, a member of the breast imaging team talks to the patient. “Number one, we tell her the results face-to-face. Then we try to get the follow-up scheduled as quickly as possible,” she says

The breast imager essentially acts as the primary-care physician for a patient with a breast condition, at least until it’s determined that a surgeon may be needed, says Baker. It’s not realistic for all radiologists to interact with their patients in the same way, Baker points out. “I’m always happy to talk about the things that breast imagers do for patients and referring clinicians in making the best patient-care experience possible,” he says. “But it is another step altogether to claim that chest radiologists, general radiologists, or abdominal imagers easily can follow our lead if only they would get on board.”
All radiologists, however, can bolster efforts toward very attainable goals, such as clear, expedited communication and collaboration with patients and referring physicians. A lot of breast imagers set up surgical consults for patients who need them. “A lot of patients are overwhelmed when they are told something is wrong. It helps them get through the whole process when you schedule a biopsy or other follow-up service for them,” says Monticciolo

Structuring the Information

A big part of effectively communicating with both patients and other physicians — alleviating anxiety and improving outcomes — is by using standardized and patient-friendly language. Breast imagers were among the first radiologists to embrace structured reporting and accept a common vocabulary. This reporting strategy promotes standardized, concise, descriptive reports with definitive directive recommendations, which add value for referring clinicians.3 The purpose of structured reporting is to communicate to colleagues clearly and to make the information that is reported accessible to the software applications that also will process it.4 It makes information available in electronic records systems and can aid in decision-making. In the expanding age of big data and machine learning, structured reporting and the ability to create and populate large databases for data mining are critical components of radiology.5

“We developed databases to track our performance earlier than the rest of radiology,” says Smetherman. “The requirements were such that we had to.” BI-RADS may be the best example in radiology of structured reporting and standardized language.6 It is a risk-assessment and quality-assurance tool for mammography, ultrasound, and MRI and uses standardized language to improve consistency in education and practice. One of its goals was to make mammography reporting more easily understandable to any non-radiologists reading a report.

It is just as important that patients understand what’s in their reports and what their options are for follow-up. “Radiologists who are just starting to talk to patients will have to be careful about using jargon,” says Baker. “I’ve had several patients who are not very medically savvy come back to me not knowing they had cancer and that it was malignant.” They were told that the results of their biopsy were “positive” and the patients took that to indicate good news. You have to meet the patient at the knowledge base they have, Baker says. “We treat everyone from CEOs to patients with very little education. And even the CEOs don’t always have a good grasp of their medical situation,” he says.

Since 1999, MQSA has required that the interpreting physician send every patient who receives a mammogram a written mammography report expressed in terms easily understood by a lay person. BI-RADS has developed sample lay report letters to provide patients with clear results of their breast imaging procedures and instructions on what to do as a result.

Embracing the Technology

Ensuring that patients understand their situation and receive the best possible care can only happen when they have access to the most efficacious imaging tests. Numerous studies have shown that ultrasound and MRI are powerful supplemental modalities that can detect breast cancers not otherwise visible with mammography. Newer technologies, such as tomosynthesis, contrast-enhanced mammography, and breast CT imaging are fueling improved detection and characterization of breast lesions.7 Digital breast tomosynthesis (DBT), in particular, is being adopted more and more by radiology practices across the country, Baker notes.

DBT will be commonplace most likely within the next decade, Baker says. It’s available now at nearly 40 percent of mammography facilities in the United States. It will take a little while, Smetherman agrees, to see the benefits from patients not coming back for additional procedures and tests as a result of false positives. “It takes a front-end investment, whether investing in equipment or more storage space for the additional images generated from DBT,” she says. “And there’s the time of the radiologists to interpret the studies. But over the years practices will save money with fewer patients coming back.”
Perhaps more important to the success of breast imagers than a willingness to adopt new technology is a self-imposed awareness of who they are treating. What has put breast imaging in a different place from much of radiology is that it is very much tied to the large-scale screening of a population who believe they are well but may have a disease. “It’s important that patients not slip through the cracks,” Smetherman says. “We can’t have patients not coming in and then ending up with a cancer that could have been prevented.”

Breast imagers are poised to take their perspective into the future. Through new technologies and a proven track record of patient-focused care, other radiologists may want to keep an eye on their colleagues as all radiologists move toward value- and evidence-based payment models.


By Chad Hudnall, Managing Editor, ACR Press

 ENDNOTES
1. Mammography Saves Lives. Available at bit.ly/Mammography_Saves.
2. Bailey G. Leading the way in patient interaction. ACR Bulletin. 2016;71(10). Available at
bit.ly/Lead_Way.
3. Jones J. The perfect radiology report. ACR Bulletin. 2016;71(3). Available at
bit.ly/Perfect_Report.
4. Mayo RC, Parikh JR. Breast imaging: the face of Imaging 3.0. J Am Coll Radiol.
2016;13(8):1003–1007.
5. Ridley E. SIIM: Deep learning can help assess breast density. Available at bit.ly/Breast_DL.
6. Cramer JA, Eisenmenger LB, Pierson NS, et al. Structured and templated reporting: an
overview. Appl Radiol. Available at bit.ly/Template_Reporting.
7. Helvie MA. Digital mammography imaging: breast tomosynthesis and advanced applications.
Radiologic Clin of North Am. 2010;48(5):917–929.

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