Effects of salinization on the occurrence of a long-lived vertebrate in a desert river.

The lower Pecos River located in the southwest USA, is a naturally saline river system that has been significantly altered in relatively recent years. Climate change, coupled with anthropogenic disturbances such as dam construction have led to portions of the river becoming more susceptible to increased salinization and declines in water quality. These alterations have been documented to be detrimental to multiple freshwater communities; however, there is a lack of knowledge on how these alterations influence long-lived species in the river, such as freshwater turtles, where the effects can appear over dramatically different temporal scales. The Rio Grande Cooter (Pseudemys gorzugi) is a species of concern known to occur in the Pecos River. To understand the current distribution and habitat requirements for P. gorzugi in the Pecos River, we used a single-season, single-species occupancy modeling framework to estimate occurrence while accounting for the sampling process. Day of year, water surface area, and water visibility had the greatest influence on the ability to detect the species given a sampling unit is occupied. Conductivity (a measure of salinity) had the greatest influence on the occupancy probability for the species, where sites with higher conductivity coincided with lower occupancy probabilities. This study indicates that increased salinization on the lower Pecos River is a cause for concern regarding freshwater turtle populations within the Chihuahuan Desert.

Can Radiologists Predict the Presence of Ductal Carcinoma In Situ and Invasive Breast Cancer?

OBJECTIVE: We hypothesize that radiologists' estimated percentage likelihood assessments for the presence of ductal carcinoma in situ (DCIS) and invasive cancer may predict histologic outcomes. MATERIALS AND METHODS: Two hundred fifty cases categorized as BI-RADS category 4 or 5 at four University of California Medical Centers were retrospectively reviewed by 10 academic radiologists with a range of 1-39 years in practice. Readers assigned BI-RADS category (1, 2, 3, 4a, 4b, 4c, or 5), estimated percentage likelihood of DCIS or invasive cancer (0-100%), and confidence rating (1 = low, 5 = high) after reviewing screening and diagnostic mammograms and ultrasound images. ROC curves were generated. RESULTS: Sixty-two percent (156/250) of lesions were benign and 38% (94/250) were malignant. There were 26 (10%) DCIS, 20 (8%) invasive cancers, and 48 (19%) cases of DCIS and invasive cancer. AUC values were 0.830-0.907 for invasive cancer and 0.731-0.837 for DCIS alone. Sensitivity of 82% (56/68), specificity of 84% (153/182), positive predictive value (PPV) of 66% (56/85), negative predictive value (NPV) of 93% (153/165), and accuracy of 84% ([56 + 153]/250) were calculated using an estimated percentage likelihood of 20% or higher as the prediction threshold for invasive cancer for the radiologist with the highest AUC (0.907; 95% CI, 0.864-0.951). Every 20% increase in the estimated percentage likelihood of invasive cancer increased the odds of invasive cancer by approximately two times (odds ratio, 2.4). For DCIS, using a threshold of 40% or higher, sensitivity of 81% (21/26), specificity of 79% (178/224), PPV of 31% (21/67), NPV of 97% (178/183), and accuracy of 80% ([21 + 178]/250) were calculated. Similarly, these values were calculated at thresholds of 2% or higher (BI-RADS category 4) and 95% or higher (BI-RADS category 5) to predict the presence of malignancy. CONCLUSION: Using likelihood estimates, radiologists may predict the presence of invasive cancer with fairly high accuracy. Radiologist-assigned estimated percentage likelihood can predict the presence of DCIS, albeit with lower accuracy than that for invasive cancer.

Inter-reader Variability in the Use of BI-RADS Descriptors for Suspicious Findings on Diagnostic Mammography: A Multi-institution Study of 10 Academic Radiologists.

RATIONALE AND OBJECTIVES: The study aimed to determine the inter-observer agreement among academic breast radiologists when using the Breast Imaging Reporting and Data System (BI-RADS) lesion descriptors for suspicious findings on diagnostic mammography. MATERIALS AND METHODS: Ten experienced academic breast radiologists across five medical centers independently reviewed 250 de-identified diagnostic mammographic cases that were previously assessed as BI-RADS 4 or 5 with subsequent pathologic diagnosis by percutaneous or surgical biopsy. Each radiologist assessed the presence of the following suspicious mammographic findings: mass, asymmetry (one view), focal asymmetry (two views), architectural distortion, and calcifications. For any identified calcifications, the radiologist also described the morphology and distribution. Inter-observer agreement was determined with Fleiss kappa statistic. Agreement was also calculated by years of experience. RESULTS: Of the 250 lesions, 156 (62%) were benign and 94 (38%) were malignant. Agreement among the 10 readers was strongest for recognizing the presence of calcifications (k = 0.82). There was substantial agreement among the readers for the identification of a mass (k = 0.67), whereas agreement was fair for the presence of a focal asymmetry (k = 0.21) or architectural distortion (k = 0.28). Agreement for asymmetries (one view) was slight (k = 0.09). Among the categories of calcification morphology and distribution, reader agreement was moderate (k = 0.51 and k = 0.60, respectively). Readers with more experience (10 or more years in clinical practice) did not demonstrate higher levels of agreement compared to those with less experience. CONCLUSIONS: Strength of agreement varies widely for different types of mammographic findings, even among dedicated academic breast radiologists. More subtle findings such as asymmetries and architectural distortion demonstrated the weakest agreement. Studies that seek to evaluate the predictive value of certain mammographic features for malignancy should take into consideration the inherent interpretive variability for these findings.

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review.

Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.

Impact of Breast Density Legislation on Breast Cancer Risk Assessment and Supplemental Screening: A Survey of 110 Radiology Facilities.

Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p < 0.831). In anticipation of breast density legislation, 33% (16/48), 6% (3/48), and 6% (3/48) of facilities in states with laws implemented handheld whole breast ultrasound (WBUS), automated WBUS, and tomosynthesis, respectively. The ratio of facilities offering handheld WBUS was significantly higher in states with a law than in states without (p < 0.001). In response to breast density legislation, more than 33% of facilities are offering supplemental screening with WBUS and tomosynthesis, and many are performing formal risk assessment for determining patient management.

Patients' Perceptions of Radiation Exposure Associated With Mammography.

OBJECTIVE: Radiation associated with breast imaging is a sensitive issue, particularly for women who undergo mammography as a screening measure to detect breast cancer. Misinformation and misunderstanding regarding the risks associated with ionizing radiation have created heightened public concern and fear, which may result in avoidance of diagnostic procedures. The objectives of this study were to ascertain patients' knowledge and opinion of ionizing radiation as a whole and specifically in mammography, as well as to determine common misunderstandings and points of view that may affect women's decisions about whether to have a mammogram. MATERIALS AND METHODS: Over a 9-month period, a total of 1725 patients presenting for a mammogram completed a 25-point questionnaire focused on the following: general knowledge of radiation dose in common imaging modalities, the amount of radiation associated with a mammogram relative to five radiation benchmarks, and patients' opinions of the involvement of radiation in their health care. RESULTS: Although 65% of the women receiving a mammogram responded that they had been informed of the risks and benefits of the examination, 60% overestimated the radiation in a mammogram. CONCLUSION: Efforts should be made to accurately inform women of the risks and benefits of mammography, specifically highlighting the low dose of mammographic ionizing radiation and providing objective facts to ensure that they are making an informed decision regarding screening.

Criteria for identifying radiologists with acceptable screening mammography interpretive performance on basis of multiple performance measures.

OBJECTIVE: Using a combination of performance measures, we updated previously proposed criteria for identifying physicians whose performance interpreting screening mammography may indicate suboptimal interpretation skills. MATERIALS AND METHODS: In this study, six expert breast imagers used a method based on the Angoff approach to update criteria for acceptable mammography performance on the basis of two sets of combined performance measures: set 1, sensitivity and specificity for facilities with complete capture of false-negative cancers; and set 2, cancer detection rate (CDR), recall rate, and positive predictive value of a recall (PPV1) for facilities that cannot capture false-negative cancers but have reliable cancer follow-up information for positive mammography results. Decisions were informed by normative data from the Breast Cancer Surveillance Consortium (BCSC). RESULTS: Updated combined ranges for acceptable sensitivity and specificity of screening mammography are sensitivity≥80% and specificity≥85% or sensitivity 75-79% and specificity 88-97%. Updated ranges for CDR, recall rate, and PPV1 are: CDR≥6 per 1000, recall rate 3-20%, and any PPV1; CDR 4-6 per 1000, recall rate 3-15%, and PPV1≥3%; or CDR 2.5-4.0 per 1000, recall rate 5-12%, and PPV1 3-8%. Using the original criteria, 51% of BCSC radiologists had acceptable sensitivity and specificity; 40% had acceptable CDR, recall rate, and PPV1. Using the combined criteria, 69% had acceptable sensitivity and specificity and 62% had acceptable CDR, recall rate, and PPV1. CONCLUSION: The combined criteria improve previous criteria by considering the interrelationships of multiple performance measures and broaden the acceptable performance ranges compared with previous criteria based on individual measures.

A survey of breast imaging fellowship programs: current status of curriculum and training in the United States and Canada.

PURPOSE: The Society of Breast Imaging and the Education Committee of the ACR Breast Commission conducted a survey of breast imaging fellowship programs to determine the status of fellowship curricula, help identify strengths and potential areas for improvement, and assess the current demand for fellowship programs. METHODS: In 2012, a two-part survey was emailed to breast imaging fellowship directors from 72 fellowship programs. RESULTS: Of the 66 respondents, a total of 115 positions were identified. There were 90 positions with 9-12 months of breast imaging, and 25 positions with 6 months focused on breast imaging. Approximately two-thirds of programs reported an increase in the number of fellowship applicants, with three-quarters having 3 or more applicants for each position. All programs offered digital mammography, breast MRI, and diagnostic ultrasound services, and nearly all provided experience with interventional procedures. Approximately one-third provided breast screening ultrasound training. More than two-thirds required at least a 1-day rotation with a breast surgeon. Important nonclinical areas of training were not addressed in many programs. Approximately 40% of programs did not offer training related to the practice audit, and one-third of programs did not provide formal training related to quality control. CONCLUSIONS: Breast imaging fellowships are currently in higher demand than in the past. Most fellowship programs provide training in the key imaging modalities and interventional procedures. Potential gaps in training for many programs include the practice audit, quality control procedures, breast positioning, and mammography technical factors.

Educational interventions to improve screening mammography interpretation: a randomized controlled trial.

OBJECTIVE: The objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation. MATERIALS AND METHODS: We randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance. RESULTS: One hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015). CONCLUSION: In this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

The California breast density information group: a collaborative response to the issues of breast density, breast cancer risk, and breast density notification legislation.

In anticipation of breast density notification legislation in the state of California, which would require notification of women with heterogeneously and extremely dense breast tissue, a working group of breast imagers and breast cancer risk specialists was formed to provide a common response framework. The California Breast Density Information Group identified key elements and implications of the law, researching scientific evidence needed to develop a robust response. In particular, issues of risk associated with dense breast tissue, masking of cancers by dense tissue on mammograms, and the efficacy, benefits, and harms of supplementary screening tests were studied and consensus reached. National guidelines and peer-reviewed published literature were used to recommend that women with dense breast tissue at screening mammography follow supplemental screening guidelines based on breast cancer risk assessment. The goal of developing educational materials for referring clinicians and patients was reached with the construction of an easily accessible Web site that contains information about breast density, breast cancer risk assessment, and supplementary imaging. This multi-institutional, multidisciplinary approach may be useful for organizations to frame responses as similar legislation is passed across the United States. Online supplemental material is available for this article.

Establishing a gold standard for test sets: variation in interpretive agreement of expert mammographers.

RATIONALE AND OBJECTIVES: Test sets for assessing and improving radiologic image interpretation have been used for decades and typically evaluate performance relative to gold standard interpretations by experts. To assess test sets for screening mammography, a gold standard for whether a woman should be recalled for additional workup is needed, given that interval cancers may be occult on mammography and some findings ultimately determined to be benign require additional imaging to determine if biopsy is warranted. Using experts to set a gold standard assumes little variation occurs in their interpretations, but this has not been explicitly studied in mammography. MATERIALS AND METHODS: Using digitized films from 314 screening mammography exams (n = 143 cancer cases) performed in the Breast Cancer Surveillance Consortium, we evaluated interpretive agreement among three expert radiologists who independently assessed whether each examination should be recalled, and the lesion location, finding type (mass, calcification, asymmetric density, or architectural distortion), and interpretive difficulty in the recalled images. RESULTS: Agreement among the three expert pairs for recall/no recall was higher for cancer cases (mean 74.3 ± 6.5) than for noncancers (mean 62.6 ± 7.1). Complete agreement on recall, lesion location, finding type and difficulty ranged from 36.4% to 42.0% for cancer cases and from 43.9% to 65.6% for noncancer cases. Two of three experts agreed on recall and lesion location for 95.1% of cancer cases and 91.8% of noncancer cases, but all three experts agreed on only 55.2% of cancer cases and 42.1% of noncancer cases. CONCLUSION: Variability in expert interpretive is notable. A minimum of three independent experts combined with a consensus should be used for establishing any gold standard interpretation for test sets, especially for noncancer cases.

Diagnostic mammography: identifying minimally acceptable interpretive performance criteria.

PURPOSE: To develop criteria to identify thresholds for the minimally acceptable performance of physicians interpreting diagnostic mammography studies. MATERIALS AND METHODS: In an institutional review board-approved HIPAA-compliant study, an Angoff approach was used to set criteria for identifying minimally acceptable interpretive performance for both workup after abnormal screening examinations and workup of a breast lump. Normative data from the Breast Cancer Surveillance Consortium (BCSC) was used to help the expert radiologist identify the impact of cut points. Simulations, also using data from the BCSC, were used to estimate the expected clinical impact from the recommended performance thresholds. RESULTS: Final cut points for workup of abnormal screening examinations were as follows: sensitivity, less than 80%; specificity, less than 80% or greater than 95%; abnormal interpretation rate, less than 8% or greater than 25%; positive predictive value (PPV) of biopsy recommendation (PPV2), less than 15% or greater than 40%; PPV of biopsy performed (PPV3), less than 20% or greater than 45%; and cancer diagnosis rate, less than 20 per 1000 interpretations. Final cut points for workup of a breast lump were as follows: sensitivity, less than 85%; specificity, less than 83% or greater than 95%; abnormal interpretation rate, less than 10% or greater than 25%; PPV2, less than 25% or greater than 50%; PPV3, less than 30% or greater than 55%; and cancer diagnosis rate, less than 40 per 1000 interpretations. If underperforming physicians moved into the acceptable range after remedial training, the expected result would be (a) diagnosis of an additional 86 cancers per 100,000 women undergoing workup after screening examinations, with a reduction in the number of false-positive examinations by 1067 per 100,000 women undergoing this workup, and (b) diagnosis of an additional 335 cancers per 100,000 women undergoing workup of a breast lump, with a reduction in the number of false-positive examinations by 634 per 100,000 women undergoing this workup. CONCLUSION: Interpreting physicians who fall outside one or more of the identified cut points should be reviewed in the context of an overall assessment of all their performance measures and their specific practice setting to determine if remedial training is indicated.

Cost minimization analysis of ultrasound-guided diagnostic evaluation of probably benign breast lesions.

The objective of this study was to compare direct health care costs for two competing diagnostic strategies for probably benign breast lesions detected by ultrasound in young women. We developed a decision analytic model and performed a cost minimization analysis comparing ultrasound-guided vacuum-assisted core biopsy and conservative short-term diagnostic ultrasound follow-up. Relative probabilities for diagnostic outcomes were derived from pooled analysis of the medical literature. Direct health care costs were estimated using United States national average figures from calendar year 2010. Deterministic sensitivity analyses were conducted, as well as a first-order Monte Carlo simulation to confirm cost differences between the two strategies. The conservative short-term imaging follow-up strategy ($639.55 average cost per patient) was the most economical strategy compared to immediate vacuum-assisted core biopsy ($879.55 average cost per patient). Sensitivity analyses demonstrated that the preferred strategy is most dependent on the probabilities of detecting change in appearance on follow-up ultrasound, having a benign finding on immediate core biopsy, and finding cancer on a biopsy triggered by an interval change in ultrasound appearance. The model was also sensitive to the costs of vacuum-assisted core biopsy and diagnostic ultrasound. Conservative imaging follow-up of BIRADS 3 breast masses by ultrasound is cost saving compared to immediate vacuum-assisted core biopsy, with a potential of saving more than one-third of overall costs associated with the diagnostic work-up of such lesions. Watchful waiting with short-term interval follow-up ultrasounds will spare women from unnecessary procedures and spare the United States health care system from unnecessary direct health care costs.

Patients' willingness to participate in a breast cancer biobank at screening mammogram.

To characterize patients' willingness to donate a biospecimen for future research as part of a breast cancer-related biobank involving a general screening population. We performed a prospective cross-sectional study of 4,217 women aged 21-89 years presenting to our facilities for screening mammogram between December 2010 and October 2011. This HIPAA-compliant study was approved by our institutional review board. We collected data on patients' interest in and actual donation of a biospecimen, motivators and barriers to donating, demographic information, and personal breast cancer risk factors. A multivariate logistic regression analysis was performed to identify patient-level characteristics associated with an increased likelihood to donate. Mean patient age was 57.8 years (SD 11.1 years). While 66.0 % (2,785/4,217) of patients were willing to donate blood or saliva during their visit, only 56.4 % (2,378/4,217) actually donated. Women with a college education (OR = 1.27, p = 0.003), older age (OR = 1.02, p < 0.001), previous breast biopsy (OR = 1.23, p = 0.012), family history of breast cancer (OR = 1.23, p = 0.004), or a comorbidity (OR = 1.22, p = 0.014) were more likely to donate. Asian-American women were significantly less likely to donate (OR = 0.74, p = 0.005). The major reason for donating was to help all future patients (42.3 %) and the major reason for declining donation was privacy concerns (22.3 %). A large proportion of women participating in a breast cancer screening registry are willing to donate blood or saliva to a biobank. Among minority participants, Asian-American women are less likely to donate and further qualitative research is required to identify novel active recruitment strategies to insure their involvement.

Ordering of CT by emergency department provider type: analysis of a nationally representative sample.

OBJECTIVE: Given the growing concern about CT overutilization, we provide a descriptive trend analysis of CT studies ordered in U.S. emergency departments by nonphysician health care providers and examine whether there is a significant difference in ordering patterns between nonphysicians and physicians. MATERIALS AND METHODS: We used a nationally representative data sample for 2001-2008 to describe trends in CT studies ordered in U.S. emergency departments by nonphysician health care providers. We performed a multivariate logistic regression with hospital fixed effects on the most recently available data to determine whether there is a difference in ordering patterns between the two provider groups. RESULTS: From 2001 to 2008, the number of emergency department visits associated with CT studies managed solely by nonphysician health care providers increased from 100,626 to 620,296. Over this same period, the proportion of emergency department visits associated with CT managed solely by nonphysician providers grew from 1.5% to 3.6%. Controlling for hospital-level and patient-level variables, patient visits managed solely by nonphysician providers had 0.38 times the odds of CT utilization compared with patient visits managed by physicians. CONCLUSION: Although both the total number and the proportion of emergency department visits managed independently by nonphysician providers and associated with CT have grown rapidly in the past decade, nonphysician health care providers are less likely to order CT compared with physicians. The types of ordering providers and their differing practices should become part of the discourse regarding appropriate CT utilization.

Mammographic signs of systemic disease.

Although mammography is primarily used for the detection of breast cancer, it can occasionally reveal breast abnormalities related to extramammary disease. Cardiovascular diseases such as congestive heart failure and central venous obstruction may manifest as venous engorgement and breast edema at mammography. Pathologic arterial calcifications seen at mammography can indicate an underlying risk factor for accelerated atherosclerosis such as chronic renal failure. Connective tissue diseases including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis-polymyositis, and systemic scleroderma typically manifest with bilateral axillary lymphadenopathy, and stromal calcifications are also seen in the latter three disease processes. Some diseases such as neurofibromatosis type 1 and filariasis may manifest with pathognomonic findings at mammography, whereas other systemic diseases such as Wegener granulomatosis, sarcoidosis, and amyloidosis can manifest as nonspecific breast masses that are indistinguishable from breast cancer and usually require tissue biopsy for confirmation. Knowledge of the imaging characteristics of various systemic diseases affecting the breast will aid the radiologist in differentiating systemic disease from suspect breast lesions, thereby helping ensure appropriate follow-up. Furthermore, recognition of systemic diseases such as Cowden syndrome that are associated with an increased risk of breast cancer will allow the radiologist to recommend appropriate surveillance.

Breast imaging training and attitudes: update survey of senior radiology residents.

OBJECTIVE: The purpose of this study was to investigate the training and attitudes of senior residents regarding breast imaging. MATERIALS AND METHODS: In 2008 a follow-up survey was completed by a chief or senior resident at 201 radiology training programs in North America. Questions included organization of breast imaging rotation, resident responsibilities, clinical practice protocols at the institution, resident impressions regarding breast imaging, and resident interest in performing breast imaging after residency. Results were compared with those of a survey completed in 2000. RESULTS: Of 201 training programs, 200 (99.5%) had dedicated breast imaging rotations; 190 (95%), 12 weeks or longer; and 39 (19%), 16 weeks or longer. Residents regularly performed real-time ultrasound imaging in 138 programs (69%), needle localization in 159 (79%), ultrasound-guided biopsy in 154 (77%), and stereotactically guided biopsy in 145 programs (72%). One hundred sixty-two residents (81%) reported that interpreting mammograms was more stressful than interpretation of other imaging studies; 143 (71%) believed that only breast imaging subspecialists should interpret mammograms; and 104 (52%) would not consider pursuing a breast imaging fellowship. As in 2000, the most common reasons cited for not considering a fellowship were lack of interest in the field, fear of lawsuits, and the stressful nature of the job. CONCLUSION: Residency programs have devoted more time to breast imaging and made improvements in their curricula, but current residents report decreased opportunities to perform some studies and procedures. Although most residents would not consider a fellowship and did not want to interpret mammograms in future practice, the percentage of residents who would not consider breast imaging as a subspecialty has decreased since 2000. An accurate picture of current breast imaging curricula and variations among residency programs is necessary to identify and correct systemic problems and to improve the training of future breast imagers.

Use of BI-RADS 3-probably benign category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial.

PURPOSE: To determine (a) how often the Breast Imaging Reporting and Data System (BI-RADS) category 3 was used in the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), either at the time of screening mammography or after work-up, (b) how often subjects actually returned for the recommended follow-up examination, and (c) the rate and stages of any malignancies subsequently found in subjects for whom short-term interval follow-up was recommended. MATERIALS AND METHODS: This study was approved by the Institutional Review Board at all institutions where subjects were enrolled. All subjects participating in DMIST gave informed consent and the study was HIPAA-compliant. A total of 47,599 DMIST-eligible and evaluable subjects, all of whom consented to undergo both digital and screen-film mammography, were included in this analysis. Cases referred for short-term interval follow-up based on digital, screen-film, or both imaging examinations were determined. Compliance with the recommendations and the final outcome (malignancy diagnosis at biopsy or no malignancy confirmed through follow-up) of each evaluable case were determined. RESULTS: A total of 1114 of the 47,599 (2.34%) subjects had tumors assigned a BI-RADS 3 category and were recommended to undergo short-interval follow-up. In this study, 791 of 1114 (71%) of the subjects were compliant with the recommendation and returned for short-interval follow-up. Of the women who did not return for short-interval follow-up, 70% (226 of 323) did return for their next annual mammography. Among all subjects whose tumors were assigned a BI-RADS 3 category either at screening mammography or after additional work-up, nine of 1114 (0.81%) were found to have cancer. Of the nine biopsy-proved cancers, six were invasive cancers and three were ductal carcinoma in situ stage Tis-T1c. The invasive cancers were all less than 2 cm in size. CONCLUSION: In DMIST, radiologists used the BI-RADS 3 classification infrequently (2.3% of patients). Tumors assigned a BI-RADS 3 category had a low rate of malignancy. The relatively high rate of noncompliance with short-interval follow-up recommendations (323 of 1114, or 29%) supports prior recommendations that radiologists thoroughly evaluate lesions before placing them in this category.