The Impact of Mammographic, Radiologist, and Patient Factors on the Likelihood of Probably Benign (BI-RADS 3) Assessment at Diagnostic Mammography.

OBJECTIVE: To evaluate the association of mammographic, radiologist, and patient factors on BI-RADS 3 assessment at diagnostic mammography in patients recalled from screening mammography. METHODS: This Institutional Review Board-approved retrospective study of consecutive unique diagnostic mammography examinations in asymptomatic patients recalled from screening mammography March 5, 2014, to December 31, 2019, was conducted in a single large United States health care institution. Mammographic features (mass, calcification, distortion, asymmetry), breast density, prior examination, and BI-RADS assessment were extracted from reports by natural language processing. Patient age, race, and ethnicity were extracted from the electronic health record. Radiologist years in practice, recall rate, and number of interpreted diagnostic mammograms were calculated. A mixed effect logistic regression model evaluated factors associated with likelihood of BI-RADS 3 compared with other BI-RADS assessments. RESULTS: A total of 12 080 diagnostic mammography examinations were performed during the study period, yielding 2010 (16.6%) BI-RADS 3 and 10 070 (83.4%) other BI-RADS assessments. Asymmetry (odds ratio [OR] = 6.49, P <.001) and calcification (OR = 5.59, P <.001) were associated with increased likelihood of BI-RADS 3 assessment; distortion (OR = 0.20, P <.001), dense breast parenchyma (OR = 0.82, P <.001), prior examination (OR = 0.63, P = .01), and increasing patient age (OR = 0.99, P <.001) were associated with decreased likelihood. Mass, patient race or ethnicity, and radiologist factors were not significantly associated with BI-RADS 3 assessment. Malignancy rate for BI-RADS 3 lesions was 1.6%. CONCLUSION: Asymmetry and calcifications had an increased likelihood of BI-RADS 3 assessment at diagnostic evaluation with low likelihood of malignancy, while radiologist features had no association.

Imaging characteristics of interval cancers detected on Full Field Digital Mammography (FFDM) versus Digital Breast Tomosynthesis (DBT).

OBJECTIVE: To compare imaging features of interval cancers detected in patients screened with full field digital mammography (FFDM) versus digital breast tomosynthesis (DBT). MATERIALS/METHODS: This retrospective observational study consisted of female patients undergoing screening DM or FFDM at an academic medical center and two outpatient imaging facilities between January 2012 and June 2017. A natural language processing algorithm queried breast imaging reports for breast density and BI-RADS category. This was cross-referenced to an institutional breast cancer registry to identify interval cancers. Retrospective consensus review of the cases was done to categorize imaging features of interval cancers on FFDM vs DBT. RESULTS: The rate of interval cancers was comparable in patients screened with FFDM (30/39793) and DBT (29/32180) (p = 0.58). There was no significant difference in the rate, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. The most common mammographic features on diagnostic imaging across both groups was the presence of a mass (13/47). Almost equally common was negative diagnostic mammogram with mass detected only on ultrasound (11/47). The rate of interval cancers detected by high-risk surveillance breast MRI was increased in patients who previously had screening with DBT relative to those who had screening with FFDM (p = 0.0419). CONCLUSION: There is no significant difference in rate of detection, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. However, across both cohorts, the most common features on diagnostic mammogram were either the presence of a mass or a negative mammogram.

Positive predictive value of axillary lymph node cortical thickness and nodal, clinical, and tumor characteristics in newly diagnosed breast cancer patients.

PURPOSE: Axillary lymph nodes (LNs) with cortical thickness > 3 mm have a higher likelihood of malignancy. To examine the positive predictive value (PPV) of axillary LN cortical thickness in newly diagnosed breast cancer patients, and nodal, clinical, and tumor characteristics associated with axillary LN metastasis. METHODS: Retrospective review of axillary LN fine needle aspirations (FNAs) performed 1/1/2018-12/31/2019 included 135 axillary FNAs in 134 patients who underwent axillary surgery. Patient demographics, clinical characteristics, histopathology, and imaging features were obtained from medical records. Hypothesis testing was performed to identify predictors of axillary LN metastasis. RESULTS: Cytology was positive in 72/135 (53.3%), negative in 61/135 (45.2%), and non-diagnostic in 2/135 (1.5%). At surgery, histopathology was positive in 84 (62.2%) and negative in 51 (37.8%). LN cortices were thicker in metastatic compared to negative nodes (p < 0.0001). PPV of axillary LNs with cortical thickness ≥ 3 mm, ≥ 3.5 mm, ≥ 4 mm and, ≥ 4.25 mm was 0.62 [95% CI 0.53, 0.70], 0.63 [0.54, 0.72], 0.67 [0.57, 0.76] , and 0.74 [0.64, 0.83], respectively. At multivariable analysis, abnormal hilum (OR = 3.44, p = 0.016) and diffuse cortical thickening (OR = 2.86, p = 0.038) were associated with nodal metastasis. CONCLUSION: In newly diagnosed breast cancer patients, increasing axillary LN cortical thickness, abnormal fatty hilum, and diffuse cortical thickening are associated with nodal metastasis. PPV of axillary LN cortical thickness ≥ 3 mm and ≥ 3.5 mm is similar but increases for cortical thickness ≥ 4 mm. FNA of axillary LNs with cortex < 4 mm may be unnecessary for some patients undergoing sentinel LN biopsy.

Synthetic Mammography: Benefits, Drawbacks, and Pitfalls.

Digital breast tomosynthesis (DBT) allows three-dimensional assessment of breast tissue; however, DBT requires a two-dimensional (2D) image for comparison with prior mammograms and accurate interpretation of calcifications. Traditionally, full-field digital mammography (FFDM) has been performed after the DBT image acquisition. Synthetic mammography (SM), the 2D reconstruction of the tomosynthesis slice dataset, has been designed to replace FFDM. Advantages of SM include decreased image acquisition time and decreased radiation exposure, with maintained or improved screening performance metrics. Because SM algorithms give extra weight to lesion-like characteristics (eg, calcifications and architectural distortions), they may enable increased visibility of these characteristics relative to that at FFDM. Although SM algorithms were designed to improve lesion identification, they have led to varied outcomes in studies reported in the literature. Compared with FFDM, SM has been reported to be associated with a higher false-positive rate for calcifications, decreased conspicuity of asymmetries, lower breast density assessments, and imaging artifacts (eg, metallic artifact, bright-band artifact, blurring of the axilla, and truncation artifact). The authors review the literature on SM, including its implementation, benefits, and artifacts. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Patient and System Factors Associated With Completed Follow-Up of Probably Benign (BI-RADS 3) Breast Imaging Findings.

OBJECTIVE: Evaluate patient factors and health system test ordering and scheduling processes associated with completed BI-RADS 3 breast imaging follow-up. METHODS: Retrospective review of reports from January 1, 2021, to July 31, 2021, identified BI-RADS 3 findings corresponding to unique patient encounters (index examinations). The electronic health record was queried for patient, examination, and health system ordering or scheduling data including follow-up order status (order placed, performed; order placed, scheduled, but not performed; order placed, unscheduled; no order placed); ordering provider specialty and health system affiliation (primary care versus other, internal versus external to health system); and ordering department (radiology staff versus referring physician staff). Patient home addresses were categorized by area deprivation index (University of Wisconsin's Neighborhood Atlas). Univariable and multivariable analysis identified patient, examination, and ordering or scheduling factors associated with completed follow-up imaging within 15 months of BI-RADS 3 assessment. RESULTS: There were 3,104 unique BI-RADS 3 assessments, 2,561 (82.5%) with completed BI-RADS 3 follow-up within 15 months of study examination. In multivariable analysis, factors associated with incomplete follow-up included ultrasound (odds ratio [OR] 0.48; 95% confidence interval [95% CI] 0.38-0.60; P < .001) and MRI (OR 0.71; 95% CI 0.50-1.00; P = .049) versus mammogram; patients living in the highest disadvantaged neighborhoods (OR 0.70; 95% CI 0.50-0.98; P = .04); patients <40 years (OR 0.14; 95% CI 0.11-0.19; P < .001); Asian race (OR 0.55; 95% CI 0.37-0.81; P = .003); order placement >3 months (OR, 0.05; 95% CI 0.02-0.16; P < .001) after index examination or scheduling >6 months after order placement (OR, 0.35; 95% CI 0.14-0.87; P = .02); order placement by breast oncology or breast surgery departments (OR 0.35; 95% CI 0.17-0.73; P = .01) versus radiology department. DISCUSSION: Incomplete BI-RADS 3 follow-up is associated with ultrasound or MRI, most socioeconomically disadvantaged patients, younger patients, Asian race, delayed order entry, and follow-up examination ordering and scheduling by non-radiology departments.

Frequency and Outcomes of BI-RADS Category 3 Assessments in Patients With a Personal History of Breast Cancer: Full-Field Digital Mammography Versus Digital Breast Tomosynthesis.

BACKGROUND. Studies establishing the validity of BI-RADS category 3 excluded patients with personal history of breast cancer (PHBC). Use of category 3 in patients with PHBC may be impacted not only by this population's increased breast cancer risk, but also by adoption of digital breast tomosynthesis (DBT) over full-field digital mammography (FFDM). OBJECTIVE. The purpose of this article was to compare the frequency, outcomes, and additional characteristics of BI-RADS category 3 assessments between FFDM and DBT in patients with PHBC. METHODS. This retrospective study included 14,845 mammograms in 10,118 patients (mean age, 63 years) with PHBC who had undergone mastectomy and/or lumpectomy. Of these, 8422 examinations were performed by FFDM from October 2014 to September 2016, and 6423 examinations by FFDM with DBT from February 2017 to December 2018, after interval conversion of the center's mammography units. Information was extracted from the EHR and radiology reports. FFDM and DBT groups were compared in the entire sample and among index category 3 lesions (i.e., earliest category 3 assessment per lesion). RESULTS. The frequency of category 3 assessment was lower for DBT than FFDM (5.6% vs 6.4%; p = .05). DBT, compared with FFDM, showed a lower malignancy rate for category 3 lesions (1.8% vs 5.0%; p = .04), higher malignancy rate for category 4 lesions (32.0% vs 23.2%; p = .03), and no difference in malignancy rate for category 5 lesions (100.0% vs 75.0%; p = .24). Analysis of index category 3 lesions included 438 and 274 lesions for FFDM and DBT, respectively. For category 3 lesions, DBT, compared with FFDM, showed lower PPV3 (13.9% vs 36.1%; p = .02) and a more frequent mammographic finding of mass (33.2% vs 23.1%; p = .003). CONCLUSION. The malignancy rate for category 3 lesions in patients with PHBC was less than the accepted limit (2%) for DBT (1.8%), but not FFDM (5.0%). A lower malignancy rate for category 3 lesions but higher malignancy rate for category 4 lesions for DBT supports more appropriate application of category 3 assessment in patients with PHBC through use of DBT. CLINICAL IMPACT. These insights may help establish whether category 3 assessments in patients with PHBC are within benchmarks for early detection of second cancers and reduction of benign biopsies.

Frequency and Clinical Utility of Alerts for Intra-Institutional Radiologist Discrepant Opinions.

OBJECTIVE: Determine the rate of documented notification, via an alert, for intra-institutional discrepant radiologist opinions and addended reports and resulting clinical management changes. METHODS: This institutional review board-exempt, retrospective study was performed at a large academic medical center. We defined an intra-institutional discrepant opinion as when a consultant radiologist provides a different interpretation from that formally rendered by a colleague at our institution. We implemented a discrepant opinion policy requiring closed-loop notification of the consulting radiologist's second opinion to the original radiologist, who must acknowledge this alert within 30 days. This study included all discrepant opinion alerts created December 1, 2019, to December 31, 2021, of which two radiologists and an internal medicine physician performed consensus review. Primary outcomes were degree of discrepancy and percent of discrepant opinions leading to change in clinical management. Secondary outcome was report addendum rate compared with an existing peer learning program using Fisher's exact test. RESULTS: Of 114 discrepant opinion alerts among 1,888,147 reports generated during the study period (0.006%), 58 alerts were categorized as major (50.9%), 41 as moderate (36.0%), and 15 as minor discrepancies (13.1%). Clinical management change occurred in 64 of 114 cases (56.1%). Report addendum rate for discrepant opinion alerts was 4-fold higher than for peer learning alerts at our institution (66 of 315 = 21% versus 432 of 8,273 =5.2%; P < .0001). DISCUSSION: Although discrepant intra-institutional radiologist second opinions were rare, they frequently led to changes in clinical management. Capturing these discrepancies by encouraging alert use may help optimize patient care and document what was communicated to the referring or consulting care team by consulting radiologists.

Multimodality Imaging Review of HER2-positive Breast Cancer and Response to Neoadjuvant Chemotherapy.

Human epidermal growth factor receptor 2 (HER2/neu or ErbB2)-positive breast cancers comprise 15%-20% of all breast cancers. The most common manifestation of HER2-positive breast cancer at mammography or US is an irregular mass with spiculated margins that often contains calcifications; at MRI, HER2-positive breast cancer may appear as a mass or as nonmass enhancement. HER2-positive breast cancers are often of intermediate to high nuclear grade at histopathologic analysis, with increased risk of local recurrence and metastases and poorer overall prognosis. However, treatment with targeted monoclonal antibody therapies such as trastuzumab and pertuzumab provides better local-regional control and leads to improved survival outcome. With neoadjuvant treatments, including monoclonal antibodies, taxanes, and anthracyclines, women are now potentially able to undergo breast conservation therapy and sentinel lymph node biopsy versus mastectomy and axillary lymph node dissection. Thus, the radiologist's role in assessing the extent of local-regional disease and response to neoadjuvant treatment at imaging is important to inform surgical planning and adjuvant treatment. However, assessment of treatment response remains difficult, with the potential for different imaging modalities to result in underestimation or overestimation of disease to varying degrees when compared with surgical pathologic analysis. In particular, the presence of calcifications at mammography is especially difficult to correlate with the results of pathologic analysis after chemotherapy. Breast MRI findings remain the best predictor of pathologic response. The authors review the initial manifestations of HER2-positive tumors, the varied responses to neoadjuvant chemotherapy, and the challenges in assessing residual cancer burden through a multimodality imaging review with pathologic correlation. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Patterns of Screening Recall Behavior Among Subspecialty Breast Radiologists.

RATIONALE AND OBJECTIVES: Determine whether there are patterns of lesion recall among breast imaging subspecialists interpreting screening mammography, and if so, whether recall patterns correlate to morphologies of screen-detected cancers. MATERIALS AND METHODS: This Institutional Review Board-approved, retrospective review included all screening examinations January 3, 2012-October 1, 2018 interpreted by fifteen breast imaging subspecialists at a large academic medical center and two outpatient imaging centers. Natural language processing identified radiologist recalls by lesion type (mass, calcifications, asymmetry, architectural distortion); proportions of callbacks by lesion types were calculated per radiologist. Hierarchical cluster analysis grouped radiologists based on recall patterns. Groups were compared to overall practice and each other by proportions of lesion types recalled, and overall and lesion-specific positive predictive value-1 (PPV1). RESULTS: Among 161,859 screening mammograms with 13,086 (8.1%) recalls, Hierarchical cluster analysis grouped 15 radiologists into five groups. There was substantial variation in proportions of lesions recalled: calcifications 13%-18% (Chi-square 45.69, p < 0.00001); mass 16%-44% (Chi-square 498.42, p < 0.00001); asymmetry 13%-47% (Chi-square 660.93, p < 0.00001) architectural distortion 6%-20% (Chi-square 283.81, p < 0.00001). Radiologist groups differed significantly in overall PPV1 (range 5.6%-8.8%; Chi-square 17.065, p = 0.0019). PPV1 by lesion type varied among groups: calcifications 9.2%-15.4% (Chi-square 2.56, p = 0.6339); mass 5.6%-8.5% (Chi-square 1.31, p = 0.8597); asymmetry 3.4%-5.9% (Chi-square 2.225, p = 0.6945); architectural distortion 5.6%-10.8% (Chi-square 5.810, p = 0.2138). Proportions of recalled lesions did not consistently correlate to proportions of screen-detected cancer. CONCLUSION: Breast imaging subspecialists have patterns for screening mammography recalls, suggesting differential weighting of imaging findings for perceived malignant potential. Radiologist recall patterns are not always predictive of screen-detected cancers nor lesion-specific PPV1s.

Live Mammographic Screening Interpretation Versus Offline Same-Day Screening Interpretation at a Tertiary Cancer Center.

OBJECTIVES: The aim of this study was to compare screening mammography performance metrics for immediate (live) interpretation versus offline interpretation at a cancer center. METHODS: An institutional review board-approved, retrospective comparison of screening mammography metrics at a cancer center for January 1, 2018, to December 31, 2019 (live period), and September 1, 2020, to March 31, 2022 (offline period), was performed. Before July 2020, screening examinations were interpreted while patients waited (live period), and diagnostic workup was performed concurrently. After the coronavirus disease 2019 shutdown from March to mid-June 2020, offline same-day interpretation was instituted. Patients with abnormal screening results returned for separate diagnostic evaluation. Screening metrics of positive predictive value 1 (PPV1), cancer detection rate (CDR), and abnormal interpretation rate (AIR) were compared for 17 radiologists who interpreted during both periods. Statistical significance was assessed using χ2 analysis. RESULTS: In the live period, there were 7,105 screenings, 635 recalls, and 51 screen-detected cancers. In the offline period, there were 7,512 screenings, 586 recalls, and 47 screen-detected cancers. Comparison of live screening metrics versus offline metrics produced the following results: AIR, 8.9% (635 of 7,105) versus 7.8% (586 of 7,512) (P = .01); PPV1, 8.0% (51 of 635) versus 8.0% (47 of 586); and CDR, 7.2/1,000 versus 6.3/1,000 (P = .50). When grouped by >10% AIR or <10% AIR for the live period, the >10% AIR group showed a significant decrease in AIR for offline interpretation (from 12.7% to 9.7%, P < .001), whereas the <10% AIR group showed no significant change (from 7.4% to 6.7%, P = .17). CONCLUSIONS: Conversion to offline screening interpretation from immediate interpretation at a cancer center was associated with lower AIR and similar CDR and PPV1. This effect was seen largely in radiologists with AIR > 10% in the live setting.

A Prospective Intervention to Reduce Burnout Among Academic Radiologists.

RATIONALE AND OBJECTIVES: Few studies have examined what constitutes effective interventions to reduce burnout among radiologists. We compared self-reported burnout among academic medical center radiologists before and after a series of departmental initiatives intended to increase wellbeing and professional satisfaction. MATERIALS AND METHODS: This Institutional Review Board-approved, prospective study took place 2017-2019 in a tertiary academic medical center. In pre- (2017) and post-intervention (2019) periods, we administered the previously-validated Stanford Physician Wellness Survey to faculty in our 11-division radiology department. Faculty rated their burnout level across 8 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, organizational/personal values alignment, perceived quality of supervisory leadership). Between the two surveys, departmental initiatives focusing on culture, team building, work-life balance, and personal well-being were implemented (e.g., electronic medical record training, shorter work hours). Pre- and post-survey results were compared, using Whitney-Mann U test to calculate Z scores. RESULTS: Faculty members rated lower professional fulfillment (Z-3.04, p=0.002), higher emotional exhaustion (Z=2.52, p=0.012), increased sleep-related impairment (Z=2.38, p=0.012), and reduced organizational/personal values alignment (Z=-4.10, p<0.0001) between the two surveys. No significant differences were identified associated with interpersonal disengagement (Z=1.82, p=0.069), self-compassion (Z=1.39, p=0.164), negative impact of work on personal relationship (Z=0.89, p=0.372) and perceived supervisory leadership quality (Z=0.07, p=0.942). CONCLUSION: Despite numerous departmental initiatives intended to improve culture, workplace efficiency, work-life balance, and personal wellness, self-reported burnout was unchanged or worsened over time.Physician and employee wellness embedded into institutional culture maybe more effective than departmental improvement initiatives.

Mixed and Purely Hyperechoic Breast Masses: A Radiologic-Pathologic Review.

Breast US is a mainstay of modern-day breast imaging, especially in the diagnostic and interventional realm. The BI-RADS atlas described six echo patterns relative to the subcutaneous mammary fat: anechoic, hypoechoic, complex cystic and solid, isoechoic, heterogeneous, and hyperechoic. Hyperechoic breast masses demonstrate increased echogenicity relative to subcutaneous mammary fat or equal to fibroglandular tissue. Pathologically, the hyperechoic pattern at breast US results from the intermingling of different components: adipose tissue, fibrous tissue or stroma, secretions, blood or vascularity, and calcifications. Most hyperechoic masses are benign, especially homogeneously hyperechoic masses. However, hyperechogenicity does not exclude malignancy. Two echo patterns have been identified in hyperechoic malignant lesions, including those with a hypoechoic center and hyperechoic rim known as the rim pattern and a mass with hyperechoic areas distributed through the mass known as a dispersed pattern. This article aims to illustrate the echogenic patterns of breast lesions and various benign and malignant hyperechoic breast lesions with radiologic-pathologic correlation and to increase awareness of heterogeneously hyperechoic breast lesions as a manifestation of malignancy.

Assessment of a Large-Scale Peer Learning Program's Value by Manual Review of Case Submissions.

OBJECTIVE: Prior studies used submission numbers or report addendum rates to measure peer learning programs' (PLP) impact. We assessed the educational value of a PLP by manually reviewing cases submitted to identify factors correlating with meaningful learning opportunities (MLOs). METHODS: This institutional review board-exempted, retrospective study was performed in a large academic radiology department generating >800,000 reports annually. A PLP facilitating radiologist-to-radiologist feedback was implemented May 1, 2017, with subsequent pay-for-performance initiatives encouraging increasing submissions, >18,000 by 2019. Two radiologists blinded to submitter and receiver identity categorized 336 randomly selected submissions as a MLO, not meaningful, or equivocal, resolving disagreements in consensus review. Primary outcome was proportion of MLOs. Secondary outcomes included percent engagement by subspecialty clinical division and comparing MLO and report addendum rates via Fisher's exact tests. We assessed association between peer learning category, pay-for-performance interventions, and subspecialty division with MLOs using logistic regression. RESULTS: Of 336 PLP submissions, 65.2% (219 of 336) were categorized as meaningful, 27.4% (92 of 336) not meaningful, and 7.4% (25 of 336) equivocal, with substantial reviewer agreement (86.0% [289 of 336], κ = 0.71, 95% confidence interval 0.64-0.78). MLO rate (65.2% [219 of 336]) was five times higher than addendum rate (12.9% [43 of 333]) for the cohort. MLO proportion (adjusted odds ratios 0.05-1.09) and percent engagement (0.5%-3.6%) varied between subspecialty divisions, some submitting significantly fewer MLOs (P < .01). MLO proportion did not vary between peer learning categories. CONCLUSION: Educational value of a large-scale PLP, estimated through manual review of case submissions, is likely a more accurate measure of program impact. Incentives to enhance PLP use did not diminish the program's educational value.

Patient Experience Scores for Radiologists: Comparison With Nonradiologist Physicians and Changes After Public Posting in an Institutional Online Provider Directory.

BACKGROUND. Patients are increasingly using online information regarding patient experiences to guide care decisions. OBJECTIVE. The purpose of our study was to compare patient experience scores between radiologists and nonradiologist physicians and to assess changes in scores after their public posting in an online physician directory. METHODS. This retrospective study included data collected from May 1, 2017, to November 30, 2018, at a single large academic medical center. After all institutional outpatient visits, patients were e-mailed the Press Ganey Medical Practice Survey, which included 10 questions (answered using a Likert scale and converted to 100-point range) relating to the patient's experience with the specific provider for the encounter. Surveys were distributed to patients after radiology encounters if involving an image-guided invasive procedure. Mean scores for each question and the mean weighted overall score were displayed on each physician's publicly available profile on the hospital's online physician directory and were updated monthly. Scores were compared between radiologists and nonradiologist physicians; temporal changes were assessed. RESULTS. The response rate was 18.0% (96,057/533,983). After exclusions (23,989 surveys completed without provider ratings; 183 surveys evaluating physician assistants), 71,885 physician surveys were evaluated: 2703 surveys for 65 radiologists, 49,403 surveys for 916 physicians in 17 nonsurgical specialties, and 19,779 surveys for 262 physicians in 13 surgical specialties. Over the study period, the mean overall score was 95.6 for radiologists and 95.9 for nonradiologists (94.6 for surgical specialties, 96.4 for nonsurgical specialties). For the 10 individual questions, scores ranged for radiologists from 94.6 (time spent with patient) to 96.8 (friendliness/courtesy) and for nonradiologists from 94.6 (time spent with patient) to 97.0 (friendliness/courtesy). The mean overall score increased from the first month to the final month for radiologists from 94.2 to 97.1 and for nonradiologists from 95.7 to 96.3. For radiologists, the largest improvement was for instructions regarding postprocedure follow-up care (increased from 91.4 to 97.4). CONCLUSION. Radiologists received high scores on patient experience surveys when evaluated on encounters involving invasive procedures, achieving scores similar to those for other physicians. Scores improved over time, possibly related to online posting of survey results. CLINICAL IMPACT. The findings support the utility of implementing patient experience surveys in radiology.

Self-reported Burnout: Comparison of Radiologists to Nonradiologist Peers at a Large Academic Medical Center.

RATIONALE AND OBJECTIVES: Relatively little data exist on factors associated with radiologists' burnout versus other medical specialties. We compared self-reported burnout among academic medical center radiologists versus nonradiologist peers to inform initiatives to increase wellbeing and professional satisfaction. MATERIALS AND METHODS: In 2017, our large urban academic medical center administered the Stanford Physician Wellness Survey to faculty in fifteen clinical departments (fourteen academic, one community-based). Faculty rated burnout via Likert scale (0-no burnout; 1-occasional stress/no burnout; 2-one or more burnout symptoms; 3-persistent burnout symptoms; 4-completely burned out); burnout defined as >=2. Responses in 11 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, perceived appreciation, control over schedule, organizational/personal values alignment, electronic health record, perceived quality of supervisory leadership) compared radiologists versus nonradiologists for association with burnout, using Whitney-Mann U test to calculate Z scores. RESULTS: There was no significant difference in overall self-reported burnout between radiologists and nonradiologists, nor in self-rating for emotional exhaustion, interpersonal disengagement, self-compassion, control over schedule, organizational/personal values alignment, or electronic health record experience. Radiologists had significantly lower self-rating for work happiness (Z = -2.669, p = 0.0076), finding work meaningful (Z = -2.77351, p = 0.0055), perceiving physicians as highly valued (Z = -2.5486, p = 0.0108), and believing leadership treated them with respect and dignity (Z = -3.44149, p = 0.0006). CONCLUSION: Compared to nonradiologist colleagues, radiologists were less likely to find work meaningful and more likely to feel unhappy and undervalued in the workplace and by leadership. Initiatives to increase perceived appreciation, leadership relationships, and meaningfulness of work for radiologists may reduce burnout.

MRI Changes in Breast Skin Following Preoperative Therapy for Patients with Inflammatory Breast Cancer.

RATIONALE AND OBJECTIVES: Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability. MATERIALS AND METHODS: We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy. RESULTS: Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR. CONCLUSION: Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

Impact of Electronic Procedural Protocoling on the Timeliness of Pre-operative Breast Localization Procedures.

OBJECTIVE: To evaluate the impact of a new electronic procedural protocol on start times of pre-operative breast localization procedures. METHODS: This HIPAA-compliant, Institutional Review Board-exempted, quality improvement initiative was performed at a large tertiary academic center. In May 2018, an electronic version of the pre-procedure protocol for breast localizations was created within the electronic health record; prior to this time, the protocol was completed manually on a paper form. Mean time between: (1) appointment time and procedure start time, (2) procedure begin-to-end time, and (3) arrival to appointment time were compared for all female patients undergoing pre-operative breast localization procedures during 4-month periods pre-implementation of the electronic procedural protocol (January-April 2018), and post-implementation (June-September 2018), excluding the May 2018 implementation month. Statistical analysis was done by two tailed t-test and statistical process control charting. RESULTS: Pre-implementation, 427 procedures were performed, and post-implementation 409 procedures were performed. Three pre-implementation cases performed more than 3 hours prior to appointment time were excluded (presumed to be rescheduled cases). Mean time between appointment time and procedure start time decreased from 2.7 minutes after to 5.6 minutes before appointment start time, an 8.3-minute improvement (P = 0.0001), with sustained improvement by statistical process control analysis. Mean time for procedure length increased by 4.7 minutes (P = 0.001). There was no significant difference in mean time of patient arrival to appointment time pre- and post-implementation. CONCLUSION: Implementation of an electronic protocol process for pre-operative breast localizations was associated with a significant and sustained reduction in time between appointment time and procedure start time.