Abbreviated Protocol Breast MRI.

OBJECTIVE. Patients with dense breast tissue are seeking supplemental screening because of the limited sensitivity of mammography. Abbreviated protocol (AP) breast MRI is attractive because it offers a higher cancer detection rate, shorter scan time, and lower cost than full MRI. This article explores the issues of balancing the benefits of AP MRI with safety concerns about gadolinium-based contrast agents, lack of standardization of protocols and field strengths, potential decrease in performance metrics, and potential for overdiagnosis. CONCLUSION. Important questions need to be addressed before AP MRI can be used routinely for breast cancer screening. Evidence is lacking from well-designed prospective trials that can confirm the accuracy and efficacy of AP MRI are comparable with those of other breast imaging modalities. Determining which patients benefit most from AP MRI will help shape future screening guidelines.

Fast MRI breast cancer screening - Ready for prime time.

OBJECTIVE: The manuscript discusses landmark studies using abbreviated MRI for breast cancer screening. This includes abbreviated dynamic contrast enhanced MRI and diffusion weighted imaging. Our institutional experience with abbreviated MR protocol for breast cancer screening is also described. CONCLUSION: Abbreviated MRI protocols were found to demonstrate value for screening of breast cancer. It has been shown that abbreviated protocol MRI provides similar diagnostic sensitivities to full protocol MRI for breast cancer in women with increased lifetime risk. Our institutional abbreviated MRI protocol for breast cancer offers improved time and workflow efficiencies and has the potential to increase the number of breast cancers detected and the detection of pathologically relevant invasive breast cancer at earlier stages.

Implementing Abbreviated MRI Screening Into a Breast Imaging Practice.

OBJECTIVE. The purpose of this article is to describe steps for implementing abbreviated breast MRI into a breast imaging practice. CONCLUSION. Mammographic screening for breast cancer has been the standard of care. However, breast cancer remains a leading cause of death of women. Studies have shown that MRI performed with an abbreviated protocol for women at average and slightly increased risk depicts mammographically occult biologically significant cancers at early stages.

Changes in the Utilization of the BI-RADS Category 3 Assessment in Recalled Patients Before and After the Implementation of Screening Digital Breast Tomosynthesis.

RATIONALE AND OBJECTIVES: The purpose of this study was to compare the utilization of the Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment in patients recalled from screening before and after the implementation of digital breast tomosynthesis (DBT). MATERIALS AND METHODS: This was a retrospective review of 11,478 digital mammography (DM) screening exams and 9350 DM+DBT screening exams. Lesions assigned a BI-RADS category 3 at diagnostic exam were classified as architectural distortions, asymmetries, calcifications, masses, and "other" and followed for a minimum of 2 years. RESULTS: The addition of DBT to screening DM resulted in a 30.4% relative reduction (10.3 women per 1000) in the utilization of BI-RADS category 3 compared to screening DM alone (3.4% for DM versus 2.4% for DM+DBT; p < 0.0001). There was a statistically significant change in the distribution of category 3 findings with DM+DBT characterized by an increase in calcifications and architectural distortions and a decrease in asymmetries. There was no change in category 3 assessment for masses. Although both cohorts had delayed cancer detection rates that exceeded the recommended 2% benchmark (2.3% for DM and 3.6% for DM+DBT), when limited to invasive malignancies, the delayed cancer detection rates were below the 2% benchmark (1.5% for DM and 0.9% for DM+DBT). Screening DM+DBT resulted in a 9.2% relative reduction in recall rate compared to DM (13.0% for DM versus 11.8% for DM+ DBT, p = 0.012). CONCLUSION: Implementation of DBT in the screening population decreased the overall number of patients assigned to short-term follow-up by 10.3 per 1000 women while maintaining comparable rates of delayed cancer detection.

Utilizing the Hub-and-Spoke Model to Deliver Quality Breast Imaging in a Large Health System.

Healthcare systems are constantly expanding and gaining new territories. This growth is met with challenges in the organization and delivery of quality health care services to a large geographical area. The need for provider and staff coverage at the new sites often outpaces the rate at which additional providers and staff are hired. The need for new technology, equipment, and administrative support to oversee the new sites may also lag. The overall result could compromise patient experience at these outlying locations. The breast imaging division at University Hospitals Cleveland Medical Center (UHCMC) instituted many changes to support UHCMC's continual growth while focusing on consistent quality of care and optimal patient experience. Changes included adoption of the hub-and-spoke organization-design model and incorporation of the integrated practice unit (IPU) concept. In the hub-and-spoke organization-design model, full services are offered at a central hub, with additional limited services provided at the peripheral spoke sites. The IPU is a dedicated team of clinical and nonclinical personnel providing the full care cycle centered on a specific medical condition such as breast health. The breast imaging hubs and spokes are incorporated into the breast health IPUs to provide uniform quality care across a large health system. The purpose of this article is to describe how the breast imaging division, functioning as members of the breast care IPU, utilized the hub-and-spoke concept to provide quality breast imaging services throughout the expanding health system.

Improved Screening Mammogram Workflow by Maximizing PACS Streamlining Capabilities in an Academic Breast Center.

The aim of this study was to perform an operational improvement project targeted at the breast imaging reading workflow of mammography examinations at an academic medical center with its associated breast centers and satellite sites. Through careful analysis of the current workflow, two major issues were identified: stockpiling of paperwork and multiple worklists. Both issues were considered to cause significant delays to the start of interpreting screening mammograms. Four workflow changes were suggested (scanning of paperwork, worklist consolidation, use of chat functionality, and tracking of case distribution among trainees) and implemented in July 2015. Timestamp data was collected 2 months before (May-Jun) and after (Aug-Sep) the implemented changes. Generalized linear models were used to analyze the data. The results showed significant improvements for the interpretation of screening mammograms. The average time elapsed for time to open a case reduced from 70 to 28 min (60 % decrease, p < 0.001), report turn-around time with preliminary signature decreased from 151 to 107 min (29 % decrease, p < 0.001), and report turn-around time final signature from 153 to 139 min (9 % decrease, p = 0.002). These improvements were achieved while keeping the efficiency of the workflow for diagnostic mammograms at large unaltered even with increased volume of mammography examinations (31 % increase of 4344 examinations for May-Jun to 5678 examinations for Aug-Sep). In conclusion, targeted efforts to improve the breast imaging reading workflow for screening mammograms in a teaching environment provided significant performance improvements without affecting the workflow of diagnostic mammograms.

Addition of shear-wave elastography during second-look MR imaging-directed breast US: effect on lesion detection and biopsy targeting.

PURPOSE: To determine if adding shear-wave elastography (SWE) to second-look ultrasonography (US) after breast dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging helps find or target lesions seen on DCE MR images for US-guided biopsy. MATERIALS AND METHODS: This HIPAA-compliant prospective study was approved by the institutional review board, and written informed consent was obtained from patients. From May 2011 to July 2012, 73 women with 96 Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 lesions after DCE MR imaging prospectively consented to undergo SWE during second-look US. If a lesion was not confidently seen with B-mode US, SWE during real-time scanning was performed to determine if SWE helped find or target lesions for US biopsy. A qualitative SWE six-point color scale was used to record the maximum elasticity in and around lesions. All lesions underwent US or DCE MR imaging-guided core biopsy. RESULTS: Median participant age was 52 years (range, 21-81 years). In 72 patients who underwent DCE MR imaging, 96 BI-RADS category 4 or 5 lesions were detected in 81 breasts. There were 29 (30%) malignancies (one malignancy was of nonbreast origin), 14 (15%) high-risk lesions, and 53 (55%) benign lesions. US revealed 22 cancers, and seven cancers were detected only with MR imaging. Real-time SWE helped find one lesion and target four lesions that were incompletely assessed with gray-scale US. These five lesions that were localized or targeted for biopsy were invasive cancers, representing 23% of the 22 malignancies detected with US. CONCLUSION: Real-time SWE added to second-look US after DCE MR imaging increased the detection rate of cancers and helped target cancers for US-guided biopsy.

Neglecting to screen women between 40 and 49 years old with mammography: what is the impact on treatment morbidity and potential risk reduction?

OBJECTIVE: The purpose of this study is to determine whether there were significant differences with respect to treatment recommendations, stage at diagnosis, and identification of high-risk lesions for women 40-49 years old undergoing screening mammography (screened) compared to women with a symptom needing a diagnostic evaluation (nonscreened). MATERIALS AND METHODS: We reviewed the pathology results of all imaging-guided biopsies performed at the three breast center locations of University Hospitals Case Medical Center from January 1, 2008, to December 31, 2011. In patients diagnosed with a high-risk lesion or breast cancer, the reason for presentation, pathology, tumor size, stage, receptor characteristics, and treatment were recorded. The chi-square test was used for statistical analysis. RESULTS: Of 230 primary breast cancers, 149 were in the screened group and 81 were considered nonscreened. Nonscreened patients were more likely to undergo chemotherapy (p = 0.042). Eighty-one percent of the high-risk lesions were diagnosed in the screened patients. Screened patients with cancer were significantly more likely to receive a diagnosis at earlier stages (p = 0.001), to have negative axillary lymph nodes (p = 0.005), and to have smaller tumors (p < 0.001). CONCLUSION: In addition to the benefits of receiving a diagnosis at earlier stages, with smaller tumors and node negativity, patients with breast cancer undergoing screening mammography aged 40-49 years are less likely to require chemotherapy and its associated morbidities. The majority of high-risk lesions were diagnosed in the screened group, which may lead to the benefit of chemoprevention, lowering their risk of subsequent breast cancer, or screening with MRI, which may diagnose future mammographically occult malignancies.

Neglecting to screen women between the ages of 40 and 49 years with mammography: what is the impact on breast cancer diagnosis?

OBJECTIVE: The purpose of this study was to compare breast cancer stage at diagnosis in two groups of women between 40 and 49 years old: women undergoing screening mammography and women with a symptom needing diagnostic workup. This comparison is indicative of the impact of forgoing screening in this age group, as recommended by the United States Preventive Services Task Force. MATERIALS AND METHODS: A retrospective chart review was used to collect the results of imaging-guided core needle biopsies performed in women between the ages of 40 and 49 years from January 1, 2008, to December 31, 2009. In patients diagnosed with breast cancer or a high-risk lesion, the reason for presentation, pathology, tumor size, stage, and receptor characteristics were recorded. The chi-square test was used for statistical analysis. RESULTS: Of 108 primary breast cancers, 71 were detected in the screened group and 37 in the unscreened group. The screened group was significantly more likely to be diagnosed with ductal carcinoma in situ than the unscreened group (22 vs 1, chi-square = 11.6, p = 0.001). Furthermore, screened patients with invasive carcinoma were significantly more likely to be diagnosed at earlier stages (chi-square = 5.02, p = 0.025). The size of invasive breast cancer in the screened group was significantly smaller as well (chi-square = 9.3, p = 0.002). Of the high-risk lesions, atypical ductal hyperplasia (n = 29) and lobular carcinoma in situ (n = 8) were most frequently seen. CONCLUSION: Breast cancer patients undergoing screening mammography were diagnosed at earlier stages with smaller tumors. Screening also allows detection of high-risk lesions, which may prompt chemoprevention and lower subsequent breast cancer risk. We continue to support screening mammography in women between the ages of 40 and 49 years.