Diana L. Lam

Are Qualitative Assessments of Background Parenchymal Enhancement, Amount of Fibroglandular Tissue on MR Images, and Mammographic Density Associated with Breast Cancer Risk?

PURPOSE To investigate whether qualitative magnetic resonance (MR) imaging assessments of background parenchymal enhancement (BPE), amount of fibroglandular tissue (FGT), and mammographic density are associated with risk of developing breast cancer in women who are at high risk. MATERIALS AND METHODS In this institutional review board-approved HIPAA-compliant retrospective study, all screening breast MR images obtained from January 2006 to December 2011 in women aged 18 years or older and at high risk for but without a history of breast cancer were identified. Women in whom breast cancer was diagnosed after index MR imaging comprised the cancer cohort, and one-to-one matching (age and BRCA status) of each woman with breast cancer to a control subject was performed by using MR images obtained in women who did not develop breast cancer with follow-up time maximized. Amount of BPE, BPE pattern (peripheral vs central), amount of FGT at MR imaging, and mammographic density were assessed on index images. Imaging features were compared between cancer and control cohorts by using conditional logistic regression. RESULTS Twenty-three women at high risk (mean age, 47 years ± 10 [standard deviation]; six women had BRCA mutations) with no history of breast cancer underwent screening breast MR imaging; in these women, a diagnosis of breast cancer (invasive, n = 12; in situ, n = 11) was made during the follow-up interval. Women with mild, moderate, or marked BPE were nine times more likely to receive a diagnosis of breast cancer during the follow-up interval than were those with minimal BPE (P = .007; odds ratio = 9.0; 95% confidence interval: 1.1, 71.0). BPE pattern, MR imaging amount of FGT, and mammographic density were not significantly different between the cohorts (P = .5, P = .5, and P = .4, respectively). CONCLUSION Greater BPE was associated with a higher probability of developing breast cancer in women at high risk for cancer and warrants further study.

Communicating Potential Radiation-Induced Cancer Risks From Medical Imaging Directly to Patients

OBJECTIVE Over the past decade, efforts have increasingly been made to decrease radiation dose from medical imaging. However, there remain varied opinions about whether, for whom, by whom, and how these potential risks should be discussed with patients. We aimed to provide a review of the literature regarding awareness and communication of potential radiation-induced cancer risks from medical imaging procedures in hopes of providing guidance for communicating these potential risks with patients. MATERIALS AND METHODS We performed a systematic literature review on the topics of radiation dose and radiation-induced cancer risk awareness, informed consent regarding radiation dose, and communication of radiation-induced cancer risks with patients undergoing medical imaging. We included original research articles from North America and Europe published between 1995 and 2014. RESULTS From more than 1200 identified references, a total of 22 original research articles met our inclusion criteria. Overall, we found that there is insufficient knowledge regarding radiation-induced cancer risks and the magnitude of radiation dose associated with CT examinations among patients and physicians. Moreover, there is minimal sharing of information before nonacute imaging studies between patients and physicians about potential long-term radiation risks. CONCLUSION Despite growing concerns regarding medical radiation exposure, there is still limited awareness of radiation-induced cancer risks among patients and physicians. There is also no consensus regarding who should provide patients with relevant information, as well as in what specific situations and exactly what information should be communicated. Radiologists should prioritize development of consensus statements and novel educational initiatives with regard to radiation-induced cancer risk awareness and communication.

How Radiologists Get Paid: Resource-Based Relative Value Scale and the Revenue Cycle

OBJECTIVE To learn the impact of health care reform, it is important for radiologists to first understand basic administrative aspects of medicine. This article describes the processes of radiology billing, reimbursement, and the revenue cycle, which includes the importance of proper coding, the resource-based relative value scale, and accounts receivable. CONCLUSION An understanding of the basics of medical practice management can help radiologists effectively provide optimal patient care. This article provides an overview of one component of this topic--the current radiology reimbursement system.

Opportunities for Patient-centered Outcomes Research in Radiology

Recently created in 2010, the Patient-Centered Outcomes Research Institute (PCORI) supports patient-centered comparative effectiveness research with a focus on prioritizing high-impact studies and improving trial design methodology. The Association of University Radiologists Radiology Research Alliance Task Force on patient-centered outcomes research in Radiology aims to review recently funded imaging-centric projects that adhere to the methodologies established by PCORI. We provide an overview of the successful application of PCORI standards to radiology topics, highlight how these methodologies differ from other forms of radiology research, and identify opportunities for new projects as well as potential barriers for involvement. Our hope is that review of specific case examples in radiology will clarify the use and value of PCORI methods mandated and supported nationally by the Affordable Care Act.

Imaging Surveillance After Primary Breast Cancer Treatment

OBJECTIVE Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard digital mammography, including digital breast tomosynthesis (DBT), breast ultrasound, and MRI, may improve outcomes. This article reviews the evidence on the performance and effectiveness of breast imaging modalities available for surveillance after treatment of sporadic unilateral primary breast cancer and identifies additional factors to be considered when selecting an imaging surveillance regimen. CONCLUSION Evidence review supports the use of mammography for surveillance after primary breast cancer treatment. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. DBT offers the most promise as a potential modality to replace standard digital mammography as a front-line surveillance test; a single published study to date has shown a significant decrease in recall rates compared with standard digital mammography alone. Most guidelines do not support the use of whole-breast ultrasound in breast cancer surveillance, and further studies are needed to define the characteristics of women who may benefit from MRI surveillance. The emerging evidence about surveillance imaging outcomes suggests that additional factors, including patient and imaging characteristics, tumor biology and gene expression profile, and choice of treatment, warrant consideration in selecting personalized posttreatment imaging surveillance regimens.

Imaging-Based Screening: Understanding the Controversies

OBJECTIVE The goals of this article are to provide an overview of controversial aspects of imaging-based screening and to elucidate potential risks that may offset anticipated benefits. CONCLUSION Current controversial topics associated with imaging-based screening include false-positive results, incidental findings, overdiagnosis, radiation risks, and costs. Alongside the benefits of screening, radiologists should be prepared to discuss these additional diagnostic consequences with providers and patients to better guide shared decision making regarding imaging-based screening.

Can MRI biomarkers at 3 T identify low-risk ductal carcinoma in situ? ☆,☆☆

OBJECTIVE The objective was to explore whether 3-T magnetic resonance imaging (MRI) can identify low-risk ductal carcinoma in situ (DCIS). METHODS Dynamic contrast-enhanced and diffusion-weighted (DWI) MRI features of 36 DCIS lesions [8 low risk, Van Nuys Pathologic Classification (VNPC) 1; 28 high risk, VNPC 2/3] were reviewed. An MRI model that best identified low-risk DCIS was determined using multivariate logistic regression. RESULTS Low-risk DCIS exhibited different DWI properties [i.e., higher contrast-to-noise ratio (P=.02) and lower normalized apparent diffusion coefficients (P=.04)] than high-risk DCIS. A model combining these DWI features provided best performance (area under receiver operating characteristic curve =0.86). CONCLUSIONS DWI may help identify DCIS lesions requiring less therapy.

Are Physicians Influenced by Their Own Specialty Society's Guidelines Regarding Mammography Screening? An Analysis of Nationally Representative Data

OBJECTIVE The purpose of this study is to determine whether primary care physicians were influenced by their own specialty societys mammography screening recommendations after the 2009 U.S. Preventive Services Task Forces (USPSTF) revised recommendations were released. MATERIALS AND METHODS We performed an analysis of cross-sectional nationally representative data for 2007-2012 from the National Ambulatory Medical Care Survey (NAMCS). All office-based preventive services visits for women 40 years old or older were included. Multivariate regression analyses were used to identify changes over time in the mammography referral rate per 1000 visits by physician specialty, adjusting for patient- and office-level covariates. All analyses were weighted to account for the multistage probability sampling design of NAMCS. RESULTS Our analysis represented an average of 35,947,290 office visits per year. Overall, between 2007-2008 and 2011-2012, mammography referral rates (per 1000 visits) decreased from 285 to 215 referrals (-25.0% adjusted change; p = 0.006). The largest decrease was among family physicians (from 230 to 128; -49.0% adjusted change; p < 0.001), followed by internal medicine physicians (from 135 to 79; -45.8% adjusted change; p = 0.038). No statistically significant change was noted among obstetricians and gynecologists over time (from 476 to 419; -14.4% adjusted change; p = 0.23). DISCUSSION Family and internal medicine physicians, whose societies adhered to 2009 USPSTF recommendations for biennial screening starting at age 50 years, showed statistically significant decreases in mammography referral rates over time. Obstetricians and gynecologists, whose society continued to recommend annual screening starting at age 40 years, showed no statistically significant change in mammography referral rates over time. Physicians may be influenced by their own societys recommendations, which may influence their shared decision-making discussions with patients.

Drug injection-related fat necrosis of the breast with FDG PET-CT uptake

A 52-year-old woman was found to have a lung mass and bilateral breast lesions on computed tomography (CT). Subsequent positron emission tomography/CT demonstrated marked uptake in the lung mass and mild uptake within the breast lesions. A diagnostic mammogram and targeted ultrasound were performed to exclude primary breast malignancy or metastases from presumed pulmonary malignancy. A pertinent history of recent intravenous drug use with heroin injection into bilateral breasts, together with imaging features, facilitated diagnosis of fat necrosis. Fat necrosis is a common diagnosis in breast imaging and may be an incidental finding on positron emission tomography/CT in the oncologic setting. The presence of fat along with suggestive clinical history can lead to the diagnosis and appropriate assignment of either benign, breast imaging-reporting and data system (BI-RADS) 2, or probably benign, BI-RADS 3, category with short interval follow-up. Appropriate work-up of incidental fluorodeoxyglucose-avid breast masses with diagnostic mammogram ± ultrasound is warranted to avoid incorrect interpretation as neoplastic processes.

Lessons From the Happiest Place on Earth

THE ROOTS OF DISNEY AND ITS RELEVANCE TO BUSINESS When the Disneyland resort opened in the summer of 1955, it consisted of a single theme park built on a 160acre orange grove in Anaheim, California. Today, it comprises 2 theme parks, 3 hotels, an entertainment district, and an expansive shopping area, all in California alone. More than 600 million people have visited the park, many as return guests, making the Disney theme parks the number one tourist attraction in America [1]. The Disneyland model is highly regarded for its organizational effectiveness and is taught in several business school curricula. Additionally, the Disney Institute has been established to provide business leaders with insights regarding the Disney approach to human resource management, brand development, and customer service; roughly a third of its attendees work in the health care industry [2]. At first glance, Disney may seem an unusual role model for health care leaders. However, a closer inspection shows several similarities between the challenges of operating a theme park and those faced by hospital administrators. Disney executives are charged with sustaining the massive Disney enterprise while battling long lines and ensuring a pleasant experience for their