Jay R. Parikh

Impact of Mammography Detection on the Course of Breast Cancer in Women Aged 40–49 Years

PURPOSE To analyze trends in detection method related to breast cancer stage at diagnosis, treatments, and outcomes over time among 40-49-year-old women. MATERIALS AND METHODS i This study was institutional review board approved, with a waiver of informed consent, and HIPAA compliant. A longitudinal prospective cohort study was conducted of women aged 40-49 years who had primary breast cancer, during 1990-2008, and were identified and tracked by a dedicated registry database (n = 1977). Method of detection--patient detected (PtD), physician detected (PhysD), or mammography detected (MamD)--was chart abstracted. Disease-specific survival and relapse-free survival statistics were calculated by using the Kaplan-Meier method for stage I-IV breast cancer. RESULTS A significant increase in the percentage of MamD breast cancer over time (28%-58%) and a concurrent decline in patient and physician detected (Pt/PhysD) breast cancer (73%-42%) (Pearson x(2) = 72.72, P < .001) were observed over time from 1990 to 2008, with an overall increase in lower-stage disease detection and a decrease in higher-stage disease. MamD breast cancer patients were more likely to undergo lumpectomy (67% vs 48% of Pt/PhysD breast cancer patients) and less likely to undergo modified radical mastectomy (25% vs 47% of the Pt/PhysD breast cancer patients) (P < .001). Uncorrected for stage, 13% of MamD breast cancer patients underwent surgery and chemotherapy versus 22% of Pt/PhysD breast cancer patients (P < .001), and 31% of MamD breast cancer patients underwent surgery, radiation therapy, and chemotherapy versus 59% of Pt/PhysD breast cancer patients (x(2) = 305.13, P < .001). Analyzing invasive cancers only, 5-year relapse-free survival for MamD breast cancer patients was 92% versus 88% for Pt/PhysD patients (log-rank test, 12.47; P < .001). CONCLUSION Increased mammography-detected breast cancer over time coincided with lower-stage disease detection resulting in reduced treatment and lower rates of recurrence, adding factors to consider when evaluating the benefits of mammography screening of women aged 40-49 years.

Burnout of Radiologists: Frequency, Risk Factors, and Remedies: A Report of the ACR Commission on Human Resources

Burnout is a concern for radiologists. The burnout rate is greater among diagnostic radiologists than the mean for all physicians, while radiation oncologists have a slightly lower burnout rate. Burnout can result in unprofessional behavior, thoughts of suicide, premature retirement, and errors in patient care. Strategies to reduce burnout include addressing the sources of job dissatisfaction, instilling lifestyle balance, finding reasons to work other than money, improving money management, developing a support group, and seeking help when needed.

Improved Prognosis of Women Aged 75 and Older with Mammography-detected Breast Cancer

PURPOSE To evaluate the characteristics and outcomes of women aged 75 years and older with mammography-detected breast cancer, an age group not represented in mammography screening effectiveness studies. MATERIALS AND METHODS We conducted a HIPAA-compliant, prospective cohort study with waiver of informed consent in patients with primary breast cancer, aged 75 years and older, with stage 0-IV disease from 1990 to 2011, identified and tracked with our registry database (n = 1162). Details including stage, treatment, outcomes, and method of detection (by patient, physician, or mammography) were noted from the chart at the time of diagnosis. Kaplan-Meier estimation was used to compare invasive disease-specific survival rates. RESULTS Among patients with breast cancer aged 75 years and older, mammography detection of cancers increased over time, from 49% to 70% (P < .001). Mammography-detected cases were more often stage I (62%), whereas patient- and physician-detected cases were more likely stage II and III (59%). Over time, from 1990 to 2011, the incidence of stage II cancers decreased by 8%, the incidence of stage III cancers decreased by 8%, and the incidence of stage 0 cancers increased by 15% (P < .001). Patients with mammography-detected invasive breast cancer were more often treated with lumpectomy and radiation and underwent fewer mastectomies and less chemotherapy than patients with cancer detected by patients and physicians (P < .001). Mammography detection was associated with significantly better 5-year disease-specific survival for invasive breast cancer (97% vs 87% for patient- and physician-detected cancer [P < .001], respectively). CONCLUSION Mammography-detected breast cancer in women 75 years and older was diagnosed at an earlier stage, required less treatment, and had better disease-specific survival than patient- or physician-detected breast cancer. These findings indicate that the same benefits of mammography detection observed in younger women extend to older women.

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.

Strategic Expansion Models in Academic Radiology

In response to economic pressures, academic institutions in the United States and their radiology practices, are expanding into the community to build a larger network, thereby driving growth and achieving economies of scale. These economies of scale are being achieved variously via brick-and-mortar construction, community practice acquisition, and partnership-based network expansion. We describe and compare these three expansion models within a 4-part framework of: (1) upfront investment; (2) profitability impact; (3) brand impact; and (4) risk of execution.

Cost-Effectiveness of Increasing Access to Mammography Through Mobile Mammography for Older Women

OBJECTIVES: To compare the costs of mobile and stationary mammography and examine the incremental cost‐effectiveness of using mobile mammography to increase screening rates.

Breast Imaging: The Face of Imaging 3.0

In preparation for impending changes to the health care delivery and reimbursement models, the ACR has provided a roadmap for success via the Imaging 3.0 (®)platform. The authors illustrate how the field of breast imaging demonstrates the following Imaging 3.0 concepts: value, patient-centered care, clinical integration, structured reporting, outcome metrics, and radiologys role in the accountable care organization environment. Much of breast imagings success may be adapted and adopted by other fields in radiology to ensure that all radiologists become more visible and provide the value sought by patients and payers.

ACR Appropriateness Criteria® on Nonpalpable Mammographic Findings (Excluding Calcifications)

Screening mammography can detect breast cancer before it becomes clinically apparent. However, the screening process identifies many false-positive findings for each cancer eventually confirmed. Additional tools are available to help differentiate spurious findings from real ones and to help determine when tissue sampling is required, when short-term follow-up will suffice, or whether the finding can be dismissed as benign. These tools include additional diagnostic mammographic views, breast ultrasound, breast MRI, and, when histologic evaluation is required, percutaneous biopsy. The imaging evaluation of a finding detected at screening mammography proceeds most efficiently, cost-effectively, and with minimization of radiation dose when approached in an evidence-based manner. The appropriateness of the above-referenced tools is presented here as they apply to a variety of findings often encountered on screening mammography; an algorithmic approach to workup of these potential scenarios is also included. The recommendations put forth represent a compilation of evidence-based data and expert opinion of the ACR Appropriateness Criteria(®) Expert Panel on Breast Imaging.

Breast imaging: A paradigm for accountable care organizations

OBJECTIVE Accountable care organizations (ACOs) are being promoted by the Centers of Medicare Services as alternative payment models for radiology reimbursement. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation through mandatory accreditation, and value demonstration through established outcome metrics, breast imaging offers a unique paradigm for the ACO model in radiology. CONCLUSION In radiology, breast imaging represents the paradigm for ACOs.

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.