Volume 3 Number 1 Winter 97

Master List Volume 3 Number 1 Winter 1997

IN THIS ISSUE

Major Policy Changes Coming for Radiology Film Management

by: Lincoln L. Berland, MD

FAQs

Mammography

View the UAB Radiology Teaching Files

Major Policy Changes Coming for Radiology Film Management

By: Lincoln L. Berland, M.D.

Digital acquisition of ICU portable examinations
as shown here has
improved their
accessibility, storage,
and retrieval.

It is no secret that finding Radiology examinations at UAB can be a big headache. Although the vast majority of films are handled routinely and smoothly, the small percentage which are lost or time-consuming to find still amount to a large number and can be profoundly frustrating and irritating to healthcare workers and patients, and may at times adversely affect our ability to manage patients.

The causes of this problem are surprisingly complex. The size of our sprawling medical center, the need to transport literally thousands of jackets and examinations among three major films libraries and over 100 other sites every day, the administrative divisions between the Clinic and Hospital, and the "culture" of disregard for proper film handling have fostered a serious chronic crisis. The solutions described below may not be easy to accept for some who have become accustomed to uncontrolled access and undisciplined management of film files. However, the time has come to accept the bitter medicine.

After considerable reorganization and augmentation of our human and physical resources, we are announcing plans to make fundamental changes in the policies and procedures for obtaining films at UAB. The fundamental principle which must be applied to assure successful access for anyone who needs films for clinical purposes is rigid adherence to security, tracking, check-out and check-in procedures. While we will make no effort to limit access to films, we will physically control access to areas holding films. We will insist that films be formally checked-out every time they are moved. No longer will isolated films be allowed to be removed without an entire examination or jacket. Only authorized individuals will be permitted to check out films. Individuals who check out films will be held accountable for returning those films. This means that those who fail to return films within an approved time will lose check-out privileges.

These changes are planned for full implementation in early 1997. We seek the support of all members of the UAB medical community to make this difficult transition as smooth as possible. Just as we have experienced the inconveniences of increased security in many other aspects of our life, so will we have to endure these changes to assure the security and availability of the precious clinical information offered by radiographic examinations. You will be hearing more about the details of these changes in various media as the date of implementation approaches. However, there is no reason to wait to be more careful in handling your film. Thank you for your help.

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FAQs - Frequently Asked Questions - Mammography

Q: At what age should a woman get her first screening mammogram and how often after that?

Annual screening of women over age 50 is recommended by all organizations which have developed screening guidelines. An upper age limit for screening has not been agreed upon. Medicare, which covers most women 65 and over, funds screening mammograms every two years for eligible women. Screening of women age 40-49 remains a controversial area. In the US, largely because of the aging of the "baby boom" population, the absolute number of women who develop breast cancer in their 40's is about the same as that of women who develop the disease in their 50's. It is also likely that the impact of detecting breast cancer is greater in younger women. At UAB, we have strongly urged that if screening is to be done in women 40-49 that it be done at annual intervals. Lead times are shorter in younger women likely due to hormonal influences (which may also be an issue in women on estrogen replacement although this is unproven). Long interscreen intervals result in unacceptable numbers of interval cancers, i.e., those which become detectable as palpable cancers between screens. Although none of the randomized controlled clinical trials, other than the Canadian trial, was specifically designed to address the issue of screening women in their 40's, the results of these trials, at the most recent meta-analysis, indicate a 24% benefit in survival for women who were screened in their 40's.

Q: Are the recommendations different for women with a positive family history of breast cancer?

There is currently no information to suggest that screening intervals shorter than one year are efficacious, even in women with a strong family history of breast cancer. However, beginning screening at an earlier age is generally recommended for women with family histories of premenopausal breast cancer in first degree relatives (mother, sister, daughter) and in those with evidence suggesting genetic breast cancer. The appropriate screening recommendations for women who test positive for the breast cancer genes, BRCA1 and BRCA2, have not been established. A guideline for when breast cancer screening should be initiated in high-risk women suggests it begin 10 years earlier than the earliest breast cancer which occurred in the family, but not before age 25.

Q: What is the appropriate study to order for a patient under 30
...with a palpable lump?
...with breast pain or tenderness?

In general, young women with breast lumps should be evaluated with breast ultrasound. Xray imaging is only performed if the ultrasound examination is inconclusive or suggests the presence of breast cancer. This policy is not rigid as young obese or multiparous women may be better evaluated with xray mammography, particularly when a discrete mass is not identified.

Patients with diffuse breast pain or tenderness usually require reassurance, not breast imaging studies. Localized breast pain, which the patient consistently pinpoints with a single finger, is rarely associated with breast cancer and is a rare symptom. However, when present, such cases merit diagnostic evaluation with ultrasound and/or xray mammography.

Once a patient with a significant breast symptom (mass, retraction, single duct nipple discharge, etc.) reaches the age of 30, the initial examination is usually xray mammography, supplemented by additional examinations if necessary.

Q: Why is ultrasound done in addition to the mammogram?

Ultrasound is a superb adjunctive examination to xray mammography, but cannot substitute for it in its screening function. As mentioned earlier, it is the primary examination for young women with palpable abnormalities and also for those who are pregnant or lactating. It is also routinely performed in women with clinical findings whose mammograms are unrevealing and in those whose mammograms show areas which require further characterization. Ultrasound is also used to guide interventional procedures, such as needle localization, fine needle aspiration and biopsy, large core needle biopsy, and even ductography.

Ultrasound can reliably diagnose most breast cysts and can be used to guide cyst puncture for those cysts which are symptomatic or do not meet stringent criteria for diagnosis of a cyst on ultrasound. It can also provide reassurance that no mass underlies a questionably palpable area. Recent evidence suggests that ultrasound can aid in benign-malignant differentiation of solid breast masses and prevent biopsy for many noncancerous masses, such as fibroadenomas. In addition, ultrasound allows recognition of some cancers which are inapparent on xray mammography.

Q: What other diagnostic procedures do you perform?

Needle localization breast biopsy is performed to guide surgical excision of nonpalpable lesions. This may be done with xray or ultrasound guidance. Xray guidance is generally required for lesions manifest as microcalcifications without mass. For the last few years, with the use of fine needle aspiration and core biopsy to preselect patients who require surgery, the cancer yield of needle localization biopsies at UAB has exceeded 50% overall, and 70% overall for those lesions manifest as mass. This has been accomplished without an increase in average tumor size or node positivity. Nearly 90% of needle localized cancers are 1.5 cm in size or smaller, 60% are 1 cm or smaller, and over 90% are node-negative.

Fine needle aspiration or biopsy

are usually performed with ultrasound guidance. Although cyst puncture for palpable lesions can be accomplished without guidance, it is more reliably accomplished when the cyst can be entered (and fully evacuated) under direct vision. For fine needle aspiration biopsies, the cytotechnologist and cytopathologist are present during the performance of the procedure and results are available within 15 minutes.

Large core needle biopsy

is performed with ultrasound guidance (our preference for mass lesions) or stereotactic guidance. Although this can be performed to confirm malignancy in highly suspicious lesions, more commonly it is done to verify that a lesion is benign and thus prevent surgical biopsy or multiple followup examinations. Results are generally available within 24 hours.

Ductography is performed

to define ductal anatomy in patients with single duct nipple discharges. It is not an appropriate examination for patients with multiple duct discharge. Ultrasound can be used to guide entry of the ductogram cannula into the duct, but more commonly this is done by directly inserting the cannula into the discharging duct ostium on the nipple.

Q: Do you discuss your findings with the patient?

All patients who come to UAB for either screening or diagnostic mammography are informed of the results of their examinations before they leave the department. In most cases, if the patient is able, any diagnostic examinations up to and including large core needle biopsy, are performed at the time of her scheduled examination, even if the original examination was for screening. This significantly reduces delays in reporting and acting on results, improves patient compliance, helps avoid miscommunication, and results in significant cost savings. The percentage of patients who receive diagnostic examinations, such as breast ultrasound, is relatively low, well within national standards. The performance of the UAB Mammography Center in breast cancer detection and evaluation of breast abnormalities is among the best in the world.

Q: How do I get the results of your evaluation?

A report on all breast imaging examinations is available on the day of the examination for most patients. Some reports are slightly delayed if the comparison UAB examination is not available at the time of scheduling. Because the transcribed report takes somewhat longer to generate due to a somewhat antiquated computer system (which is currently being updated), patients usually know their results before the final report reaches the physician. Physicians are notified by telephone of all biopsy results and of all results indicating the need for further intervention. This is usually accomplished at the time the patient is in the department unless the referring physician is unavailable. For UAB patients, if both the patient and her physician are willing, an appointment is scheduled with UAB Surgical Oncology for those patients requiring surgical interventions. This appointment is usually scheduled within a week of the imaging study and often on the same or following day.

A computerized database is maintained for all mammographic examinations and allows tracking of patients for whom followup or surgical consultation is recommended. If followup information is lacking for any patient, the referring physician and/or patient are called to determine whether appropriate followup measures have been performed, and, if not, to assure that they are. Pathology reports are obtained for all patients who have biopsies performed.

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Visions is published quarterly by the University of Alabama Hospital Department of Radiology. Professor and Chairman: Robert J. Stanley, M.D. Vice-Chairman for Operations and Academic Affairs: Robert E. Koehler, M.D. Vice Chairman for Planning and Administration: Lincoln Berland, M.D. Director of Outpatient Services: Peter Dempsey, M.D. Visions Staff-Managing Editor: Pat Moore. Editors/Writers: Lincoln Berland, M.D. Kay Hamrick, M.D. Robert Lopez, M.D. UAB Office of Marketing and Media Relations Staff- Editor: JoLynn Orr. Art Director: Jason Bickell. Please direct questions, comments, and suggestions as follows: Attention Angie French or Lincoln Berland, M.D. Fax: 975-7213 Address: NHB 623B EMAIL: lberland@uabmc.edu

Q: At what age should a woman get her first screening mammogram and how often after that?	Annual screening of women over age 50 is recommended by all organizations which have developed screening guidelines. An upper age limit for screening has not been agreed upon. Medicare, which covers most women 65 and over, funds screening mammograms every two years for eligible women. Screening of women age 40-49 remains a controversial area. In the US, largely because of the aging of the "baby boom" population, the absolute number of women who develop breast cancer in their 40's is about the same as that of women who develop the disease in their 50's. It is also likely that the impact of detecting breast cancer is greater in younger women. At UAB, we have strongly urged that if screening is to be done in women 40-49 that it be done at annual intervals. Lead times are shorter in younger women likely due to hormonal influences (which may also be an issue in women on estrogen replacement although this is unproven). Long interscreen intervals result in unacceptable numbers of interval cancers, i.e., those which become detectable as palpable cancers between screens. Although none of the randomized controlled clinical trials, other than the Canadian trial, was specifically designed to address the issue of screening women in their 40's, the results of these trials, at the most recent meta-analysis, indicate a 24% benefit in survival for women who were screened in their 40's.
Q: Are the recommendations different for women with a positive family history of breast cancer?	There is currently no information to suggest that screening intervals shorter than one year are efficacious, even in women with a strong family history of breast cancer. However, beginning screening at an earlier age is generally recommended for women with family histories of premenopausal breast cancer in first degree relatives (mother, sister, daughter) and in those with evidence suggesting genetic breast cancer. The appropriate screening recommendations for women who test positive for the breast cancer genes, BRCA1 and BRCA2, have not been established. A guideline for when breast cancer screening should be initiated in high-risk women suggests it begin 10 years earlier than the earliest breast cancer which occurred in the family, but not before age 25.
Q: What is the appropriate study to order for a patient under 30 ...with a palpable lump? ...with breast pain or tenderness?	In general, young women with breast lumps should be evaluated with breast ultrasound. Xray imaging is only performed if the ultrasound examination is inconclusive or suggests the presence of breast cancer. This policy is not rigid as young obese or multiparous women may be better evaluated with xray mammography, particularly when a discrete mass is not identified. Patients with diffuse breast pain or tenderness usually require reassurance, not breast imaging studies. Localized breast pain, which the patient consistently pinpoints with a single finger, is rarely associated with breast cancer and is a rare symptom. However, when present, such cases merit diagnostic evaluation with ultrasound and/or xray mammography. Once a patient with a significant breast symptom (mass, retraction, single duct nipple discharge, etc.) reaches the age of 30, the initial examination is usually xray mammography, supplemented by additional examinations if necessary.
Q: Why is ultrasound done in addition to the mammogram?	Ultrasound is a superb adjunctive examination to xray mammography, but cannot substitute for it in its screening function. As mentioned earlier, it is the primary examination for young women with palpable abnormalities and also for those who are pregnant or lactating. It is also routinely performed in women with clinical findings whose mammograms are unrevealing and in those whose mammograms show areas which require further characterization. Ultrasound is also used to guide interventional procedures, such as needle localization, fine needle aspiration and biopsy, large core needle biopsy, and even ductography. Ultrasound can reliably diagnose most breast cysts and can be used to guide cyst puncture for those cysts which are symptomatic or do not meet stringent criteria for diagnosis of a cyst on ultrasound. It can also provide reassurance that no mass underlies a questionably palpable area. Recent evidence suggests that ultrasound can aid in benign-malignant differentiation of solid breast masses and prevent biopsy for many noncancerous masses, such as fibroadenomas. In addition, ultrasound allows recognition of some cancers which are inapparent on xray mammography.
Q: What other diagnostic procedures do you perform?	Needle localization breast biopsy is performed to guide surgical excision of nonpalpable lesions. This may be done with xray or ultrasound guidance. Xray guidance is generally required for lesions manifest as microcalcifications without mass. For the last few years, with the use of fine needle aspiration and core biopsy to preselect patients who require surgery, the cancer yield of needle localization biopsies at UAB has exceeded 50% overall, and 70% overall for those lesions manifest as mass. This has been accomplished without an increase in average tumor size or node positivity. Nearly 90% of needle localized cancers are 1.5 cm in size or smaller, 60% are 1 cm or smaller, and over 90% are node-negative.
Fine needle aspiration or biopsy	are usually performed with ultrasound guidance. Although cyst puncture for palpable lesions can be accomplished without guidance, it is more reliably accomplished when the cyst can be entered (and fully evacuated) under direct vision. For fine needle aspiration biopsies, the cytotechnologist and cytopathologist are present during the performance of the procedure and results are available within 15 minutes.
Large core needle biopsy	is performed with ultrasound guidance (our preference for mass lesions) or stereotactic guidance. Although this can be performed to confirm malignancy in highly suspicious lesions, more commonly it is done to verify that a lesion is benign and thus prevent surgical biopsy or multiple followup examinations. Results are generally available within 24 hours.
Ductography is performed	to define ductal anatomy in patients with single duct nipple discharges. It is not an appropriate examination for patients with multiple duct discharge. Ultrasound can be used to guide entry of the ductogram cannula into the duct, but more commonly this is done by directly inserting the cannula into the discharging duct ostium on the nipple.
Q: Do you discuss your findings with the patient?	All patients who come to UAB for either screening or diagnostic mammography are informed of the results of their examinations before they leave the department. In most cases, if the patient is able, any diagnostic examinations up to and including large core needle biopsy, are performed at the time of her scheduled examination, even if the original examination was for screening. This significantly reduces delays in reporting and acting on results, improves patient compliance, helps avoid miscommunication, and results in significant cost savings. The percentage of patients who receive diagnostic examinations, such as breast ultrasound, is relatively low, well within national standards. The performance of the UAB Mammography Center in breast cancer detection and evaluation of breast abnormalities is among the best in the world.
Q: How do I get the results of your evaluation?	A report on all breast imaging examinations is available on the day of the examination for most patients. Some reports are slightly delayed if the comparison UAB examination is not available at the time of scheduling. Because the transcribed report takes somewhat longer to generate due to a somewhat antiquated computer system (which is currently being updated), patients usually know their results before the final report reaches the physician. Physicians are notified by telephone of all biopsy results and of all results indicating the need for further intervention. This is usually accomplished at the time the patient is in the department unless the referring physician is unavailable. For UAB patients, if both the patient and her physician are willing, an appointment is scheduled with UAB Surgical Oncology for those patients requiring surgical interventions. This appointment is usually scheduled within a week of the imaging study and often on the same or following day. A computerized database is maintained for all mammographic examinations and allows tracking of patients for whom followup or surgical consultation is recommended. If followup information is lacking for any patient, the referring physician and/or patient are called to determine whether appropriate followup measures have been performed, and, if not, to assure that they are. Pathology reports are obtained for all patients who have biopsies performed.