Breast Imaging: What’s
Important?
Freddie J. Combs, MD
The Great Mammography Debate
The Great Mammography Debate
• Breast imaging has long been a source of passionate
debate and controversy within the medical
community and society at large.
The Great Mammography Debate
• Breast imaging has long been a source of passionate
debate and controversy within the medical
community and society at large.
• So why all the fuss…????
The Great Mammography Debate
• Breast imaging has long been a source of passionate
debate and controversy within the medical
community and society at large.
• So why all the fuss…????
“Because it’s out there, man…It’s
out there.”
Hot PINK Topic
• Seems like you can’t go anywhere these days
without seeing PINK.
It’s in the News
It’s in Hollywood
It’s in Advertising
It’s in Advertising
REALLY!!!
???
Even Here…..
Breast Cancer
• Let’s start with some useful facts for providers
and patients.
Some Important Statistics
Some Important Statistics
• About 1 in 8 women (approx. 12%) and 1 in
1,000 men will develop invasive breast cancer
in their lifetime
Some Important Statistics
• About 1 in 8 women (approx. 12%) and 1 in
1,000 men will develop invasive breast cancer
in their lifetime
• In 2013 an estimated 299,220 new cases of
invasive and non-invasive (in situ) breast
cancers were diagnosed in the U.S.
Some Important Statistics
• About 1 in 8 women (approx. 12%) and 1 in
1,000 men will develop invasive breast cancer
in their lifetime
• In 2013 an estimated 299,220 new cases of
invasive and non-invasive (in situ) breast
cancers were diagnosed in the U.S.
• Approx. 39,620 women died of Breast cancer
in 2013 (2nd only to lung cancer)
Rose Bowl holds 93,000
Angel Stadium Holds 45,000
But Wait, There’s More….
• 2nd most common cancer in U.S. women
(behind skin cancer)
But Wait, There’s More….
• 2nd most common cancer in U.S. women
(behind skin cancer)
• 30% of all cancers diagnosed in women
But Wait, There’s More….
• 2nd most common cancer in U.S. women
(behind skin cancer)
• 30% of all cancers diagnosed in women
• 3,000,000 U.S. breast cancer survivors
But Wait, There’s More….
• 2nd most common cancer in U.S. women
(behind skin cancer)
• 30% of all cancers diagnosed in women
• 3,000,000 U.S. breast cancer survivors
• 15% diagnosed have a family history. Risk
doubles with history in a 1st degree relative
But Wait, There’s More….
• 2nd most common cancer in U.S. women
(behind skin cancer)
• 30% of all cancers diagnosed in women
• 3,000,000 U.S. breast cancer survivors
• 15% diagnosed have a family history. Risk
doubles with history in a 1st degree relative
• 85% have no family history. Most breast
cancers are not genetically linked
Ok, so…you got any Good News?
Ok, so…you got any Good News?
• Since widespread screening for breast cancer
began in the 1990’s there has been a decline
in mortality
Ok, so…you got any Good News?
• Since widespread screening for breast cancer
began in the 1990’s there has been a decline
in mortality
• CDC data from 2001-2010 shows breast
cancer mortality rate decreased by 2% per
year
Ok, so…you got any Good News?
• Since widespread screening for breast cancer
began in the 1990’s there has been a decline
in mortality
• CDC data from 2001-2010 shows breast
cancer mortality rate decreased by 2% per
year
• Factors include early detection with improved
screening, advances in treatment and
increased awareness
Mortality Rate 1992-2010
Mortality Rate 1992-2010
Dude…What about Genes??
Dude, what about genes?
Dude, what about genes?
Dude, what about genes?
• 5-10% of breast cancers are linked to specific
gene mutations. BRCA1 & 2 most common
Dude, what about genes?
• 5-10% of breast cancers are linked to specific
gene mutations. BRCA1 & 2 most common
• BRCA1 carries a 50-80% and BRCA2 a 40-70%
risk of developing breast cancer by age 70
Dude, what about genes?
• 5-10% of breast cancers are linked to specific
gene mutations. BRCA1 & 2 most common
• BRCA1 carries a 50-80% and BRCA2 a 40-70%
risk of developing breast cancer by age 70
• Cancers in women with gene mutations tend
to occur early (before age 50) and may be
aggressive
HBOC Gene Testing: Who Qualifies
• The Patient History:
HBOC Gene Testing: Who Qualifies
• The Patient History:
• Breast cancer at age 50 or younger or ovarian cancer
at any age
HBOC Gene Testing: Who Qualifies
• The Patient History:
• Breast cancer at age 50 or younger or ovarian cancer
at any age
• Male with breast cancer at any age
HBOC Gene Testing: Who Qualifies
• The Patient History:
• Breast cancer at age 50 or younger or ovarian cancer
at any age
• Male with breast cancer at any age
• Ashkenazi Jewish descent and a personal or family
history of breast, ovarian or pancreatic cancer (HBOC
cancers)
(HBOC cancers are Breast, Ovarian and Pancreatic)
HBOC Gene Testing: Who Qualifies
• The Family History:
HBOC Gene Testing: Who Qualifies
• The Family History:
• 2 breast cancers in the same family member or on the same
side of the family
HBOC Gene Testing: Who Qualifies
• The Family History:
• 2 breast cancers in the same family member or on the same
side of the family
• Family member diagnosed with triple negative breast cancer
at any age (ER/PR/Her2Nu all negative)
HBOC Gene Testing: Who Qualifies
• The Family History:
• 2 breast cancers in the same family member or on the same
side of the family
• Family member diagnosed with triple negative breast cancer
at any age (ER/PR/Her2Nu all negative)
• Pancreatic cancer and an HBOC-associated cancer in the same
person or on same side of the family
HBOC Gene Testing: Who Qualifies
• The Family History:
• 2 breast cancers in the same family member or on the same
side of the family
• Family member diagnosed with triple negative breast cancer
at any age (ER/PR/Her2Nu all negative)
• Pancreatic cancer and an HBOC-associated cancer in the same
person or on same side of the family
• 3 or more breast cancers on the same side of the family
HBOC Gene Testing: Who Qualifies
• The Family History:
• 2 breast cancers in the same family member or on the same
side of the family
• Family member diagnosed with triple negative breast cancer
at any age (ER/PR/Her2Nu all negative)
• Pancreatic cancer and an HBOC-associated cancer in the same
person or on same side of the family
• 3 or more breast cancers on the same side of the family
• Known BRCA1 or BRCA2 mutation in the family
Affordable Care Act considers gene testing as a preventive measure
Aside from Gene Testing, Who’s else is
High Risk?
• Several models exist for calculating risk.
Models may include Lifetime Risk (LTR), Tenyear risk, probability of a BRCA mutation
• Tyrer-Cuzick (IBIS), Gail, Claus, BRCAPRO,
BOADICEA are the most used models and offer
downloadable online versions
• IBIS shown to be most consistently accurate
model. We use this at PBCC on all patients
IBIS examples
A more useful IBIS example
(IBIS= International Breast Cancer Intervention Study)
Enough with the stats, let’s get to the
practice related stuff….
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
• WHO should we evaluate?
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
• WHO should we evaluate?
• WHEN should we evaluate them?
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
• WHO should we evaluate?
• WHEN should we evaluate them?
• HOW should we do it?
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
• WHO should we evaluate?
• WHEN should we evaluate them?
• HOW should we do it?
Answer: It depends on who you ask……….
Enough with the stats, let’s get to the
practice related stuff….
The Basic Questions:
• WHO should we evaluate?
• WHEN should we evaluate them?
• HOW should we do it?
Answer: It depends on who you ask……….
So, let’s ask the experts!
The USPSTF Says:
The USPSTF Says:
• Routine screening mammogram every 2 years for women ages
50-74 with consideration for starting earlier biennial screening
based on patient’s beliefs regarding benefits and harms.
The USPSTF Says:
• Routine screening mammogram every 2 years for women ages
50-74 with consideration for starting earlier biennial screening
based on patient’s beliefs regarding benefits and harms.
• Recommends against teaching SBE (Self-breast Examination).
The USPSTF Says:
• Routine screening mammogram every 2 years for women ages
50-74 with consideration for starting earlier biennial screening
based on patient’s beliefs regarding benefits and harms.
• Recommends against teaching SBE (Self-breast Examination).
• Insufficient evidence to recommend for or against CBE
(Clinical Breast Exam), digital mammography and MRI.
The ACR Says (a lot):
The ACR Says (a lot):
•
Yearly mammograms starting at 40 for women at average risk.
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
a. Woman with known mutation or genetic syndrome with increased breast cancer
risk: yearly starting by age 30, but not before age 25.
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
a. Woman with known mutation or genetic syndrome with increased breast cancer
risk: yearly starting by age 30, but not before age 25.
b. Untested women with a first-degree relative with known BRCA mutation: yearly
starting by age 30, but not before age 25.
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
a. Woman with known mutation or genetic syndrome with increased breast cancer
risk: yearly starting by age 30, but not before age 25.
b. Untested women with a first-degree relative with known BRCA mutation: yearly
starting by age 30, but not before age 25.
c. Woman with a 20% or greater lifetime risk based on breast cancer risk models:
yearly starting by age 30, but not before age 25, or 10 years earlier than the age at
which the youngest first-degree relative was diagnosed, whichever is later.
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
a. Woman with known mutation or genetic syndrome with increased breast cancer
risk: yearly starting by age 30, but not before age 25.
b. Untested women with a first-degree relative with known BRCA mutation: yearly
starting by age 30, but not before age 25.
c. Woman with a 20% or greater lifetime risk based on breast cancer risk models:
yearly starting by age 30, but not before age 25, or 10 years earlier than the age at
which the youngest first-degree relative was diagnosed, whichever is later.
d. Woman with a history of chest (mantle) radiation between the ages of 10 and
30: yearly starting 8 years after the radiation therapy, but not before age 25.
The ACR Says (a lot):
•
•
Yearly mammograms starting at 40 for women at average risk.
Screen women < 40 at increased risk for breast cancer as follows:
a. Woman with known mutation or genetic syndrome with increased breast cancer
risk: yearly starting by age 30, but not before age 25.
b. Untested women with a first-degree relative with known BRCA mutation: yearly
starting by age 30, but not before age 25.
c. Woman with a 20% or greater lifetime risk based on breast cancer risk models:
yearly starting by age 30, but not before age 25, or 10 years earlier than the age at
which the youngest first-degree relative was diagnosed, whichever is later.
d. Woman with a history of chest (mantle) radiation between the ages of 10 and
30: yearly starting 8 years after the radiation therapy, but not before age 25.
e. Woman with biopsy-proven lobular neoplasia, atypical ductal hyperplasia (ADH),
ductal carcinoma in-situ (DCIS), invasive breast cancer, or ovarian cancer: yearly
from time of diagnosis, regardless of age.
Screening for Breast Cancer
• Regardless of which set of recommendations
you follow, it all starts with our old friend….
Screening for Breast Cancer
• Regardless of which set of recommendations
you follow, it all starts with our old friend….
The Mammogram
Sensitivity and Specificity for Screening
SCREENING TEST(S)
SENSITIVITY %
SPECIFICITY %
Mammogram
71-83
91-93
MRI
75-97
91-96
Mammogram/US
76
84
Mammogram/MRI
84-94
86-95
•Sensitivity of mammography varies depending upon density and Radiologist
•Addition of ultrasound and MRI to mammography detects more cancers but leads to
an increase in recall rates and procedures (false positives)
Ichikawa LE , Barlow WE , Anderson ML , et al .Time trends in radiologists’ interpretive performance at screening mammography fromthe communitybased Breast Cancer Surveillance Consortium, 1996-2004 . Radiology 2010 ; 256 ( 1 ): 74 – 82
Berg WA, Zhang Z, Lehrer D, et al. Detection of Breast Cancer With Addition of Annual Screening Ultrasound or a Single Screening MRI to Mammography in
Women With Elevated Breast Cancer Risk. JAMA. 2012;307(13):1394-1404.
Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial
risk for breast cancer. J Clin Oncol. 23(33):8469-76, 2005.
Mammography:
Mammography:
• Governed by the FDA via the Mammography
Quality Standards Act of 1992 (MQSA)
• MQSA requires all facilities and technologists
that perform mammograms and interpreting
physicians to maintain certification (via the
ACR) to ensure consistency.
• Make sure your patients are
going to an accredited facility!
Mammography:
• May be performed using screen-film or digital
technique. Sensitivity is equivalent but digital
performs better in dense tissue and allows use
of CAD (Computer-Aided Diagnosis) software.
Mammography:
• May be performed using screen-film or digital
technique. Sensitivity is equivalent but digital
performs better in dense tissue and allows use
of CAD (Computer-Aided Diagnosis) software.
Old school- Workin’ Hard
Mammography:
• May be performed using screen-film or digital
technique. Sensitivity is equivalent but digital
performs better in dense tissue and allows use
of CAD (Computer-Aided Diagnosis) software.
Old school- Workin’ Hard
VS.
New school-Hardly Workin’
Mammography:
• There are two categories of Mammogram
Mammography:
• There are two categories of Mammogram
• SCREENING: routine, preventive exam in
asymptomatic women. 4 standard views (bilateral CC
and MLO)
Mammography:
• There are two categories of Mammogram
• SCREENING: routine, preventive exam in
asymptomatic women. 4 standard views (bilateral CC
and MLO)
• DIAGNOSTIC: evaluation of a specific symptom,
clinical finding or to follow-up an abnormal finding
on screening or known disease process. May include
additional views and/or other modalities
Mammography:
• There are two categories of Mammogram
• SCREENING: routine, preventive exam in
asymptomatic women. 4 standard views (bilateral CC
and MLO)
• DIAGNOSTIC: evaluation of a specific symptom,
clinical finding or to follow-up an abnormal finding
on screening or known disease process. May include
additional views and/or other modalities
• IMPORTANT DISTINCTION WHEN ORDERING
Screening Mammogram
• Two Standard Views: CC and MLO
Diagnostic Mammogram
Magnification views
Other Modalities: Ultrasound
Other Modalities: Ultrasound
• Most effective as a diagnostic tool
Other Modalities: Ultrasound
• Most effective as a diagnostic tool
• Preferred modality in pregnant or lactating women and
women under 30
Other Modalities: Ultrasound
• Most effective as a diagnostic tool
• Preferred modality in pregnant or lactating women and
women under 30
• May be useful as an adjunct to mammogram screening in
women with dense breasts and increased lifetime risk that are
not able to have MRI, but no current specific screening
recommendations
Other Modalities: Ultrasound
• Most effective as a diagnostic tool
• Preferred modality in pregnant or lactating women and
women under 30
• May be useful as an adjunct to mammogram screening in
women with dense breasts and increased lifetime risk that are
not able to have MRI, but no current specific screening
recommendations
• Best modality for biopsy
Other Modalities: Ultrasound
• Most effective as a diagnostic tool
• Preferred modality in pregnant or lactating women and
women under 30
• May be useful as an adjunct to mammogram screening in
women with dense breasts and increased lifetime risk that are
not able to have MRI, but no current specific screening
recommendations
• Best modality for biopsy
• Operator dependent. Use dedicated breast facility with
experienced techs and Radiologist
Ultrasound (Fibroadenoma)
CCancer on Ultrasound
Cyst on US
Other Modalities: Breast MRI
• High sensitivity and specificity
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
• Recommended as screening tool with mammogram in high
risk women (LTR >20%)
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
• Recommended as screening tool with mammogram in high
risk women (LTR >20%)
• Requires IV Contrast (gadolinium) to evaluate for cancer
(Don’t order a non-contrast breast MRI)
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
• Recommended as screening tool with mammogram in high
risk women (LTR >20%)
• Requires IV Contrast (gadolinium) to evaluate for cancer
(Don’t order a non-contrast breast MRI)
• No Radiation
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
• Recommended as screening tool with mammogram in high
risk women (LTR >20%)
• Requires IV Contrast (gadolinium) to evaluate for cancer
(Don’t order a non-contrast breast MRI)
• No Radiation
• Avoid in pregnancy (Gad. is Category C)
Other Modalities: Breast MRI
• High sensitivity and specificity
• Does not replace mammography
• Recommended as screening tool with mammogram in high
risk women (LTR >20%)
• Requires IV Contrast (gadolinium) to evaluate for cancer
(Don’t order a non-contrast breast MRI)
• No Radiation
• Avoid in pregnancy (Gad. is Category C)
• Limit in lactation. Avoid nursing for 24 hrs after MRI (pumpand-dump)
Breast MRI Indications
MRI
Cancer with Mets to Axilla
3-D Mammography (Tomosynthesis)
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
• Does not replace conventional mammogram
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
• Does not replace conventional mammogram
• Benefit: Improves call back rate and detection
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
• Does not replace conventional mammogram
• Benefit: Improves call back rate and detection
• Requires more radiation
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
• Does not replace conventional mammogram
• Benefit: Improves call back rate and detection
• Requires more radiation
• More expensive
3-D Mammography (Tomosynthesis)
• Combines multiple mammo images to reduce tissue
overlap (like CT)
• Does not replace conventional mammogram
• Benefit: Improves call back rate and detection
• Requires more radiation
• More expensive
• Trendy but not currently a standard
recommendation…Time will tell where it fits in
3-D Mammography (Tomosynthesis)
Quick Facts: Implants
Quick Facts: Implants
• Screening rec’s are the same for women with implants
Quick Facts: Implants
• Screening rec’s are the same for women with implants
• Reduces sensitivity of mammogram (blind spots) but overall
cancer outcomes unchanged
Quick Facts: Implants
• Screening rec’s are the same for women with implants
• Reduces sensitivity of mammogram (blind spots) but overall
cancer outcomes unchanged
• Requires additional views and more radiation
Quick Facts: Implants
• Screening rec’s are the same for women with implants
• Reduces sensitivity of mammogram (blind spots) but overall
cancer outcomes unchanged
• Requires additional views and more radiation
• Risk of rupture caused by a mammogram is very low (but not
zero). Experienced facility is key
Quick Facts: Implants
• Screening rec’s are the same for women with implants
• Reduces sensitivity of mammogram (blind spots) but overall
cancer outcomes unchanged
• Requires additional views and more radiation
• Risk of rupture caused by a mammogram is very low (but not
zero). Experienced facility is key
• MRI is preferred method to eval. implants. FDA rec’s MRI 3 yr.
after placed then q2 yrs. (Silicone)
Quick Facts: Implants
• Screening rec’s are the same for women with implants
• Reduces sensitivity of mammogram (blind spots) but overall
cancer outcomes unchanged
• Requires additional views and more radiation
• Risk of rupture caused by a mammogram is very low (but not
zero). Experienced facility is key
• MRI is preferred method to eval. implants. FDA rec’s MRI 3 yr.
after placed then q2 yrs. (Silicone)
• Overall rupture rate unknown but studies suggest at least 15%
between years 3-10 after placed
Implant Rupture (Linguine Sign)
Implant Rupture (Key Hole Sign and Free Silicone)
Radiation facts for worried patients:
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
• CXR 0.1 mSv for single view
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
• CXR 0.1 mSv for single view
• CT Scan avg. 10 mSv
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
• CXR 0.1 mSv for single view
• CT Scan avg. 10 mSv
• Roundtrip plane flight LA to NY is approx. 0.1 mSv
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
• CXR 0.1 mSv for single view
• CT Scan avg. 10 mSv
• Roundtrip plane flight LA to NY is approx. 0.1 mSv
• Natural background radiation is around 3 mSv/yr. Higher in
Colorado (pun intended)
Radiation facts for worried patients:
• Mammogram should not be routinely performed in women
under age 30 or in pregnant women
• Rad exposure is very low: 0.4 mSv (0.1 mSv per view)
• CXR 0.1 mSv for single view
• CT Scan avg. 10 mSv
• Roundtrip plane flight LA to NY is approx. 0.1 mSv
• Natural background radiation is around 3 mSv/yr. Higher in
Colorado (pun intended)
• Thyroid exposure is minimal and indirect (similar to 30 min. of
natural background radiation)
What is the official mascot of the
Radiologist?
THE HEDGE
But not for Breast Imaging….
Here’s Why….
Reporting: The No Hedging Zone
• BI-RADS:
Reporting: The No Hedging Zone
• BI-RADS: BREAST IMAGING-REPORTING AND DATA
SYSTEM
Reporting: The No Hedging Zone
• BI-RADS: BREAST IMAGING-REPORTING AND DATA
SYSTEM
• System which includes a standardized format and
lexicon designed to guide patient care and improve
physician communication.
Reporting: The No Hedging Zone
• BI-RADS: BREAST IMAGING-REPORTING AND DATA
SYSTEM
• System which includes a standardized format and
lexicon designed to guide patient care and improve
physician communication.
• BI-RADS includes specifics for mammography,
ultrasound and MRI reporting.
Reporting: The No Hedging Zone
• BI-RADS: BREAST IMAGING-REPORTING AND DATA
SYSTEM
• System which includes a standardized format and
lexicon designed to guide patient care and improve
physician communication.
• BI-RADS includes specifics for mammography,
ultrasound and MRI reporting.
• ALL breast imaging should be performed according
to BI-RADS guidelines
BI-RADS reporting must include:
BI-RADS reporting must include:
• Patient name and identifier
BI-RADS reporting must include:
• Patient name and identifier
• Date of exam
BI-RADS reporting must include:
• Patient name and identifier
• Date of exam
• Name of interpreting physician
BI-RADS reporting must include:
•
•
•
•
Patient name and identifier
Date of exam
Name of interpreting physician
Overall final assessment with BI-RADS# (0-6)
BI-RADS reporting must include:
•
•
•
•
•
Patient name and identifier
Date of exam
Name of interpreting physician
Overall final assessment with BI-RADS# (0-6)
A written report must be sent to the ordering
provider and a report in lay terms sent to the patient
within 30 days
BI-RADS reporting must include:
•
•
•
•
•
Patient name and identifier
Date of exam
Name of interpreting physician
Overall final assessment with BI-RADS# (0-6)
A written report must be sent to the ordering
provider and a report in lay terms sent to the patient
within 30 days
• Suspicious findings should be communicated to the
ordering physician within 3 business days and to the
patient within 5 days
Report format
• Date, clinical history and indication for study
(At PBCC we also include the patient’s estimated risk: IBIS)
• Comparison studies
• Technique used
• Description of breast density in BI-RADS terms
• Imaging findings using BI-RADS lexicon
• Final assessment with BI-RADS number and
recommendations for follow-up
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires
biopsy. May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS CATEGORIES: 1-6
•
•
•
•
BI-RADS: 0. FURTHER EVALUATION OR PRIORS NEEDED
BI-RADS: 1. NEGATIVE
BI-RADS: 2. BENIGN FINDINGS
BI-RADS: 3. PROBABLY BENIGN (implies <2% chance of
malignancy)
• BI-RADS: 4. SUSPICIOUS OF MALIGNANCY (requires biopsy.
May be subdivided as A,B,C: low, intermediate, moderate)
• BI-RADS: 5. HIGHLY SUSPICIOUS (requires biopsy. Implies
95% likelihood of malignancy)
• BI-RADS: 6. KNOWN MALIGNANCY (prior to treatment)
BI-RADS Bottom Line
BI-RADS Bottom Line
• BI-RADS: 1 and 2. No action needed
BI-RADS Bottom Line
• BI-RADS: 1 and 2. No action needed
• BI-RADS: 3. Short term follow-up, usually in 6
months or consider biopsy (decision may be
based on patient’s preference)
BI-RADS Bottom Line
• BI-RADS: 1 and 2. No action needed
• BI-RADS: 3. Short term follow-up, usually in 6
months or consider biopsy (decision may be
based on patient’s preference)
• BIRADS: 4 and 5. Take action. Needs biopsy
Sample Report
RIGHT BREAST DIGITAL DIAGNOSTIC MAMMOGRAM
CLINICAL HISTORY:
Asymptomatic 41 year old female seen for diagnostic evaluation of a spiculated mass in the right breast 3:00 location noted
on today's baseline screening mammography. She has a history of bilateral breast augmentation mammoplasty in March,
2006. The patient has the following family history of breast cancer: great aunt, Maternal.
IBIS estimated lifetime risk 15%
TECHNIQUE:
Digital mammographic images were obtained using a Selenia mammographic system. Standard and/or additional views were
obtained as deemed necessary.
MAMMOGRAM FINDINGS:
Magnification views of the right breast demonstrate a spiculated mass 2 cm from the nipple at
the 3:00 position, middle depth with 2 associated punctate calcifications at the anterior
inferior margin. The mass measures approximately 15 x 15 x 20 mm. There is associated
architectural distortion. No additional mass, calcification or architectural distortion is
seen to suggest malignancy.
IMPRESSION: BI-RADS 5. Highly suspicious. Same day ultrasound is pending and if visualized,
ultrasound core biopsy will be performed. lf not visualized on ultrasound, stereotactic core
biopsy is recommended.
ACR BI-RADS Category 5 - Highly Suggestìve of Malignancy.
Electronically signed by Freddie Combs. M.D. on 03127/2014
Breast Density, what’s up with that?
Breast Density, what’s up with that?
• California SB-1538 (2012) requires a written
report notifying patients of their breast density.
Many states have similar laws
• Dense breast tissue decreases mammographic
sensitivity and may be an independent risk factor
for breast cancer
• Currently no formal recommendation for
additional testing in dense breasts. Should be
individual decision made with their health care
provider
BI-RADS Breast Density Types
• Type 1: “Almost Entirely Fat” or “Mostly Fatty
Replaced” (0-25%)
BI-RADS Breast Density Types
• Type 1: “Almost Entirely Fat” or “Mostly Fatty
Replaced” (0-25%)
• Type 2: “Scattered Fibroglandular” (25-50%)
BI-RADS Breast Density Types
• Type 1: “Almost Entirely Fat” or “Mostly Fatty
Replaced” (0-25%)
• Type 2: “Scattered Fibroglandular” (25-50%)
• Type 3: “Heterogeneously Dense”. (50-75%)
BI-RADS Breast Density Types
• Type 1: “Almost Entirely Fat” or “Mostly Fatty
Replaced” (0-25%)
• Type 2: “Scattered Fibroglandular” (25-50%)
• Type 3: “Heterogeneously Dense”. (50-75%)
• Type 4: “Extremely Dense” (>75%)
Breast Density Images
Our Approach at PBCC to Screening
• Patient History
• Risk Assessment (IBIS)-Lifetime Risk (LTR)
Low Risk: 0-11%
Intermediate Risk: 12-19%
High Risk: 20%+
• Assess Breast density on screening
mammogram
PBCC Screening Protocol
Low Risk
Intermediate Risk
High Risk
(0-11%)
(12-19%)
(20%+)
• Mammogram
• Mammogram
• Screening US if
Dense Breasts
• Mammogram
• Screening MRI
• Screening US if
can’t have MRI
Summary
Summary
• Breast Cancer is a common but mostly treatable
disease
Summary
• Breast Cancer is a common but mostly treatable
disease
• Screening is the key to early diagnosis but only works
if patients trust that it is safe and effective (and it is!)
Summary
• Breast Cancer is a common but mostly treatable
disease
• Screening is the key to early diagnosis but only works
if patients trust that it is safe and effective (and it is!)
• It is our job to: Educate patients, order appropriate
imaging, provide consistent follow-up and
communicate.
Summary
• Breast Cancer is a common but mostly treatable
disease
• Screening is the key to early diagnosis but only works
if patients trust that it is safe and effective (and it is!)
• It is our job to: Educate patients, order appropriate
imaging, provide consistent follow-up and
communicate.
• This is a team effort!
What’s best for your patients?
• MQSA/ACR certified breast center
What’s best for your patients?
• MQSA/ACR certified breast center
• Digital imaging preferred
What’s best for your patients?
• MQSA/ACR certified breast center
• Digital imaging preferred
• Experienced Radiologists and Techs
What’s best for your patients?
•
•
•
•
MQSA/ACR certified breast center
Digital imaging preferred
Experienced Radiologists and Techs
Evidence based imaging protocols
What’s best for your patients?
•
•
•
•
•
MQSA/ACR certified breast center
Digital imaging preferred
Experienced Radiologists and Techs
Evidence based imaging protocols
Timely reporting to physicians using BI-RADS
format and easy to understand patient
information
Get to know your Breast Imagers
Get to know your Breast Imagers
• Breast cancer is a complex disease on many
levels with many gray areas in screening and
diagnosis. We owe it to our patients to work
together to provide consistent information
Get to know your Breast Imagers
• Breast cancer is a complex disease on many
levels with many gray areas in screening and
diagnosis. We owe it to our patients to work
together to provide consistent information
• Even basic screening can be terrifying to
patients. Sometimes the most important
service we provide is REASSURANCE
THANK YOU!
Mammography:
• Swedish Two-County Trial, a landmark study
started in 1977 demonstrated a 31% reduction
in mortality and 25% reduction in Stage II or
later cancers. (1977-84)
Tabár L, Vitak B, Chen TH, et al.. Swedish two-county trial: impact of mammography screening on breast cancer mortality
during 3 decades. Radiology 2011;260(3):658–663.