1. Breast Imaging: What’s Important?
Freddie J. Combs, MD

2. The Great Mammography Debate

3. The Great Mammography Debate
Breast imaging has long been a source of passionate debate and controversy within the medical community and society at large.

4. 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…????

5. 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.”

6. Hot PINK Topic
Seems like you can’t go anywhere these days without seeing PINK.

7. It’s in the News

8. It’s in Hollywood

9. It’s in Advertising

10. It’s in Advertising
REALLY!!!???

11. Even Here…..

12. Breast Cancer
Let’s start with some useful facts for providers and patients.

13. Some Important Statistics

14. Some Important Statistics
About 1 in 8 women (approx. 12%) and 1 in 1,000 men will develop invasive breast cancer in their lifetime

15. 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.

16. 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)

17. Rose Bowl holds 93,000

18. Angel Stadium Holds 45,000

19. But Wait, There’s More….
2nd most common cancer in U.S. women (behind skin cancer)

20. But Wait, There’s More….
2nd most common cancer in U.S. women (behind skin cancer)
30% of all cancers diagnosed in women

21. 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

22. 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

23. 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

24. Ok, so…you got any Good News?

25. 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

26. 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 shows breast cancer mortality rate decreased by 2% per year

27. 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 shows breast cancer mortality rate decreased by 2% per year
Factors include early detection with improved screening, advances in treatment and increased awareness

28. Mortality Rate

29. Mortality Rate

30. Dude…What about Genes??

31. Dude, what about genes?

32. Dude, what about genes?

33. Dude, what about genes?
5-10% of breast cancers are linked to specific gene mutations. BRCA1 & 2 most common

34. 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

35. 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

36. HBOC Gene Testing: Who Qualifies
The Patient History:

37. HBOC Gene Testing: Who Qualifies
The Patient History:
Breast cancer at age 50 or younger or ovarian cancer at any age

38. 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

39. 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)

40. HBOC Gene Testing: Who Qualifies
The Family History:

41. HBOC Gene Testing: Who Qualifies
The Family History:
2 breast cancers in the same family member or on the same side of the family

42. 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)

43. 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

44. 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

45. 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

46. Aside from Gene Testing, Who’s else is High Risk?
Several models exist for calculating risk. Models may include Lifetime Risk (LTR), Ten-year 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

47. IBIS examples

48. A more useful IBIS example
(IBIS= International Breast Cancer Intervention Study)

49. Enough with the stats, let’s get to the practice related stuff….

50. Enough with the stats, let’s get to the practice related stuff….
The Basic Questions:

51. Enough with the stats, let’s get to the practice related stuff….
The Basic Questions:
WHO should we evaluate?

52. Enough with the stats, let’s get to the practice related stuff….
The Basic Questions:
WHO should we evaluate?
WHEN should we evaluate them?

53. 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?

54. 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……….

55. 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!

57. The USPSTF Says:

58. The USPSTF Says:
Routine screening mammogram every 2 years for women ages with consideration for starting earlier biennial screening based on patient’s beliefs regarding benefits and harms.

59. The USPSTF Says:
Routine screening mammogram every 2 years for women ages with consideration for starting earlier biennial screening based on patient’s beliefs regarding benefits and harms.
Recommends against teaching SBE (Self-breast Examination).

60. The USPSTF Says:
Routine screening mammogram every 2 years for women ages 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.

61. The ACR Says (a lot):

62. The ACR Says (a lot):
Yearly mammograms starting at 40 for women at average risk.

63. 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:

64. 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.

65. 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.

66. 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.

67. 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.

68. 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.

69. Screening for Breast Cancer
Regardless of which set of recommendations you follow, it all starts with our old friend….

70. Screening for Breast Cancer
Regardless of which set of recommendations you follow, it all starts with our old friend…. The Mammogram

71. 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 community-based Breast Cancer Surveillance Consortium, 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):
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): , 2005.

72. Mammography:

73. 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!

74. 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.

75. 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

76. 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’

77. Mammography:
There are two categories of Mammogram

78. Mammography: There are two categories of Mammogram
SCREENING: routine, preventive exam in asymptomatic women. 4 standard views (bilateral CC and MLO)

79. 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

80. 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

81. Screening Mammogram
Two Standard Views: CC and MLO

83. Diagnostic Mammogram

84. Magnification views

85. Other Modalities: Ultrasound

86. Other Modalities: Ultrasound
Most effective as a diagnostic tool

87. Other Modalities: Ultrasound
Most effective as a diagnostic tool
Preferred modality in pregnant or lactating women and women under 30

88. 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

89. 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

90. 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

91. Ultrasound (Fibroadenoma)

92. CCancer on Ultrasound

93. Cyst on US

94. Other Modalities: Breast MRI
High sensitivity and specificity

95. Other Modalities: Breast MRI
High sensitivity and specificity
Does not replace mammography

96. Other Modalities: Breast MRI
High sensitivity and specificity
Does not replace mammography
Recommended as screening tool with mammogram in high risk women (LTR >20%)

97. 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)

98. 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

99. 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)

100. 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 (pump-and-dump)

101. Breast MRI Indications

102. MRI

104. Cancer with Mets to Axilla

105. 3-D Mammography (Tomosynthesis)

106. 3-D Mammography (Tomosynthesis)
Combines multiple mammo images to reduce tissue overlap (like CT)

107. 3-D Mammography (Tomosynthesis)
Combines multiple mammo images to reduce tissue overlap (like CT)
Does not replace conventional mammogram

108. 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

109. 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

110. 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

111. 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

112. 3-D Mammography (Tomosynthesis)

113. Quick Facts: Implants

114. Quick Facts: Implants
Screening rec’s are the same for women with implants

115. Quick Facts: Implants
Screening rec’s are the same for women with implants
Reduces sensitivity of mammogram (blind spots) but overall cancer outcomes unchanged

116. 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

117. 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

118. 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)

119. 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

120. Implant Rupture (Linguine Sign)

121. Implant Rupture (Key Hole Sign and Free Silicone)

122. Radiation facts for worried patients:

123. Radiation facts for worried patients:
Mammogram should not be routinely performed in women under age 30 or in pregnant women

124. 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)

125. 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

126. 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

127. 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

128. 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)

129. 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)

130. What is the official mascot of the Radiologist?

131. THE HEDGE

133. But not for Breast Imaging….

134. Here’s Why….

135. Reporting: The No Hedging Zone
BI-RADS:

136. Reporting: The No Hedging Zone
BI-RADS: BREAST IMAGING-REPORTING AND DATA SYSTEM

137. 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.

138. 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.

139. 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

140. BI-RADS reporting must include:

141. BI-RADS reporting must include:
Patient name and identifier

142. BI-RADS reporting must include:
Patient name and identifier
Date of exam

143. BI-RADS reporting must include:
Patient name and identifier
Date of exam
Name of interpreting physician

144. BI-RADS reporting must include:
Patient name and identifier
Date of exam
Name of interpreting physician
Overall final assessment with BI-RADS# (0-6)

145. 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

146. 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

147. 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

148. 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)

149. 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)

150. 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)

151. 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)

152. 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)

153. 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)

154. 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)

155. 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)

156. BI-RADS Bottom Line

157. BI-RADS Bottom Line
BI-RADS: 1 and 2. No action needed

158. 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)

159. 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

160. 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, 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

161. Breast Density, what’s up with that?

162. 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

163. BI-RADS Breast Density Types
Type 1: “Almost Entirely Fat” or “Mostly Fatty Replaced” (0-25%)

164. BI-RADS Breast Density Types
Type 1: “Almost Entirely Fat” or “Mostly Fatty Replaced” (0-25%)
Type 2: “Scattered Fibroglandular” (25-50%)

165. 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%)

166. 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%)

167. Breast Density Images

168. 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

169. PBCC Screening Protocol
(0-11%)
Low Risk
Mammogram
Intermediate Risk
(12-19%)
Screening US if Dense Breasts
High Risk
(20%+)
Screening MRI
Screening US if can’t have MRI

170. Summary

171. Summary
Breast Cancer is a common but mostly treatable disease

172. 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!)

173. 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.

174. 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!

175. What’s best for your patients?
MQSA/ACR certified breast center

176. What’s best for your patients?
MQSA/ACR certified breast center
Digital imaging preferred

177. What’s best for your patients?
MQSA/ACR certified breast center
Digital imaging preferred
Experienced Radiologists and Techs

178. What’s best for your patients?
MQSA/ACR certified breast center
Digital imaging preferred
Experienced Radiologists and Techs
Evidence based imaging protocols

179. 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

180. Get to know your Breast Imagers

181. 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

182. 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

183. THANK YOU!

184. 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. ( )
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.