1. Med Info 402 – Spring 2009

2.  Introduction of team  Introduction of case  Presentation of case  Conclusion  Questions

3.  Mark Morris  Mengchun Ling (Jennifer)  Chad Hodge

4. Participants:Sally Smith, Patient : Jennifer Kathy Williams, Radiologic Technologist : Mark Lora Tabbar, Radiologist : Jennifer Lisa McKee, Receptionist : Mark Jon Miller, PCP Partner : Chad Narrator: Chad / Mark / Jennifer Ms. Smith is a 36-year-old woman who is active and plays mixed doubles tennis. In a recent match at her club, a tennis ball struck Ms. Smith in the chest from the opposing team's male player. It was a hard blow and knocked Ms. Smith to her knees. The pain continued for several hours and she used Advil to help the pain. The following morning, she did a physical breast exam because she had read somewhere that it was possible to get breast cancer from an injury, and this was the second injury in that area in the past six months (she had been the driver in a previous car accident and the seat belt had bruised her upper left breast where the seat belt crosses her chest). Near the area of the current trauma, she felt a lump that was about half the size of a ping-pong ball. She was concerned, and contacted her PCP's office. As her regular PCP was out on vacation, her PCP's partner was covering the calls. The receptionist transferred her to the head nurse at the office, and after hearing the story the nurse said she would have Dr. Miller place an electronic order at the Pacific Breast Center for an imaging study (mammogram).

10. The Genetic Counselor has a variety of high risk assessment models - including both environmental and hereditary - and she sees that Sally has a five-year risk of 1.1% and a lifetime risk of 29.5%. Anything higher than 20% is considered "high risk". (The risk of breast cancer to women is, on average, 12.5% over their lifetime.)

13. The American Cancer Society recommends yearly screening mammograms after age 40, or earlier based on family history.

17.  This will initiate several processes:  Higher level surveillance will be requested from the Patient's insurance company, including regular MRI's in addition to mammograms due to their higher sensitivity. This will be done on a six-month rotating schedule, so for instance a mammogram would be in June, and an MRI in December, etc. This gives the patient a six-month review.  Patient's PCP will be notified  PBC's genetic counselor will do a complete assessment of the Patient, including options on how to lower her risk of breast cancer.

18. Mammogram: Sensitivity: 75 – 90 % Specificity: 90 – 95 % PV+: <50yo = 20% 50-69yo = 60 – 80 % Quality Determinants of Mammography PPV based on abnormal screening5-10 % PPV when biopsy recommended25-40 % Tumors found, Stage 0 or 1>50 % Tumors found, minimal cancer>30 % Node Positivity<25 % Cancers found per 1,000 cases2-10 Recall rate<10 % Sensitivity>85 % Specificity> 90 %

19. DenseNormal Digital Mammography is a relatively new technology (approved for use by the FDA in 2000), but has been statistically shown to be superior to film mammography in dense breasts. Both digital and film mammography have sufficient resolution to view findings with a size of approximately 50 microns.

24. The ultrasound machine views the breast in two millimeter "slices“. The radiologist can see the lesion through 9 layers of tissue - indicating a lesion of slightly less than two centimeters.

25. Ultrasound guided core needle biopsy order. FDA guidelines also require the radiologist to contact the PCP to report the findings via the telephone.

29. Traumatic Fat NecrosisFat NecrosisUltrasound Fat Necrosis

32.  The workflow described in this presentation is an evolutionary workflow, not revolutionary. At every step of the process, where possible, electronic means were used to solicit and report information - from the PCP order to the breast center, to the patient entering in their own history to populate and update their electronic records. With this workflow, that is largely absent in clinics across the USA today, tremendous lost time, as well as patient stress levels, can be saved.

33.  Questions?  Additional reading:  http://well.blogs.nytimes.com/2009/02/24/the- anxiety-of-the-biopsy/ http://well.blogs.nytimes.com/2009/02/24/the- anxiety-of-the-biopsy/  States that the average wait time was 2.5 days, but many women had to wait five days or longer.  Patient stress levels are raised during this waiting period.  http://www.cancer.org/downloads/STT/BCFF-Final.pdf http://www.cancer.org/downloads/STT/BCFF-Final.pdf  Breast cancer statistics