How Breast Cancer Develops Or "Why such a fuss about ‘Calcs’?"

Objectives:

Breast cancer doesn’t start in the skin of the breast, the fat surrounding the breast tissue or the fibrous supporting structures of the breast. Breast cancer begins with the cellular lining in the breast ducts.

Cancers, all cancers, are cellular diseases. Cancer starts when the normal cell divides abnormally, becomes atypical, starts dividing eccentrically, refuses to die when the body tells it to, begins to affect the surrounding cells and, finally, the cell becomes malignant and begins to feed off healthy cells turning them malignant. These sick cells finally become a malignant tumor and the nasty business continues.

Before or just after the changing cells become malignant many of these erratic malformed cells crowd each other out, deprive each other of oxygen and, basically kill each other off. Some of these dead cells calcify and gather is small clumps or lines. If we are lucky and skilled we can image a cluster of these dead cells and thus identify an early cancerous process before any symptom or sign is present.

The Journey down the malignancy trail:

Step one, begins with a healthy terminal duct containing a thick continuous basement layer of cells lined with a homogeneous layer of identical epithelial cells each enclosing a single vigorous nucleus.

Step two in the journey is normal hyperplasia. Hyperplasia is a normal effect of aging. As we age, the conventional ‘die trigger’ in the cells slows down and our characteristic epithelial cell layer begins to build up on itself. The cells still represent identical vigorous cells containing healthy nuclei. 

Step three along the path to breast cancer is atypical hyperplasia. Atypical hyperplasia is considered a pre-cancerous condition. The rapidly building hyperplasic cells begin to deteriorate. The walls of the cells become misshapen. The nuclei commence to look deformed. During this stage in the dark excursion the basement layer of cells remain intact and characteristic. At this step the dead cells are crowded together and sometimes the little dead cell bodies calcify. If this happens it is good because the tiny clusters of calcifications that represent the dead cells inside the duct can lead us to a burgeoning problem.

Step four is ductal carcinoma in-situ or DCIS. Step four crosses the line from ‘atypical’ to cancerous. DCIS is the earliest stage of breast cancer and the most advantageous to find. At some stage in the atypia process one or a cluster of uncharacteristic cells become cancerous cells. We have no idea why this occurs, but when it does the process begins to intensify. The malignant cells rapidly collect healthy cells and alter their structure into cancer. These malignant cells begin to form a lesion or mass within the duct. This mass begins to elongate the duct, thin and stretch the basement cell layer. The malignant process tends to create a virtual graveyard of dead cells and, if we are lucky, these cells will calcify and we will be able to pick them up on a mammogram.

Step five is infiltrating ductal carcinoma. By this stage in the grim excursion the malignant cluster of cells have broken out of the basement membrane of the duct and has begun to collect breast parenchymal tissue as food for the tumor. Infiltrating ductal carcinoma very often is seen as an ill-defined mass containing malignant type calcifications. Left undetected, infiltrating ductal breast cancer will become a large, palpable stellate mass which often represents a well established metastasized breast cancer.

Summary:

The whole point of high quality mammography screening is to find early signs of breast cancer. Our job is to create the best images we can using all the knowledge we possess about the disease we are trying to discover.

Know your enemy, know where it hides, know how it grows and know how to corner it.

Keep up the good fight.

Coping with the Handicapped Patient: The Short and Sweet To-Do List

OBJECTIVES
Mammography of high quality depends a great deal on the cooperation of our clients. When our 'clients' become 'patients' who are ill, frail, incapacitated, helpless, unbalanced, delayed or otherwise handicapped, the assignment of obtaining excellence becomes gargantuan.

Without writing a thesis on the subject, I have assembled a concise list of helpful hints under some short universal topics related to imaging disabled patients.

THE FACILITY

• Accessible parking close to entrances
• Accessible front entrance
• Doors that are wide and easy to open
• Accessible route through facility
• Sign language information
• Braille information
• Large print documentation
• Space in waiting area for wheelchairs
• Space in change area for wheelchairs
• Adjustable height examination tables
• Mammography units that will adjust to wheelchairs or gurneys
• Mammography rooms large enough to allow stretcher access

COMMUNICATION

• General Communication
• Treat every person with respect
• Do not use patient's first name useless prompted by the patient to do so
• Offer assistance but WAIT until the patient accepts your help
• Allow the patient to give you instructions on the best way to help
• Always speak to the patient rather than to the companion
• Let the patient set the pace for the procedure
• Relax, do not feel discomfort on the patient's behalf
• Assistive devices are part of the patient's personal space. Do not move them without permission
• When conversing with a chair or bed bound person, always put yourself at eye level
• Always ask before moving a patient who is immobilized in any way

Communication with the Visually Impaired

• Allow the person to take your arm when assisting
• You are acting as a guide NOT a leader
• Speak in a normal tone of voice
• Identify yourself and all others with you
• Always indicate when you are moving from one place to another during the test

Communication with the Hearing Impaired

• Tap the person softly on the shoulder or gently wave your hand to get their attention
• Look directly at the person and speak clearly, directly and expressively
• Written notes or illustrations may be of great assistance
• Do not eat, chew gum or place you hands near your face

Communication with Persons with Speech Impairment

• Give whole and unhurried attention to people who have difficulty speaking
• Be encouraging, patient and allow the person to complete their thoughts
• Ask short questions that require only very short answers
• Never pretend to understand, take your time and understand in a different way

Communication with the Cognitively Deficient

• Take the time to achieve clear understanding
• Use body language
• Use simpler words
• Use pictures, cartoons or diagrams
• Provide the patient with the same information in different ways (be creative)

POSITIONING

Positioning of the disabled patient is the most important and most difficult aspect of dealing with the handicapped. There are innumerable problems involved in safely and efficiently controlling the examination of the disabled. I hope these concise tips dealing with actual manipulation and acquisition of the required views will facilitate the technologist in obtaining quality images.

Common Concerns with Positioning the Handicapped Patient

• Inadequate amount of retroglandular tissue imaged
• Inability to position C-arm parallel to chest wall
• Inability of patient to cooperate with exam
• Exam room of inadequate size to accommodate stretcher, wheelchairs or immobilization devices
• Extra views may be necessary to view tissue adequately
• Two mammographers may be necessary to safely handle the patient and obtain satisfactory views 
• Enough time assigned to the procedure to allow it to be carried out with care, safety and precision

The Basic Positions Required for Handicapped Patients

• From Below(stretcher)/CC(Chairbound)
• Mediolateral Oblique
• 90 degree Lateromedial

OBTAINING THE REQUIRED PROJECTIONS

From Below (Stretcher)

• Stretcher patients must lie on their unaffected side
• Tube is placed in the 90 degree position and moved under the affected breast
• The compression is applied from beneath
• Mammographer should stand behind the image receptor for better control
• CC (Chairbound)
• Wheelchair patients must be able to lean into receptor 
• Wheelchair patients may have to be moved to a wheeled armless positioning chair or moveable bench
• Remove face plate if needed and turn the patient’s head away from the tube
• Have the patient grip the underside of the bucky
• Tilt the tube 5˚ if needed

Mediolateral Oblique

• A proper MLO view cannot be acquired on a stretcher bound patient without the patient being able to tolerate the head of the gurney being elevated at least 60 degrees
• Raise the head of the stretcher as far as will be permitted
• The image receptor should be placed against the stretcher, parallel to the patient's pectoralis
• Move the patient over to side of gurney and raise her arm up out of the field of vision
• Have her lean into the receptor and compress the tissue adequately
• Patients confined to wheelchairs must be able to lean into the image receptor or they must be transferred to an armless wheeled positioning chair or moveable bench

Lateromedial

• This may be the most valuable and easiest view to accomplish dealing with the stretcher bound patient
• The patient should lie flat on their side with the affected side up
• Rotate the tube so that it is parallel to the gurney
• Place the bucky along the patient's sternum
• Roll the patient slightly forward and raise her top arm out of the way
• Move the breast superior and laterally
• Bring the compression down as far laterally as possible without including the latissimus dorsa

SUMMARY

Most people will experience some form of disability as they age. Physicians often have difficulty prescribing preventative services for their disabled patients because of lack of adequate facilities.

For women with disabilities access to mammography greatly diminishes with age and increase of functional limitation. By age 65, 57% of healthy women have had a mammogram, as compared with 43% of women who are functionally challenged.

Encourage you facility to part of the solution NOT part of the problem.

COMMON POSITIONING PROBLEMS - The Solutions!

No matter which modality we are using, no matter whether we are practicing screening or diagnostic mammography, no matter what: We still have to position our patients so that all the breast tissue is demonstrated.

That is always a challenge and all the help that comes our way is useful. Here are some tips regarding positioning dilemmas with some handy remedies. I hope they are helpful.

THE CC PROJECTION: “IF”

A) The nipple is not in profile

If the nipple is not in perfect profile: Elevate the IMF a little higher Lift and pull the breast straight onto the bucky Use both hands to handle the breast (Hint): The nipple points toward the missing tissue

B) The medial Cleavage is not open and visualized

If the medial cleavage is not visualized properly: Position from the medial side Lift and drape opposite breast over the edge of the bucky Do not press the patient’s face against the face protector Place her head beside and beyond the tube

C) The lateral aspect or ‘Tail-of-Spence’ is not demonstrated

	If the lateral aspect of the breast is not seen: The Patient’s arm should be relaxed by side Her palm should be supinated with her shoulder externally rotated Control your patient’s posture with your hand around her back on her contra-lateral shoulder She should be relaxed forward bent slightly at the waist Release the breast to the compression with forward and medial orientation of your hand

D) The pectoral shadow is not visible at the chest wall and/or the PNL is not within 1cm of the PNL on the MLO

If the ½ moon of pectoral shadow is not seen at the chest wall of the CC view and/or the PNL is of an inadequate length: Elevate the IMF until the tissue no longer moves easily along the chest wall Identify the edge of the pectoral muscle visible just under the clavicle Loosen the skin over the clavicle so the tissue moves easily Compress parallel to the pectoral edge just under the clavicle Release hand in a forward medial motion

THE MLO PROJECTION: “IF”

A) The pectoral muscle is not demonstrated to or below the level of the nipple

If the pectoral muscle is not seen to the level of the nipple or below: Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum Compress the projection parallel to the pectoral axis along the sternal edge

B) The pectoral muscle is not relaxed and convex in shape

If the pectoral shadow does not appear convexly shaped: DO NOT rest your patient’s arm along the top edge of the bucky Patient’s shoulder should be open, relaxed  The corner of the bucky high up and well back in the axilla Patient’s arm should be slightly bent hanging loosely down the back of the bucky Relaxed hand…NO gripping the handle

C) The breast is not ‘up & out’ and/or the retro mammary space is not visualized behind the parenchyma

If the retro mammary space is obscured by parenchyma and the breast is not adequately ‘up & out’: Move the breast from the lateral edge medially  Ensure the breast mound moves freely in your grip Support the breast tissue from the inferior border using you entire hand Immobilize the breast tissue on the bucky in the ‘up & out’ position using the edge of your hand to support the pectoral axis along the sternum Release the breast to compression with a distinct out and away motion

D) The Infra-mammary Fold is not clearly seen curving to the abdomen un-obscured by wrinkles, folds or belly

If the IMF is not open and fold free: Support the breast and always release with and up & out motion Have the patient tilt her hips slightly backwards Do not release your hold on the breast until the projection is immobilized by the compression Gently run your thumb and finger down behind the breast along the IMF/belly border to clear folds, wrinkles and tummy

E) Nipple is not in profile

If the nipple shadow is not in perfect profile: Make sure the patient’s feet are directly facing the bucky Control the breast from the mobile lateral border only Immobilize the breast parenchyma parallel to the pectoral muscle until the compression holds the projection (Hint): The nipple points toward the missing tissue

SUMMARY

Mammography is a sensitive, complicated and difficult specialty. All our patients vary as to body habitus, temperament and compliance. It is essential we demonstrate all the tissue, see it clearly and know that all the borders of the breast are verified. 

Breast Imaging is an area of DI where we work autonomously much of the time. We are responsible for checking and correcting our own work. I hope these tips will assist in the arduous task of perfecting your technique and knowledge. 

STANDARDIZATION OF MAMMOGRAPHY POSITIONING

Standardization of modern mammographic positioning techniques helps to improve image quality. We can improve the quality assurance of our departments and ensure versatile, consistent examinations. Each technologist can produce intelligent, comprehensive breast images if we all practice from the same base. Correction rather than repetition is the key.

Many certification processes involve positioning competency testing. This ensures that all certified mammographers will be practicing from a uniform standard. If part of your responsibility is department stability and unvarying excellence of mammograms then a ‘POSITIONING COMPETENCY CHECKLIST’ may be of assistance in your department. 

This type of checklist helps students to check their positioning case by case. It helps all of us check our positioning on those days when NOTHING is working. It can help clinical instructors offer helpful constructive suggestions. Positioning checklists are used to great advantage in many departments to regulate the quality of their positioning. 

Using a standard checklist lets both staff and reviewer know exactly what is required thereby making any necessary routine staff evaluations easier and way less stressful for everyone involved. 

I have a couple of really simple ‘clip and post’ checklists that can help any mammographer ‘check and correct’ her cases on the fly. I use mine all the time I hope you find them helpful too.

POSITIONING COMPETENCY CHECKLIST ‘CC’ PROJECTION

In order to include the maximum amount of breast tissue on the CRANIOCAUDAL projection, the technologist should be able to perform the following steps: 

PERFORMED STEPS	YES	NO
1. Have your patient stand facing the unit with her feet perpendicular to the bucky
2. Externally rotate the patient’s arm on the side being imaged and make sure it is relaxed at her side.
3. Determine the proper film receptor size and photocell position.
4. Stand on the medial side of the imaged breast.
5. Elevate IMF to its maximum height and adjust bucky appropriately.
6. Use both hands to lift and pull breast onto receptor.
7. Center breast over photocell with nipple in profile (if possible).
8. Anchor breast solidly with one hand and never let go!
9. Lift and drape the opposite breast over the corner of the bucky.
10. Place your arm across the patient’s back and rest it on her shoulder to relax it and keep her tilted toward the bucky.
11. Rotate the patient’s head away from the breast being imaged.
12. Have the patient incline towards the unit with her head forward and beyond faceplate.
13. With your hand still on the patient’s shoulder, loosen the skin over clavicle.
14. Pull the lateral tissue anteriorly and medially as the compression takes over.

POSITIONING COMPETENCY CHECKLIST ‘MLO’ PROJECTION

In order to include the maximum amount of breast tissue on the MEDIOLATERAL projection, the technologist should be able to perform the following steps:

PERFORMED STEPS	YES	NO
1. Have your patient stand facing the unit with her feet perpendicular to the bucky
2. Determine proper film receptor size and photocell position.
3. Determine degree of obliquity (parallel to pectoral muscle).
4. Rotate C-arm so that the long axis is parallel to the pectoral muscle.
5. Adjust height of bucky tray so that the top corner is level with the highest point of the axilla.
6. Lift arm of the side being imaged and place shoulder up and over the corner of the bucky.
7. Place corner of the bucky as high up and as far back in the axilla as possible but still anterior to the lattissimus dorsi.
8. Place the patient’s hand of the side being imaged on the C-arm, with her elbow flexed and her shoulder relaxed over the corner of the bucky.
9. Pull the breast and the pectoral as far anteriorly and medially as possible with the flat front surface of your hand.
10. Scoop breast tissue up, your hand grasping the lateral border of the breast with fingers and the medial border with thumb.
11. Hold breast up and out with the thumb supporting the base of the breast and the fingers are holding the medial aspect pointing up and out.
12. NEVER LET GO!
13. Center breast with nipple in profile if possible and apply compression starting with corner of paddle just under the clavicle.
14. With thumb and first two fingers smooth down abdominal tissue to open IMF.

“Lesion, Lesion, Where Is the Lesion?”

OBJECTIVES:
The radiologist cannot determine the characteristics of a lesion if it is only shown in one projection. He/she cannot even determine if the lesion is real or illusionary. When a lesion appears only in one view on a four view routine mammogram, we have to ask ourselves several pertinent questions before we start randomly taking useless extraneous projections.

1. Which projection does the lesion show in?
2. Where does the lesion fall in that projection?
3. Is the lesion real or made up of overlapping parenchyma?
4. What can we do to find the area in another projection?
5. How can we confirm that we have seen the lesion or overlapping area clearly in another projection?

Most commonly, an apparent lesion will appear in the MLO view and not in the CC projection. This is due to the fact that more breast tissue is imaged in this projection that any other view we take. To locate the area in the CC projection should be a planned excursion not a wild ride of random projections looking for ‘something’ illusive.
The Excursion from a Lesion Seen Only in the MLO View to Placement in CC Projection:

• Measure where the lesion falls in the MLO view. Take three measurements: the distance from the nipple, the distance from the superior edge and the distance from the inferior edge.
• Obtain a true lateral view of the breast, being sure to include the questionable area in the projection. Take the same three measurements: the distance from the nipple, the distance from the superior edge and the distance from the inferior edge.
• Hang the images on the viewbox with the Lateral view first, the MLO view in the center and CC view at the end. Be sure that the images are hung so the inferior/superior borders of the Lateral and MLO projections are aligned.
• Using a long ruler and a grease pencil draw a straight line from the lesion projected on the Lateral image through the same lesion on the MLO image and continue the line straight through the CC projection.
• Mark an * where the line ends at the distance the lesion measures from the nipple and that is where you will find your lesion on the CC view.

This method of locating the missing lesion is called Triangulation. This triangulation method can be used to find the lesion in any one of three projections. Set the films up in the same manner and draw the line through the two projections the lesion is visible in.

A:   90º Lateral                                    B: MLO

Triangulating the MLO Lesion into the CC Projection:

A useful rule to remember when using triangulation to locate a lesion in the CC projection is: If the lesion rises in the lateral projection the area will show on the medial aspect of the CC, if the lesion falls in the lateral view it will show-up on the lateral aspect of the CC. “M(medial)uffins rise and L(lateral)ead Falls”

Is The Lesion Real Or Just Overlapping Tissue?

Roll/Turn View With A Real Lesion:

1. Spiculated Mass
2. Dense Parenchyma

A spiculated lesion overlaps a dense parenchymal shadow making the lesion indistinct and difficult to see.

1. Spiculated Lesion
2. Dense Parenchyma
3. Superior Breast Tissue is rolled Medially
4. Inferior Breast Tissue is rolled Laterally

The irregular stellate lesion is thrown clear of the dense parenchymal shadow and therefore is easily seen and a coned compression F/U view can be easily taken.

Roll/Turn View with an Illusionary or False Lesion:

1. Dense irregular parenchymal shadow
2. Dense irregular parenchymal shadow

Two dense irregular parenchymal densities combine to mimic a stellate lesion on the CC view. It is not clear on the MLO projection: Is it real?

1. Normal Parenchymal Density
2. Normal Parenchymal Density
3. Superior Breast Tissue Rolled toward the Medial Border
4. Inferior Breast Tissue Rolled toward the Lateral Border

Separated by the ‘roll/turn’ projection, it is obvious that the area      seen in the CC projection was merely overlapping normal parenchymal tissue.

If It Is Real: Where is it in the MLO Projection?

If we see an irregular density in the CC view, prove by diagnostic F/U that it is an authentic mass, and still cannot verify where it is in the MLO view, how can we find it?

1. Spiculated Lesion
2. Dense Parenchymal Pattern 

                                                                  

1. Spiculated Lesion
2. Dense Parenchymal Pattern
3. Superior Breast Tissue Rolled toward Medial Border
4. Inferior Breast Tissue Turned toward Lateral Border

Since we know which way we rolled & turned the superior & inferior borders of the breast. Then we can determine whether the lesion is superior or inferior by which way the lesion moves

In this case, the superior tissue was rolled medially and the spiculated lesion moved medially. Therefore we can conclude that the lesion we are interested in is in the superior aspect of the breast and the dense benign parenchyma was turned laterally in the inferior breast so conversely, it will be found in the inferior aspect of the breast.

                                                                                       

1. Spiculated Lesion Located in the Superior Aspect of the Breast in the MLO View
2. Obviously Negative Parenchymal Tissue Located in the Inferior Aspect of the Breast in the MLO View

SUMMARY
It is our responsibility to make the lesions found in the routine mammograms apparent to the reading radiologist. The radiologist very often just tells us, “find the lesion”.  If we know how to isolate, separate and identify those suspect areas we can help the radiologist, help the patient, save time, anxiety, technical resources, department finances and finally our mental health.

Meeting the Challenge of Diversity in our Community

OBJECTIVES
Women from minority groups have been traditionally under served in mammography. The most common barriers facing this community are insufficient education concerning personal health care and little or no access to familiar, locally based health care providers.
We are beginning to surmount some of these obstacles by providing government funded, neighborhood based, free breast screening and establishing community outreach programs to minority neighborhoods. But even when minority patients are able to gain access to conveniently located, low-cost mammography, language and/or cultural barriers make it difficult for them to receive full benefit from the procedure. It is of great urgency that the experiences and values of minority women be better understood so we can provide them with full use of prevention and early detection services.

Before The Screening
Our medical care system is modeled on middle class values and middle class education levels. Many low-income and/or minority patients are completely unfamiliar with mammography. Our patient needs careful explanation and education about screening from someone who understands her language AND her socio-cultural background.
Minority women tend to wait for a crisis before seeking health care. The concept of preventive action is foreign to them. One way of emphasizing the need for early detection and prevention in these communities is to stress the importance of their lives on the lives of their children and grandchildren. Point out that keeping their health by early detection and intervention will keep them with their families longer. It will help keep them productive and active in the community for many happy years.
Many minority women have no idea that they are at risk from breast cancer. The perception is that breast cancer is a ‘white woman’s’ disease. They do not recognize themselves in the health promotions. The concept of increased risk to women of color must be reinforced before the screening begins so that our patient will relate to what is happening to her.
In many minority communities there are important taboos concerning anyone other than a spouse or infant touching a woman’s breast. This patient must be carefully informed before the procedure that the mammographer will be touching and maneuvering her breasts. She must know that she will have to disrobe. It is important to tell her why all this is to take place. Always politely ask permission before any touching or positioning of the breast begins.
Fear of pain during mammography is widespread among minority women. They have extraordinary concerns about this. Even though, statistically, minority patients related less pain during mammography than their Caucasian counterparts. Therefore, even if the fear seems unfounded, it is important to take extra time and precautions when explaining the amount of pressure and the importance of breast compression to women from minority communities.

During The Screening
Self-introduction and discourse with minority women must be handled discretely. When calling a minority patient her given name should never be used without the patient’s permission. Introduce yourself formally, using your first name, last name and title. Always use a formal greeting such as ‘Miss’, “Mrs.” or ‘Ms.’ and never resort to slang expressions such as ‘sweetie’, ‘dearie' or ‘sweetheart’. Many ethnic groups interpret this behavior as a racial or cultural slur. When greeting your patient always start with some polite introductory inquiry into the weather, the health of her family or children. Make any request to disrobe quiet polite and discrete. A gentle “Would you mind removing your blouse and bra for a few moments?” is considered respectful.
It is a common belief among minority groups that the use of any x-ray equipment will cause cancer. It is also widely held that pressing or excessive manipulation of the breast will cause ill health of various sorts including cancer. She must be assured that the mammogram will not cause any breast problems and that the mammographer will make every effort to be quick, efficient and sensitive.
The technologist must be prepared to see and accept cultural practices different from her own. Tips of acupuncture needles, circular suction cup marks from ‘steam cups”, freely injected silicon, tattooing, ritual scarring or tiger balm plasters are all common practice within certain communities. React to these customs with respect and treat your patient with dignity.
Women of various ethnic backgrounds may be hypersensitive about the size or shape of their breast tissue. It doesn’t matter whether your patient thinks she is too big or too small. It doesn’t matter whether she feels she is too tall, too short, too fat, too thin, too simple or too sick. We must treat EVERY patient as if she is the easiest client we have ever had. Take all the responsibility for doing the test. Never suggest that the patient is making it difficult. Just keep up a continuous stream of confidence boosting conversation. Speak softly, pleasantly and congenially; your attitude will travel through your voice.
Among the refugee community we may find a serious barrier to breast examination that we do not have to deal with often. Many women from refugee backgrounds have suffered rape, humiliation, abuse and torture. These women have braved great anxiety just to get to your facility they deserve all the respect and quiet dignity we can muster. Treat these patients gently; do not rush them through. Try to give them as much time and explanation as they need to get used to the idea of the test. Don’t push them beyond their tolerance. Have a list of counselors and help groups available but do not force information on them. Allow them to back out of the examination and try again later if necessary. Be alert to all the body language, don’t force eye contact, be receptive and always use appropriate family and friends for support if available.
Finally, many ethnic societies have a pathological fear of the word ‘CANCER’. In some cases the word itself is so disruptive that it inhibits the entire mammogram. Rather than compromise the whole breast imaging session, I suggest using ‘breast health’, ‘preventative testing’ or ‘early detection of problems’. In most situations, open and honest dialogue about cancer, its detection and prevention is the best way. However, if the mere word is going to drive your patient out of the department in panic, use a milder alternative.

After The Screening
Because so many minority women have such a limited knowledge of mammography, there may be a distorted perception of what happens after a screening mammogram. These women may think that the mammographer will come and tell immediately if she has cancer or not. If nothing is said she may misinterpret that to mean the test was negative, or worse, positive and run in frenzy to her physician. It is important to have a chat with this type of patient before she leaves the department and make sure she is comfortable with what happened to her and what will happen next.
Ideally, after the mammogram, there should be a meeting with the mammographer, the interpreter, the patient and her family to explain the facility’s physician reporting system and follow-up procedures. She should understand when and how her next appointment should be made and whom she can contact for information or further explanation.

SUMMARY
Every woman deserves individual attention, an appreciation of past experience, respect for her distinct belief systems and clearly conveyed instructions and explanations. Women from culturally diverse communities present us with a challenge in this area. With a little time, sensitivity and armed with the knowledge we need to deal with these patients we can make their medical experience valuable and pleasant.

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Some Extra Solutions to Put Away in the Brilliant Bank

Problem: Communication with patients who speak different languages, come from different cultures or have sensory deprivation.

Solution: Sensory deprivation can be almost as frightening for the mammographer as it is for her patient. Remember to be sensitive to the handicap of the patient. Do not touch a blind client without plenty of auditory communication first. The key to dealing with visually impaired patients is no surprises. Do not treat a deaf patient as though they are stupid or demented. Hearing impaired people are very sensitive to this kind of slight. Use the entire visual stimulus at your command (written flash cards, videos, posters etc.). Contact your local societies for the blind and the hearing impaired. They are wonderfully helpful. They will supply you with Braille cards appropriate to your needs and information on simple, useful phrases in sign language and of course the sign language alphabet that is invaluable. With a little knowledge and effort, both you and your patient will feel at ease and confidant.
Language can be a huge barrier to the communication so essential to breast imaging. Where I practice, in Toronto (Ontario, Canada), there are, I am told, 140 different languages. A practical solution for dealing with this problem is to compile and assemble some clear language charts for the commonest of your foreign languages. Assigning one language to each tech can do this. A trip to the library will glean a dictionary - phrase book. A chart written clearly on a 24x30 cardboard can then be assembled and placed in each x-ray room. The list of words may vary slightly from department to department but a good selection for mammography might be:

• HELLO MY NAME IS…..
• THANK-YOU/PLEASE
• STOP BREATHING/BREATH AGAIN
• STEP or TURN FORWARD/BACKWARD/LEFT/RIGHT
• RELAX
• SMALL AMOUNT OF PAIN OR PRESSURE
• DO NOT MOVE
• THE TEST IS FINISHED/THE TEST IS NOT FINISHED
• DO or DO NOT DRESS
• WAIT HERE or HAVE A SEAT

A competent interpreter accompanying each foreign language or sensory-handicapped patient would be ideal; however, there is never any substitute for one on one communication. It engenders trust, understanding and co-operation between practitioner and patient.

PATIENT’S RIGHTS: WHAT ARE THEY AND HOW CAN WE MEET THEM?

Well even though we had snow just last week up here in the "great white north", the days are longer, the sun is warmer and I can smell the start of Spring. As the weather turns nice here my mind goes to some other places in the world where things are not going so well; I hope all of you are safe and doing well. My thoughts and prayers are with all of my readers in Australia, New Zealand, Japan, the Middle East and Asia. I listen to the news with my heart in my throat. Please be well.

March's techtalk is about the rights of our patients and how to preserve them. Their rights of peace, privacy, dignity are in our hands to preserve and there is plenty of legislation in place to make sure we do just that. I hope the article is helpful.

Also, please find attached a repeat sending of Louise Miller's QCC Seminar which is coming to TO April 9th 2011. Hope to see y'all there, always a rollicking good time as well as informative.

Be well, keep in touch, regards,

Anne

OBJECTIVES:

The patient’s we serve have become savvy healthcare consumers. They have rights and privileges under both a legal and moral standard. We are obligated to treat our patients with dignity, understanding and respect. What are their rights, what are our rights and how do we serve both masters?

Patient Rights:

• To participate in developing their plan of treatment in your care.
• To receive an explanation of services in accordance with the treatment plan.
• To participate voluntarily in and to consent to treatment.
• To object to, or terminate, treatment.
• To have records protected by confidentiality and not be revealed to anyone other than designated medical personnel without written authorization.

Confidentiality may only be broken under the following conditions (state laws will vary):

1. If the therapist has knowledge of child or elder abuse.
2. If the therapist has knowledge of the client's intent to harm oneself or others.
3. If the therapist receives a court order to the contrary.
4. If the client enters into litigation against the therapist.

1. To have access to their records.
2. To receive clinically appropriate care and treatment that is suited to their needs and skillfully, safely, and humanely administered with full respect for their dignity and personal integrity.
3. To be treated in an ethical manner free from abuse, discrimination, mistreatment, and/or exploitation.
4. To be treated by staff who are sensitive to one's cultural background.
5. To be afforded privacy.
6. To be free to report grievances regarding services or staff to a supervisor.
7. To be informed of expected results of all therapies prescribed, including their possible adverse effects (e.g. – radiation, compression etc).
8. To request a change in therapist.
9. To request that another clinician review the individual treatment plan for a second opinion.

Confidentiality: 

Confidentiality is a fundamental tenet of medical care. It is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions. The technologist must not release information without the patient's consent to anyone but designated healthcare professionals involved in their care.  However, confidentiality, like other ethical duties, is not absolute. It may have to be overridden to protect individual persons or the public (if the therapist has knowledge of child or elder abuse, if the therapist has knowledge of the client's intent to harm him/her self or others, if the therapist receives a court order to the contrary, if the client enters into litigation against the therapist). Before breaching confidentiality, the technologist should make every effort to discuss the issues with the patient’s primary healthcare provider and healthcare team. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable legislation.

Confidentiality is increasingly difficult to maintain in this era of computerized record keeping and electronic data processing, faxing of patient information, third-party payment for medical services, and sharing of patient care among numerous medical professionals and institutions. All healthcare personnel should be aware of the increased risk for invasion of patients' privacy and should help ensure confidentiality. Within our own institutions, we all must advocate policies and procedures to secure the confidentiality of patient records.

Discussion of the problems of an identified patient by professional staff in public places (for example, in elevators or in cafeterias) violates confidentiality and is unethical. Outside of an educational setting, discussions of a potentially identifiable patient in front of persons who are not involved in that patient's care are unwise and impair the public's confidence in the medical profession. When caring for patients who are well known to the public we should take extra care to remember that we are not free to discuss or disclose information about a patient's health without the explicit consent of the patient.

In the care of the adolescent patient, family support is important. However, this support must be balanced with confidentiality and respect for the adolescent's autonomy in health care decisions and in relationships with health care providers. We should poll our facilities to assure ourselves of the laws governing the right of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment.

Occasionally, during the performance of our duties we receive information from a patient's friends or relatives and are asked to withhold the source of that information from the patient. We are not obliged to keep such secrets from the patient. The informant should be told this and discouraged from sharing this information with us and strongly urged to address the patient directly and to encourage the patient to discuss the information with the physician. We MUST use sensitivity and judgment in deciding whether to use the information and to reveal its content and source to the patient’s referring physician. We are always obligated to act in the best interests of the patient’s care. 

Informed Consent:

Any unauthorized touching of a person is battery, even in the medical setting. The patient's consent allows all healthcare professionals to provide the care we offer. Consent may be either expressed or implied. Expressed consent most often occurs in the hospital setting, where written or oral consent is given for a particular procedure. In many medical encounters, when the patient presents for evaluation and care, consent can be presumed. The underlying condition and treatment options are explained to the patient, and treatment is rendered or refused. In medical emergencies, consent to treatment that is necessary to maintain life or restore health is usually implied unless it is known that the patient would refuse the intervention.

The doctrine of informed consent goes beyond the question of whether consent was given for a treatment or intervention. Rather, it focuses on the content and process of consent. The healthcare provider is required to provide enough information to allow a patient to make an informed judgment about how to proceed. The presentation should be understandable to the patient, should be unbiased, and should include any medical recommendation. The patient's or surrogate's concurrence must be free and un-coerced.

The principle and practice of informed consent rely on patients to ask questions when they are uncertain about the information they receive; to think carefully about their choices; and to be forth-right about their values, concerns, and reservations about a particular recommendation. Once a course of action is decided on patients should make every reasonable effort to carry out the aspects of care that are in their control or to inform the medical team promptly if it is not possible to do so. We are obligated to ensure that the patient or the surrogate is adequately informed about the nature of the patient's medical condition and the objectives of, alternatives to, possible outcomes of, and risks involved with a proposed treatment.

Competency:

All adult patients are considered competent to make decisions about medical care unless a court declares them incompetent. In practice, however, physicians and family members usually make decisions without a formal competency hearing in the courts for patients who lack decision-making capacity. This clinical approach can be ethically justified if the physician and healthcare team  has carefully determined that the patient is incapable of understanding the nature of the proposed treatment; the alternatives to it; and the risks, benefits, and consequences of it.

When a patient lacks decision-making capacity (that is, the ability to receive and express information and to make a choice consonant with that information and one's values), then, an appropriate surrogate should make decisions with the clinician. Ideally, surrogate decision makers should know the patient's preferences and act in the best interests of the patient. If the patient has designated a proxy, as through a durable power of attorney for health care, that choice should be respected. When patients have not selected surrogates, standard clinical practice is that family members serve as surrogates. Some jurisdictions designate the order in which family members will serve as surrogates. Medial professionals and facilities should be aware of all legal requirements for surrogate appointment and decision making. In some cases, all parties may agree that a close friend is a more appropriate surrogate than a relative.

Reasonable care must be taken to ensure that the surrogate's decisions are consistent with the patient's preferences and best interests. When possible, these decisions should be reached in the medical setting by physicians, surrogates, and other caregivers. Surrogates should understand that their decisions should be based on what the patient would want, not what surrogates would choose for themselves. If disagreements cannot be resolved, hospital ethics committees may be helpful. Courts should be used when doing so serves the patient, such as to establish guardianship for an unrepresented, incompetent patient; to resolve a problem when other processes fail; or to comply with the law.

Most adult patients can participate in, and thereby share responsibility for, their health care. Physicians cannot properly diagnose and treat conditions without full disclosure of patients' personal and family medical history, habits, ongoing treatments (medical and otherwise), and symptoms. The obligation to confidentiality exists in part to ensure that patients can be candid without fear of loss of privacy. All medical professionals and the facilities that serve the patient must try to create an environment in which honesty can thrive and all concerns and questions are elicited.

The Patient And The Medical Record:

Ethically and legally, patients have the right to know what is in their medical records. Legally, the actual chart and film record is the property of the physician or institution, although the information therein is the property of the patient. Most laws guarantee the patient personal access to the medical record. The physician must release information to the patient or to a third party at the request of the patient. The institution or physician should retain the original of the chart and radiographic studies and respond to a patient's request with copies unless the original record is required by law. To protect confidentiality, information should only be released with the written permission of the patient or the patient's legally authorized representative.

SUMMARY:

The patient is in our hands for a good deal of their treatment. We are obligated to act in a responsible manner toward them. We are entrusted with a great deal of sensitive information; the patient puts her faith in our professional behavior. Know your rights and responsibilities and understand your patient’s rights and obligations. Our job is getting more and more diverse with complicated medical legal implications. Ask your ethics department what your facility’s policies are. Protect yourself, your patient and your facility.