“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.

Common Positioning Problems: The Solutions!

OBJECTIVES:

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:

1. Elevate the IMF a little higher
2. Lift and pull the breast straight onto the bucky
3. Use both hands to handle the breast
4. (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:

1. Position from the medial side
2. Lift and drape opposite breast over the edge of the bucky
3. Do not press the patient’s face against the face protector
4. 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:

1. The Patient’s arm should be relaxed by side
2. Her palm should be supinated with her shoulder externally rotated
3. Control your patient’s posture with your hand around her back on her contra-lateral shoulder
4. She should be relaxed forward bent slightly at the waist
5. 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:

1. Elevate the IMF until the tissue no longer moves easily along the chest wall
2. Identify the edge of the pectoral muscle visible just under the clavicle
3. Loosen the skin over the clavicle so the tissue moves easily
4. Compress parallel to the pectoral edge just under the clavicle
5. 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:

1. Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle
2. Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum
3. 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:

1. DO NOT rest your patient’s arm along the top edge of the bucky
2. Patient’s shoulder should be open, relaxed 
3. The corner of the bucky high up and well back in the axilla
4. Patient’s arm should be slightly bent hanging loosely down the back of the bucky
5. 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’:

1. Move the breast from the lateral edge medially 
2. Ensure the breast mound moves freely in your grip
3. Support the breast tissue from the inferior border using you entire hand
4. 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
5. 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:

1. Support the breast and always release with and up & out motion
2. Have the patient tilt her hips slightly backwards
3. Do not release your hold on the breast until the projection is immobilized by the compression
4. 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:

1. Make sure the patient’s feet are directly facing the bucky
2. Control the breast from the mobile lateral border only
3. Immobilize the breast parenchyma parallel to the pectoral muscle until the compression holds the projection
4. (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 send this article once a year for those who have lost theirs or those who are new to techtalk, I hope they will lend a hand in the arduous task of perfecting your technique and knowledge.

CBE FOR THE MAMMOGRAPHER - Part 3: Overcoming Barriers to Practice

OBJECTIVES:
With the constant changing of the expectations of DI personnel our scope of practice changes year on year, full patient assessment now often comes into our scope of practice. With that in mind, the mammographers responsibilities in regards to Clinical Breast exam broaden somewhat.

I will present recommendations in three areas, the clinical breast examination itself, interpretation/ report/follow-up, and overcoming barriers to performance. Some recommendations can be implemented immediately within clinical settings, and clinicians are encouraged to lead this effort. Others will require partnerships between the clinical community and health care organizations to establish systems, increase awareness, and gather necessary information to achieve outcomes.

CLINICAL BREAST EXAMINATION 

The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE is considered to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this article represent general standards that can be immediately disseminated and adopted based on current evidence.

Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.

Overcoming Barriers to Performing Clinical Breast Examinations

The recommendations to address barriers to proficient CBE focus on examiner training, public education, and research and quality improvement.

Examiner Training
Lead responsibility for implementation: health care organizations.

 Develop and promote training systems to improve and maintain the proficiency of those who perform CBE, and encourage the integration of such systems into basic and continuing education programs health care professionals.

CBE training should build on existing training programs designed to improve CBE proficiency and include the components described below. In addition, training programs should be made more available, and these programs integrated into medical, paramedical, radiological and nursing school curricula, programs for residents and fellows, and continuing medical and nursing education. Expanding the availability of training will require collaborative efforts among clinicians, health organizations, and the community.

 Training Components:

1. Didactic Presentation: Training should include a didactic presentation that:

• Provides basic information on the anatomy and physiology of the breast
• Provides the rationale for performing CBE through background information on breast health and disease
• Identifies and describes elements of standard CBE—clinical history, visual inspection, palpation, interpretation and reporting, and follow-up of abnormal results to resolution

2. Visual Presentation: Training also should include a visual, real-time CBE performance—either a video or demonstration—so that trainees can see correct CBE techniques
3. Practice and Feedback:

Finally, and no doubt most important, trainees should have an opportunity to practice CBE skills and to obtain feedback from experienced examiners. This skills-building element should involve the use of high-quality silicone models and, if possible, instructors posing as patients. Live models provide a more realistic clinical experience, allow training in components of CBE beyond palpation, provide palpation experience with breast tissue, and can provide valuable feedback about provider-patient interactions. If instructors are not available to pose as patients during the initial training, training programs should develop a plan for ensuring that trainees are given skills practice on live models with feedback in the near future. Training also must include measuring and demonstrating adequate levels of sensitivity and specificity of lump detection.

  
Training Characteristics:

1. Training Should Be Flexible to Accommodate Diverse Settings and Trainee Needs

Training programs should be tailored to suit a variety of settings, including basic medical education, residency, fellowship, nursing education, and continuing medical education. Training in all three components—the examination, interpretation and reporting, and follow up—may not be possible to complete in one session or a brief series of sessions. It may be more effective in some cases to divide training into phases so that examiners can improve their skills in each component through successive sessions.

2. Participation in Training Should Be Incentive Based

Training and retraining programs need to provide incentives for health care professionals to participate, such as continuing education units, information and skills for clinicians, and certification that might reduce the clinician’s risk of successful malpractice claims.

3. Training Should Offer General Guidance on Follow-Up That Focuses on Resolution of Finding

The level of detail in instruction about appropriate follow up may vary across the trainee’s profession and the setting. The fundamental training principle is that providers must follow the patient to resolution or refer her to another health care professional, depending on the complexity of the problem. Within established standards of care, algorithms that are appropriate to the examiner’s health care system/institution can direct specific actions.

Strategies to Increase the Number of Qualified Trainers:

As the demand for CBE training grows, we must ensure that a sufficient supply of qualified trainers is available. Furthermore, because CBE is a tactile skill and didactic instruction alone is insufficient, institutions will need to help potential instructors become skilled at behavioral and skill-based teaching techniques, including providing constructive and motivating feedback.

Training of Trainers Should Have Four Core Elements

• Teaching all components of CBE
• Encouraging consistent performance of a standardized exam as necessary for providing a quality CBE
• Providing the necessary information for interpreting CBE findings
• Teaching new skills and improving existing skills

Public Education: Lead responsibility for implementation: health care organizations

• Promote and encourage public education about CBE so that women
• Know what to expect in the performance of CBE and follow-up care
• Understand the benefits, limitations, and potential harms associated with CBE
• Become familiar with their own breast characteristics as well as health practices that might increase the likelihood of identifying breast abnormalities

Many women are not aware that many health organizations recommend CBE in addition to regular mammograms, and most do not know what to expect in a CBE. Being informed and educated will help women become active partners with their provider in their own health care decisions. Professional organizations play a valuable role in influencing their members to follow current guidelines as a component of comprehensive breast cancer screening. Public education messages about CBE should be part of a wider effort to promote informed health care decision-making among women. Messages should be simple, clear, and tailored to different groups of women, if possible. CBE is an opportunity for dialogue between women and their providers and should parallel education about the importance of women understanding their own normal breast characteristics

Public education efforts should convey the following messages:

1. Why CBE can be important?

• It contributes to the detection of palpable breast cancers and other breast abnormalities
• It offers a test for detecting palpable breast cancers at an earlier stage of progression
• It adds to, but does not replace, mammography
• Its contribution to the detection of breast cancer among asymptomatic women is relatively small. Not all organizations recommend CBE

2. What should be expected in a proficient CBE?

• Components should include careful visual inspection and palpation of the breast and lymph nodes
• It must provide a trained examination and an opportunity for patient/provider interaction about breast health

3. What should happen if an abnormality is identified?

• Follow up should be conducted to an appropriate resolution
• Follow up is required for an abnormal CBE regardless of the results from the mammogram

4. What a woman can do to improve the quality of her CBE

• Provide a complete history
• Adhere to a schedule of appointments

5. When screening CBE should be performed.

• Premenopausal women.

These women should be screened as part of a periodic health examination according to screening guidelines.

If possible, screening should be a week or two after a woman’s period to avoid breast tenderness and shortly before her mammogram.

• Postmenopausal women.

These women should be screened as part of a periodic health examination according to screening guidelines.

If possible, screening should be shortly before a woman’s mammogram.

• Pregnant and breastfeeding women.

These women should be screened as part of a periodic health examination according to screening guidelines.

These women might expect increased breast tenderness and nodularity.

Research and Quality Improvement
Lead responsibility for implementation: health care organizations and research sponsoring organizations.

Support and encourage research in key aspects of CBE, particularly questions related to characteristics of abnormalities found by CBE, the timing of the exam, training of examiners (clinicians), reporting systems, and CBE’s contributions to early detection of breast cancer and the reduction of morbidity and mortality from the disease.

The evidence regarding many aspects of CBE is insufficient. Standardized performance, reporting, and follow up, combined with reporting and surveillance systems, could provide the foundation for assessing the relative contributions of CBE to the earlier detection of breast cancer. Such information may enable more accurate estimates of sensitivity and specificity of CBE in clinical practice settings. Information about the number of cancers first identified by CBE, particularly as a function of age and other population characteristics, could help clarify the role of this examination as a component of early detection and the most effective use of CBE relative to other screening modalities. Such data might also be used to assess the costs and benefits of CBE as an early detection test. This type of information is essential to resolving the confusion engendered by having disparate practice guidelines across organizations. Furthermore, such data could provide the basis for further enhancements in training providers to be proficient in CBE.

Research Needs:

1. CBE characteristics.

• Sensitivity and specificity
• In clinical practice
• Among women at different ages (premenopausal, perimenopausal, postmenopausal)

2. Method of initial detection of abnormalities.

• CBE, mammography, BSE
• By woman, partner, provider

3. Characteristics of masses identified.

• Size
• Shape
• Consistency
• Mobility
• External texture

4. Timing

• Effect of examination performance at different times of the menstrual cycle on sensitivity and specificity
• Effect of dissociating CBE from other screening modalities for breast cancer

5. CBE training

• Components of optimal training
• Optimal frequency
• Systems for integrating CBE training with other medical/health care training
• Characteristics of effective trainers
• Measurement of training effectiveness

6. CBE reporting systems

• Acceptability of using a uniform or standardized lexicon for reporting
• Feasibility of expanding medical records or registry databases to include information about detection of breast abnormalities by CBE
• Contribution to the earlier detection of breast cancer and reductions in breast cancer mortality

SUMMARY:
As laws change, medical teams form and shift, multi disciplinary education becomes normal and hybrid and fusion imaging becomes standard practice our responsibilities as clinicians expand and evolve. As professionals we are expected to rise to the challenges presented to us.
With education, practice and experience we can embrace these new proficiencies and continue to serve our patients with skill and renewed efficacy. Knowledge is power!