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Stage I breast carcinoma is classified when an invasive breast carcinoma is <=2 cm in diameter (T1), with no regional (axillary) lymph node metastases (N0) and no distant metastases (M0). The most common sites for metastases from breast cancer are the skeleton, lung, liver, and brain. In general, women and health care professionals prefer intensive screening and surveillance after a diagnosis of breast cancer. Screening protocols include conventional imaging such as chest radiography, bone scan, ultrasound of the liver, and MRI of brain. It is uncertain whether PET/CT will serve as a replacement for current imaging technologies. However, there are no survival or quality-of-life differences for women who undergo intensive screening and surveillance after a diagnosis of stage I breast carcinoma compared with those who do not. The ACR Appropriateness Criteria((R)) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Objective: The goal of this study was to develop a psychometrically valid survey on workplace satisfaction and examine predictors of workforce movement among breast radiologists., Methods: Actively practicing members of the Society of Breast Imaging were invited to complete a survey on workplace satisfaction. Radiologists also indicated whether they had recently left their practice or were thinking of leaving their practice., Results: In total, 228 breast radiologists provided valid responses (8.7% response rate); 45% were thinking of leaving or had left their practice. Factor analysis yielded five factors, and discriminant function analysis found six main aspects associated with workforce movement in breast radiologists: (1) not enough work-life balance; (2) salary too low; (3) not feeling valued; (4) wanting a different challenge and/or more growth opportunity; (5) safety concerns; and (6) not feeling respected by physician leadership., Conclusions: Pending further validation in larger and different cohorts, the survey created here can be administered by radiology practices to predict when breast radiologists are vulnerable to quitting. Atlhough this measure was designed for breast radiologists specifically, it could be adapted for other subspecialties., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Rationale and Objective: To compare burnout and stressors of breast radiologists prior to and during the COVID-19 pandemic., Materials and Methods: Members of the Society of Breast Imaging were emailed an IRB-approved survey in January 2021 during the COVID-19 pandemic. Survey included questions from the Maslach Burnout Inventory and specific stressors including work pace, work-life balance, care of dependents, and financial strain. Data were compared to previous surveys prior to the pandemic., Results: The response rate was 25% (261/1061) for those who opened the email. Of the respondents, 74% (194/261) were female, 82% (214/261) were white, 73% (191/261) were full time, 71% (185/261) were fellowship trained, 41% (106/261) had more than 20 years of experience, and 30% (79/261) were in academic practice.Respondents in 2021 reported frequent levels of depersonalization (2.2) and emotional exhaustion (3.4) while reporting frequent levels of personal accomplishment (5.3), a protective factor. These values were nearly identical before the pandemic in 2020: (2.2, 3.5, 5.3, respectively, p = .9). Respondents rated practicing faster than they would like as the highest stressor; however, 5 of the 6 stressors improved after the pandemic onset (p < .05). Conversely, participants perceived these stresses had gotten slightly worse since the pandemic (p < .01). Almost 50% of respondents reported they were considering leaving their practice; the most common reason was work/life balance., Conclusion: Burnout in breast radiologists remains frequent but unchanged during the COVID-19 pandemic. While participants perceived that some stressors were worse during the pandemic, there was slight improvement in most stressors between the pre-pandemic and pandemic cohorts., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jay Parikh, MD reports financial support was provided by National Institutes of Health., (© 2023 The Authors.)

The continually increasing demands placed on physicians have led to high levels of burnout, and breast radiologists are no exception. Professional coaching is a means to guide and support the radiologist through a process of positive thinking, stress reduction, goal setting, mental growth, work-life balance, and behavioral change. Professional coaching may be effective in preparation for leadership roles or in response to workplace issues or conflict. The radiologist, with the help of a coach, establishes goals, expands perception and mindset, and collaboratively may find ways to resolve issues by taking new and different approaches. This article discusses why radiologists should seek out a certified coach and what a coach can offer radiologists during these trying times, as well as outlining the coaching process. Coaching has proven useful in addressing professional growth, workplace issues, and physician burnout. At the conclusion of the article, the readers will be able to discern whether coaching can support a better quality of life for them., (© Society of Breast Imaging 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Rationale and Objectives: Promotion is an important milestone in the career of academic radiologists. Appointments, Promotion and Tenure (APT) committees require multiple letters of support from both internal and external referees. Traditional narrative letters are highly subjective, have high inter-reader variability, are time-intensive, and vulnerable to gender and other biases. The Alliance of Directors and Vice Chairs of Education in Radiology (ADVICER) recognized the need for a standardized template to assist academic faculty, letter writers, and APT committees., Materials and Methods: An ADVICER ad hoc committee of six educators with experience serving as external referees was convened to create a standardized template. Committee members performed a search of the relevant literature and internet sites, spoke with stakeholders such as APT chairs, and ultimately developed a template for faculty reviewer letters using the common clinician-educator pathway as a focal point., Results: An open source, modifiable, standardized, template was produced. The template has been made available to ADVICER members and is available on the Association of University Radiologists (AUR) website at: https://www.aur.org/resources/Template-for-Faculty-Reviewer-Letters-for-Promotion-and-Appointment CONCLUSION: This external referee template has the potential to reduce subjectivity, eliminate bias, and provide a flexible, modifiable, comprehensive faculty review letter template which will be useful for academic faculty, letter writers, and promotions committees., (Copyright © 2021 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study is to determine the major stressors affecting practicing breast radiologists., Methods: All members of the Society of Breast Imaging within the United States received an email invitation to complete an anonymous survey evaluating stressors that may contribute to physician burnout. Stressors evaluated included pace at work, work-life balance, care of dependents, job security, financial strain, decreasing reimbursement, new regulations, delivering bad news, fear of getting sued, and dealing with difficult patients, radiologists, and administrators., Results: The overall response rate was 13.5% (312/2308). For those who opened the email, response rate was 24.6% (312/1269). The most prevalent stressors reported were working too fast (222/312, 71.2%), balancing demands of work with personal life (209/312, 70.0%), fear of getting sued (164/312, 52.6%), and dealing with difficult administrators (156/312, 50%). Prevalence of stress related to new regulation requirements, job security, financial strain, decreased reimbursement, dependent care, call, delivering bad news, and dealing with difficult patients, difficult referrers, and difficult radiologists were present in fewer than 50% of respondents., Conclusion: The most prevalent sources of stress in breast imaging radiologists relate to working too fast and balancing demands of work with time needed for personal life., (© Society of Breast Imaging 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The Food and Drug Administration is currently creating national standards for language used in letters sent to women after mammography concerning dense breasts. The purpose of the current study is to survey breast radiologists on their opinions about language to be included in dense breast notification (DBN) letters., Methods: An anonymous survey (17 questions and 10 open-ended response fields) was sent to Society of Breast Imaging members between May 2019 and June 2019. Analyses were conducted using a chi-square test and the generalized linear model., Results: A total of 262 surveys were completed (25% response rate). The majority of breast radiologists believe letters should be sent to patients (91%), with most (66%) believing that patients should receive DBN letters regardless of having dense breasts or not. The majority of breast radiologists believe DBNs should be sent to referring physicians (69%), include statements that define masking (89%), inform patients that dense breasts are associated with cancer risk (77%), inform patients about the possible benefits of supplemental screening (86%), be written at the sixth- or eighth-grade reading level (92%), and should be provided in other languages in addition to English (89%); half of the respondents (51%) believe the letters should contain BI-RADS density descriptors., Conclusion: There is consensus that patients and referring physicians should receive DBN letters and that those letters should address masking, increased cancer risk, and supplemental screening. Respondents believe the letters should be written at a sixth- or eighth-grade reading level., (© Society of Breast Imaging 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Burnout is defined as a psychological syndrome arising as a response to chronic prolonged interpersonal job-related stress. Physician burnout has been increasingly recognized over the past decade as an epidemic within the United States. The goal of this study was to ascertain the prevalence of burnout amongst practicing breast imaging radiologists., Methods: A survey contained demographic questions based on workforce surveys carried out by the American College of Radiology and a validated condensed version of the Maslach Burnout Inventory (MBI) evaluating the three aspects of burnout. The radiologist members of the Society of Breast Imaging (SBI) received the survey internally from the SBI as a weekly e-mail with a web link to the survey from February 19, 2019, to March 13, 2019. The link allowed respondents to complete the survey anonymously. The authors were blinded to the SBI mailing list and the SBI was blinded to the responses., Results: A total of 370 breast imaging radiologists from the SBI responded to the survey. Overall, 290 out of 370 (78.4%) were highly burned out in at least 1 measured dimension of burnout; 197 out of 362 (54.4%) were highly burned out in at least 2 dimensions of burnout; and 27 out of 362 (7.5%) were highly burned out in all 3 dimensions of burnout. However, rates of personal accomplishment were high, with only 8.8% experiencing high burnout in the dimension of personal accomplishment., Conclusion: Our study demonstrates a high prevalence of burnout amongst breast imaging radiologists. Burnout rates were highest in the youngest breast imaging radiologists., (© Society of Breast Imaging 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Breast cryoablation is becoming more commonplace as a minimally invasive percutaneous procedure that utilizes extreme cold to destroy targeted tissue and has been used to treat symptomatic fibroadenomas and early-stage breast cancer for over a decade with promising results. The practical considerations for implementing a breast cryoablation service include developing and communicating strategic and operational plans, training and privileging the proceduralist, selecting equipment, collaborating with referring clinicians, recruiting and navigating patients, and understanding billing considerations., (© Society of Breast Imaging 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Teaching ultrasound-guided percutaneous breast interventions to a trainee may be a challenge, given the often high-anxiety environment in the subspecialty of breast imaging. This article aims to teach an organized approach, including simulation practice with an emphasis on consistent feedback and role modeling, as well as practical and relevant physics, to help trainees accelerate acquisition of these important skills during their training., (© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

OBJECTIVE. Percutaneous ultrasound-guided breast cryoablation is a minimally invasive technique that kills targeted tissue with extreme cold, requires only local anesthesia, and takes less than 45 minutes to complete. CONCLUSION. We discuss the indications for breast cryoablation, the mechanism of cell death, and types of commercially available devices; illustrate procedural technique; and review expected follow-up imaging findings in treated primary breast cancer.

Objective: To evaluate radiologists' supplemental screening recommendations for women with dense breasts, at average, intermediate, or high risk of breast cancer, and to determine if there are differences between their recommendations for their patients, their friends and family, and themselves., Methods: This is an anonymous survey of Society of Breast Imaging (SBI) members. Demographics, knowledge of breast density as a risk factor, and recommendations for screening with digital breast tomosynthesis (DBT), ultrasound (US), and magnetic resonance imaging (MRI) in women with dense breasts, at average, intermediate, or high- risk of breast cancer were assessed. The likelihood of their recommending the screening test for their patients, their family and friends, and themselves was assessed on a Likert scale from 0 to 4 (0 = "not at all likely" to 4 = "extremely likely")., Results: There were 295 responses: 67% were women, and breast imaging comprised 95% of their practice. Among participants, 53% correctly answered the question on relative risk of breast cancer when comparing extremely dense versus fatty breasts, and 57% when comparing heterogeneously dense versus scattered breasts. US is recommended at a relatively low rate (1.0-1.4 on the 0-4 scale), regardless of risk. DBT is recommended at a relatively high rate (2.5-3.0 on the 0-4 scale), regardless of risk status. MR is recommended mainly for those at high risk (3.6 on the 0-4 scale). Radiologists were more likely to recommend additional imaging for themselves than for their patients and their family and friends., Conclusion: For women with dense breasts, radiologists are "somewhat likely" to recommend US and "likely" to "very likely" to recommend DBT regardless of risk group. They are "very likely" to recommend MRI for high-risk groups., (© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Burnout is a psychological syndrome created by chronic job stress, and it is typified by emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment. In physicians, burnout occurs at alarming rates, and it is on the rise. High burnout rates are ubiquitous in radiology across multiple subspecialties. We know of no study specifically examining burnout among breast imaging radiologists, but given the rates across multiple specialties in radiology, we must assume that a significant portion of breast imaging radiologists also experience burnout. As breast imaging increases in volume and complexity, we must find new ways of practicing that help achieve a healthy work environment., (© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The purpose of this study was to describe a new, broadly applicable radiology report categorization (RADCAT) system that was developed collaboratively between radiologists and emergency department (ED) physicians, and to establish its usability and performance by interobserver variation., Methods: In collaboration with our ED colleagues, we developed the RADCAT system for all imaging studies performed in our level-1 trauma center, including five categories that span the spectrum of normal through emergent life-threatening findings. During a pilot phase, four radiologists used the system real-time to categorize a minimum of 400 reports in the ED. From this pool of categorized studies, 58 reports were then selected semi-randomly, de-identified, stripped of their original categorization, and recategorized based on the narrative radiology report by 12 individual reviewers (6 radiologists, and 6 ED physicians). Interobserver variation between all reviewers, radiologists only, and ED physicians only was calculated using Cohen's Kappa statistic and Kendall's coefficient of concordance., Results: Altogether, agreement among radiologists and ED physicians was substantial (κ = 0.73, p < 0.0001) and agreement for each category was substantial (all κ > 0.60, p < 0.0001). The lowest agreement was observed with RADCAT-3 (κ > 0.61, p < 0.0001) and the highest agreement with RADCAT-1 (κ > 0.85, p < 0.0001). A high trend in agreement was observed for radiologists and ED physicians and their combination (all W > 0.90, p < 0.0001)., Conclusions: Our RADCAT system is understandable between radiologists and ED physicians for categorizing a wide range of imaging studies, and warrants further assessment and validation. Based upon these pilot results, we plan to adopt this RADCAT scheme and further assess its performance.

Purpose To compare screening mammography recall rate, cancer detection rate (CDR), and positive predictive values (PPVs) for digital mammography before and after radiologist experience with digital breast tomosynthesis (DBT). Materials and Methods This retrospective study was approved by the institutional review board and compliant with HIPAA. The authors reviewed screening mammography audit data obtained from 2009 to 2014, during which 108 276 digital mammographic examinations were performed (50 062 before and 58 214 after experience with DBT). Recall rate, CDR, PPV of positive screening result (PPV 1 ), PPV of biopsy recommendation (PPV 2 ), and PPV of biopsies performed (PPV 3 ) of digital mammography for six radiologists were compared before (2009-2011) and after (2012-2014) experience with DBT. Radiologists worked in both a community setting, in which only digital mammography was available, and in two tertiary breast imaging centers, where they interpreted DBT images starting in 2012. Data were examined by using generalized linear mixed modeling wherein observations were nested for each radiologist over time. P < .05 was considered indicative of a statistically significant difference; 95% confidence intervals (CIs) were calculated. Results The average recall rate was 6.8% (range, 3.6%-9.7%) before experience with DBT and 7.9% (range, 5.5%-9.5%) after (P = .0316). Before experience with DBT, the recall rate increased only 0.01% for each year from 2009 to 2011 (P = .9727). After experience with DBT, the recall rate increased 0.65% for each year from 2012 to 2014 (P < .0127). CDR increased from 2.5 per 1000 examinations (95% CI: 2.2, 2.9) to 3.5 per 1000 examinations (95% CI: 3.0, 4.0; P = .0203). PPV 2 and PPV 3 increased significantly after experience with DBT, from 26.9% (95% CI: 19.9%, 35.3%) to 36.1% (95% CI: 31.7%, 40.7%; P = .0212) for PPV 2 and from 31.2% (95% CI: 24.0%, 39.3%) to 40.0% (95% CI: 35.5%, 44.6%; P = .0290) for PPV 3 . Conclusion Recall rate, CDR, PPV 2 , and PPV 3 of digital mammography increased after radiologist experience with DBT. © RSNA, 2017.

Objectives: To compare interobserver variability (IOV), reader confidence, and sensitivity/specificity in detecting architectural distortion (AD) on digital mammography (DM) versus digital breast tomosynthesis (DBT)., Methods: This IRB-approved, HIPAA-compliant reader study used a counterbalanced experimental design. We searched radiology reports for AD on screening mammograms from 5 March 2012-27 November 2013. Cases were consensus-reviewed. Controls were selected from demographically matched non-AD examinations. Two radiologists and two fellows blinded to outcomes independently reviewed images from two patient groups in two sessions. Readers recorded presence/absence of AD and confidence level. Agreement and differences in confidence and sensitivity/specificity between DBT versus DM and attendings versus fellows were examined using weighted Kappa and generalised mixed modeling, respectively., Results: There were 59 AD patients and 59 controls for 1,888 observations (59 × 2 (cases and controls) × 2 breasts × 2 imaging techniques × 4 readers). For all readers, agreement improved with DBT versus DM (0.61 vs. 0.37). Confidence was higher with DBT, p = .001. DBT achieved higher sensitivity (.59 vs. .32), p < .001; specificity remained high (>.90). DBT achieved higher positive likelihood ratio values, smaller negative likelihood ratio values, and larger ROC values., Conclusions: DBT decreases IOV, increases confidence, and improves sensitivity while maintaining high specificity in detecting AD., Key Points: • Digital breast tomosynthesis decreases interobserver variability in the detection of architectural distortion. • Digital breast tomosynthesis increases reader confidence in the detection of architectural distortion. • Digital breast tomosynthesis improves sensitivity in the detection of architectural distortion.

Breast cancer screening recommendations are based on risk factors. For average-risk women, screening mammography and/or digital breast tomosynthesis is recommended beginning at age 40. Ultrasound (US) may be useful as an adjunct to mammography for incremental cancer detection in women with dense breasts, but the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. For intermediate-risk women, US or MRI may be indicated as an adjunct to mammography depending upon specific risk factors. For women at high risk due to prior mantle radiation between the ages of 10 to 30, mammography is recommended starting 8 years after radiation therapy but not before age 25. For women with a genetic predisposition, annual screening mammography is recommended beginning 10 years earlier than the affected relative at the time of diagnosis but not before age 30. Annual screening MRI is recommended in high-risk women as an adjunct to mammography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Women and health care professionals generally prefer intensive follow-up after a diagnosis of breast cancer. However, there are no survival differences between women who obtain intensive surveillance with imaging and laboratory studies compared with women who only undergo testing because of the development of symptoms or findings on clinical examinations. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients; more imaging may be needed if the patient has locoregional symptoms (eg, palpable abnormality). Women with other risk factors that increase their lifetime risk for breast cancer may warrant evaluation with breast MRI. Furthermore, the quality of life is similar for women who undergo intensive surveillance compared with those who do not. There is little justification for imaging to detect or rule out metastasis in asymptomatic women with newly diagnosed stage I breast cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Breast cancer is the most common female malignancy and the second leading cause of female cancer death in the United States. Although the majority of palpable breast lumps are benign, a new palpable breast mass is a common presenting sign of breast cancer. Any woman presenting with a palpable lesion should have a thorough clinical breast examination, but because many breast masses may not exhibit distinctive physical findings, imaging evaluation is necessary in almost all cases to characterize the palpable lesion. Recommended imaging options in the context of a palpable mass include diagnostic mammography and targeted-breast ultrasound and are dependent on patient age and degree of radiologic suspicion as detailed in the document Variants. There is little role for advanced technologies such as MRI, positron emission mammography, or molecular breast imaging in the evaluation of a palpable mass. When a suspicious finding is identified, biopsy is indicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Breast pain (or tenderness) is a common symptom, experienced by up to 80% of women at some point in their lives. Fortunately, it is rarely associated with breast cancer. However, breast pain remains a common cause of referral for diagnostic breast imaging evaluation. Appropriate workup depends on the nature and focality of the pain, as well as the age of the patient. Imaging evaluation is usually not indicated if the pain is cyclic or nonfocal. For focal, noncyclic pain, imaging may be appropriate, mainly for reassurance and to identify treatable causes. Ultrasound can be the initial examination used to evaluate women under 30 with focal, noncyclic breast pain; for women 30 and older, diagnostic mammography, digital breast tomosynthesis, and ultrasound may all serve as appropriate initial examinations. However, even in the setting of focal, noncyclic pain, cancer as an etiology is rare. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Women newly diagnosed with stage 1 breast cancer have an early-stage disease that can be effectively treated. Evidence provides little justification for performing imaging to exclude metastasis in asymptomatic women with stage I breast cancer. No differences have been found in survival or quality of life in women regardless of whether they underwent initial workup for metastatic disease. These women generally prefer intensive follow-up to detect an early recurrence. However, survival rates do not differ between women who obtain intensive screening and surveillance, with imaging and laboratory studies, and women who undergo testing only as a result of development of symptoms or findings on clinical examinations. In addition, quality of life is similar for women who undergo intensive surveillance compared with those who do not. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients. Additional imaging may be needed if the patient has locoregional symptoms. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review by the panel include extensive analysis of current medical literature from peer-reviewed journals and application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures. When evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Mammography is the recommended method for breast cancer screening of women in the general population. However, mammography alone does not perform as well as mammography plus supplemental screening in high-risk women. Therefore, supplemental screening with MRI or ultrasound is recommended in selected high-risk populations. Screening breast MRI is recommended in women at high risk for breast cancer on the basis of family history or genetic predisposition. Ultrasound is an option for those high-risk women who cannot undergo MRI. Recent literature also supports the use of breast MRI in some women of intermediate risk, and ultrasound may be an option for intermediate-risk women with dense breasts. There is insufficient evidence to support the use of other imaging modalities, such as thermography, breast-specific gamma imaging, positron emission mammography, and optical imaging, for breast cancer screening. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Stage I breast carcinoma is classified when an invasive breast carcinoma is ≤2 cm in diameter (T1), with no regional (axillary) lymph node metastases (N0) and no distant metastases (M0). The most common sites for metastases from breast cancer are the skeleton, lung, liver, and brain. In general, women and health care professionals prefer intensive screening and surveillance after a diagnosis of breast cancer. Screening protocols include conventional imaging such as chest radiography, bone scan, ultrasound of the liver, and MRI of brain. It is uncertain whether PET/CT will serve as a replacement for current imaging technologies. However, there are no survival or quality-of-life differences for women who undergo intensive screening and surveillance after a diagnosis of stage I breast carcinoma compared with those who do not. The ACR Appropriateness Criteria ® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A palpable breast mass is one of the most common presenting features of breast carcinoma. However, the clinical features are frequently nonspecific. Imaging performed before biopsy is helpful in characterizing the nature of the mass. For women with clinically detected breast masses, the vast majority will require evaluation with ultrasound. Diagnostic mammography is the initial imaging modality of choice for women aged ≥ 40 years; ultrasound is typically necessary unless a definitively benign mass is identified as the etiology of the clinical finding. For evaluating women aged <30 years and women who are pregnant or lactating, ultrasound is used for initial evaluation. For women aged 30 to 39 years, either ultrasound or diagnostic mammography may be used for initial evaluation. MRI is rarely indicated to evaluate a clinically detected finding. Biopsy is indicated for masses with suspicious features. Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma. Correlation between imaging and the clinical finding is essential. The ACR Appropriateness Criteria ® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although some breast cancers present as palpable masses or with other clinical findings, many are detected at screening. Most screening is currently done with digital mammography, but high-risk patients or those with dense breast tissue may undergo additional screening examinations with magnetic resonance imaging or ultrasound. Additionally, digital breast tomosynthesis, contrast-enhanced mammography, and molecular breast imaging are newer technologies available at some sites. Optimal usage of breast imaging technologies remains controversial, both in screening and diagnostic settings following a new diagnosis of breast cancer. This article will review well established and newer, alternative breast imaging technologies as well as recent data regarding their role in optimizing patient care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Most male breast problems are benign, and men with typical symptoms of gynecomastia or pseudogynecomastia do not usually need imaging. When a differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings or when the clinical findings are suspicious for breast cancer, imaging is indicated. Mammography is useful in both identifying cancer and obviating the need for biopsy in patients for whom a benign mammographic impression confirms the clinical impression. However, because of the relationship of breast cancer to increasing age, age-based protocols that do not include mammography have been developed. For men with an indeterminate palpable mass, begin with ultrasound if the patient is <25 years of age, because breast cancer is highly unlikely. Mammography should be performed if ultrasound is suspicious. For men ≥25 years of age or having a highly concerning physical examination, usually begin with mammography; ultrasound is useful if mammography is inconclusive or suspicious. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare recall rate, types of abnormalities recalled, additional imaging required, biopsy positive predictive value (PPV), and cancer detection rate before and after implementation of screening digital breast tomosynthesis (DBT)., Materials and Methods: This retrospective analysis was approved by the institutional review board and complied with HIPAA. The requirement to obtain informed consent was waived. Results from all screening digital mammography (DM) examinations performed without tomosynthesis from March 1, 2011, through February 29, 2012, and DBT examinations performed from March 1, 2012, through February 28, 2013, were reviewed to identify all Breast Imaging Reporting and Data System (BI-RADS) category 0 examinations (needs additional imaging). Radiology and pathology reports were reviewed. The recall rate, biopsy PPV, and cancer detection rate were calculated. Statistical analysis was performed by using a two-proportions z test., Results: The recall rate was 9.3% (1175 of 12 577 examinations; 95% confidence interval [CI]: 8.8%, 9.9%) for DM and 6.4% (827 of 12 921 examinations; 95% CI: 6.0%, 6.8%) for DBT, an overall reduction of 31% (P < .00001). The recall rate was lower with DM than with DBT for masses (8.9% vs 26.8%, respectively), distortions (0.6% vs 5.3%), and calcifications (13.4% vs 20.3%) (P < .0001 for all). The recall rate was lower with DBT than with DM for asymmetries (13.3% vs 32.2%, respectively) and focal asymmetries (18.2% vs 32.2%) (P < .0001 for both). Diagnostic evaluation with ultrasonography (US) increased with DBT at the time of additional imaging (2.6% for DM vs 28.3% for DBT, P < .0001). There was no significant difference between DM and DBT with regard to biopsy PPV (30.2% vs 23.8%, P = .21) or cancer detection rate per 1000 patients (5.4 vs 4.6, P = .44)., Conclusion: With DBT, the recall rate decreased and the biopsy PPV and cancer detection rate did not decrease. The distribution of recalled abnormalities changed, and more patients were evaluated with US only., (© RSNA, 2014.)

Women newly diagnosed with stage 1 breast cancer have an early-stage disease that can be effectively treated. Evidence provides little justification for performing imaging to exclude metastasis in asymptomatic women with stage I breast cancer. No differences have been found in survival or quality of life in women regardless of whether they underwent initial workup for metastatic disease. These women generally prefer intensive follow-up to detect an early recurrence. However, survival rates do not differ between women who obtain intensive screening and surveillance, with imaging and laboratory studies, and women who undergo testing only as a result of development of symptoms or findings on clinical examinations. In addition, quality of life is similar for women who undergo intensive surveillance compared with those who do not. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients. Additional imaging may be needed if the patient has locoregional symptoms. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review by the panel include extensive analysis of current medical literature from peer-reviewed journals and application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures. When evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to establish practice patterns of radiology residents in regards to interpretation and reporting of outside studies for transferred patients. We performed a national survey of radiology residency chief residents, administered by email through the Association of Program Directors in Radiology (APDR). There were 81 chief resident respondents, representing 42.8 % of 187 total Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency training programs in the USA. In 97.5 % of programs, residents perform interpretations of outside studies. Up to 76.7 % of respondents state that when outside studies are reviewed by residents, an original report is available in less than one quarter of cases. While 55.1 % of respondents state that there is a mechanism for recording their findings and impressions for outside studies, only 32.1 % are aware of a policy requiring documentation. Of the respondents, 42.3 % report they have no means for documenting their findings and impressions on outside studies. Further, 65.4 % state that there is no policy requiring an attending to review and document agreement with their interpretation of outside studies. There is wide institutional variation in both policy and practice regarding reinterpretation of outside studies for patients transferred to academic hospitals. While the majority of radiology residents are providing the service of reinterpreting outside studies, only a minority of residency programs have a policy requiring (1) documentation of their impressions or (2) attending oversight and documentation of discrepant opinions.

Objective: Digital breast tomosynthesis (DBT) has been shown to improve the sensitivity of screening mammography. DBT may have the most potential impact in cases of subtle mammographic findings such as architectural distortion (AD). The objective of our study was to determine whether DBT provides better visualization of AD than digital mammography (DM) and whether sensitivity for cancer detection is increased by the addition of DBT as it relates to cases of mammographically occult AD., Materials and Methods: Retrospective review of BI-RADS category 0 reports from 9982 screening DM examinations with adjunct DBT were searched for the term "architectural distortion" and were reviewed in consensus by three radiologists. ADs were classified by whether they were seen better on DM or DBT, were seen equally well on both, or were occult on either modality. The electronic medical record was reviewed to identify additional imaging studies, biopsy results, and surgical excision pathology results., Results: Review identified 26 cases of AD, 19 (73%) of which were seen only on the DBT images. Of the remaining seven ADs, six were seen better on DBT than DM. On diagnostic workup, nine lesions were assigned to BI-RADS category 4 or 5. Surgical pathology revealed two invasive carcinomas, two ductal carcinoma in situ lesions, three radial scars, and two lesions showing atypia. The cancer detection rate of DBT in mammographically occult AD was 21% (4/19). The positive predictive value of biopsy was 44%., Conclusion: DBT provides better visualization of AD than DM and identifies a subset of ADs that are occult on DM. Identification of additional ADs on DBT increases the cancer detection rate.

Purpose: To determine the frequency, malignancy rate, and imaging characteristics of BI-RADS (Breast Imaging Reporting and Data System) 3 MRI detected lesions., Materials and Methods: A total of 4370 consecutive contrast-enhanced breast MRI exams from March 1, 2004, to March 1, 2009, were retrospectively reviewed. The study was HIPAA (Health Insurance Portability Accountability Act) compliant and Institutional Review Board approved. The frequency of BI-RADS 3 MRI interpretations and lesion type, as well as malignancy rate at follow-up were calculated., Results: There were 348/4370 (8%) BI-RADS 3 exams performed on 345 patients. There were 125 foci (35.9%), 52 non-masslike enhancements (14.9%), and 171 masses (49.1%). There were 207 lesions with biopsy or imaging follow-up of at least 24 months (mean, 32 months; range, 6-77 months) of the BI-RADS 3 lesion. Five of these 207 (2.4%) lesions were found to be malignant., Conclusion: Rate of malignancy among BI-RADS 3 MRI exams with follow-up was 2.4%. Types of lesions assigned as probably benign were 35.9% foci, 14.9% non-masslike enhancements, and 49.1% masses., (Copyright © 2013 Wiley Periodicals, Inc.)

Purpose: To determine if changing from 1.5T to 3T breast magnetic resonance imaging (MRI) is associated with a change in BI-RADS categories, positive predictive value of biopsy recommendation, or cancer detection rates in high-risk screening breast MRI., Materials and Methods: Institutional Review Board (IRB) approval was obtained for this Health Insurance Portability and Accountability Act (HIPAA)-compatible retrospective review. Prior to October 2010, breast MRI was performed at 1.5T and after October 2010 breast MRI was performed at 3T. Reports of 495 consecutive screening 3T breast MRI exams from October 2010 through October 2011 were reviewed. Comparison was made to previously collected data on 650 screening breast MRI exams at 1.5T. Data were analyzed for statistical significance using the two-sample test of proportions., Results: There were 495 screening breast MRI exams. There were 419 (84.6%) BI-RADS 1/2 results, 35 (7.1%) BI-RADS 3 results, and 41 (8.3%) BI-RADS 4/5 results. BI-RADS 4/5 results increased at 3T (P=0.04). The positive predictive value for BI-RADS 4/5 was 29.3% (12/41) at 3T, compared with 17.6% at 1.5T (P<0.001). Cancer detection rate was 2.6% at 3T, compared with 0.9% at 1.5T (P=0.02)., Conclusion: Transition to 3T breast MRI in a screening population resulted in increased BI-RADS 4/5 interpretations, positive predictive value of biopsy recommendations, and cancer detection rate., (Copyright © 2013 Wiley Periodicals, Inc.)

Purpose: To determine whether the screening mammography recall rate for individual radiologists varies as a function of imaging site., Materials and Methods: Institutional review board-approved, HIPAA-compliant retrospective review of mammography audit data was performed between May 1, 2008, and September 1, 2011, for five radiologists with expertise in breast imaging interpreting mammograms at a community office practice and an academic referral hospital. Informed consent was waived. Both sites used full-field digital mammography and batch screening interpretation. Recall rates were calculated from audit data. Breast density, history of surgery or biopsy, and availability of prior mammograms were compared in a sample of 500 mammograms from each site by using χ(2) and two-sample t tests., Results: Radiologists interpreted a total of 74 297 screening mammograms between both sites during the study. The overall mean recall rate was 7.8% ± 0.2 (standard deviation). Overall recall rate at the community site was significantly lower than at the hospital site (6.9% ± 0.3 vs 8.6% ± 0.3, P < .001). Recall rates for each radiologist were also lower at the community site: 3.7% versus 6.5% (P < .001), 9.6% versus 12.0% (P < .001), 7.5% versus 9.1% (P = .01), 7.6% versus 11.5% (P < .001), and 5.6% versus 8.0% (P = .02). There was a significantly higher proportion of patients at the hospital site with a history of surgery (13.4% vs 5.6%, P < .001) and biopsy (7.0% vs 1.4%, P < .001) but no difference in the percentage with dense breasts or in the percentage with availability of prior mammograms. Mean patient age was lower at the hospital site: 56.1 versus 62.9 years (P < .001)., Conclusion: Recall rates were higher at the hospital site, probably primarily caused by patient population factors., (RSNA, 2013)

A palpable breast mass is one of the most common presenting features of breast carcinoma. However, the clinical features are frequently nonspecific. Imaging performed before biopsy is helpful in characterizing the nature of the mass. For women with clinically detected breast masses, the vast majority will require evaluation with ultrasound. Diagnostic mammography is the initial imaging modality of choice for women aged ≥ 40 years; ultrasound is typically necessary unless a definitively benign mass is identified as the etiology of the clinical finding. For evaluating women aged <30 years and women who are pregnant or lactating, ultrasound is used for initial evaluation. For women aged 30 to 39 years, either ultrasound or diagnostic mammography may be used for initial evaluation. MRI is rarely indicated to evaluate a clinically detected finding. Biopsy is indicated for masses with suspicious features. Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma. Correlation between imaging and the clinical finding is essential. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Medicare is the primary source of funding for graduate medical education (GME) in the United States. The growing deficit, a sluggish economy, and rising health care costs have focused attention on cutting spending, and GME reimbursement from Medicare is being considered among the entitlement programs for spending reduction. At the same time, health care reform will place new demands on residency training. The authors review the history of GME financing, the potential impact of GME spending cuts and health care reform on radiology training, and the new skills residents will need to practice in the era of health reform. As health care financing evolves, so must resident education., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)