ZGBREAST IMAGING REPORTING SYSTEM

The goal of screening is to detect breast cancers early at a time when cure is possible in an effort to reduce deaths.  Although there are women who are at increased risk of developing breast cancer, the vast majority (approximately 75%) of women who develop breast cancer each year have no known elevators of risk.The randomized, controlled trials (RCT’s) have proven with certainty that early detection reduces deaths for women in the general population ages 40-74 (the ages of women who participated in the RCT’s).Consequently, all women ages 40-74 (at least) need to be screened each year to reduce deaths. Since large numbers of women need to be screened efficiently and effectively, screening programs need to be well organized so that each examination can be completed in 15 minutes or less.  It is not simply a matter of screening women, but it is also important to understand the population being screened.  For example, it is important to identify women who might be at elevated risk since they may benefit from additional screening using ultrasound or MRI. Examinations should not exist in a vacuum. The women being screened need to be followed to be certain that women who need additional evaluation receive that evaluation. It is also critical for those who are performing the screens to learn from the outcomes of their patients. All those involved in providing screening need to learn from the outcomes to determine insure that the screening study was performed properly and interpreted accurately and to learn from the results and make changes where needed.

A quality screening program should be highly organized.  Scheduling, reception, patient care, the study itself, and the interpretation of the study should be thoughtfully coordinated.  The ultimate reporting of the study should be highly structured so that the results are clear and are clearly conveyed to the patient and her doctor so that appropriate care and follow-up can take place.  

PATIENT INFORMATION IS PART OF ANY EXAMINATION

The demographics of those being screened is part of this process.  We began with a printed form that all our patients filled out that included information that was pertinent for their breast health.  These data were then incorporated into the patient’s computer file.  Any breast complaints were identified to determine if the patient actually needed a diagnostic study and not just a routine screen.  Clearly the age of the patient should be recorded along with her menopausal (pre or post) status.  Any previous history of breast cancer clearly needs to be known as well as any previous biopsies or surgery.  Recording all the demographic information and incorporating it into the patient's file was facilitated when we replaced the printed questionnaire and provided each woman with a computer tablet that she used to answer questions about her history.  Pertinent information then went directly into her file so that it could be provided to the radiologist interpreting the study on the computer reporting screen.

TECHNOLOGISTS NEED TO BE HIGHLY TRAINED TO USE THE BEST EQUIPMENT

Since the actual mammogram is the critical event, the screening examination must be the highest quality. Mammography systems used for screening should be designed to obtain the best images since this is the only chance that most women will have to have their cancers detected early.  Positioning the breast is also critical to maximize the tissues included on the examination. Technologists who perform the studies must be highly trained to ensure that they maximize the amount of tissue obtained with each study since breast cancers can occur anywhere there is breast tissue and cancers can be missed if the breast is not fully positioned in the field of view of the system.  Obviously, the accurate interpretation of a mammography screening examination is critical.  It is the only chance for most women to have their breast cancer detected at a time when cure is possible.  

GENERATING A REPORT

Once the examination has been obtained and evaluated by the radiologist a succinct report is needed to accurately convey the results of the examination clearly and completely.  Again, it is strongly urged that screening be highly organized and that the interpretation of the studies become part of each woman’s record.  Ideally this should all be part of a system that tracks each patient and follows up on her course.  If she has findings that require additional evaluation the system should check over time to be certain that follow-up occurred and what were the results.  Ultimately, the system should track each woman and by collecting outcomes data, the radiologists can determine the accuracy of their analyses and can make improvements in screening where needed.

In order to facilitate the interpretation of the studies and the generation of accurate reports, we developed a computerized reporting system.  The goal was to maximize the time spent by the radiologist looking at the images, and minimize the time spent generating the report.  Our system used simple codes that took little time to enter into the computer, but the computer could then generate a full description of any findings that could be sent to the patient’s physician.  The computer could, simultaneously, provide each woman with a report using lay terminology.

Dr. Tabar had developed a system where he looked at the images and, essentially instructed an assistant that the study was either negative or that the patient needed to be recalled for additional evaluation.  This is the simplest and most efficient method for reporting screening studies.  We preferred a slightly more detailed approach that has the radiologist using a computer to generate the report while at the same time recording fundamental information about the examination that formed a database that allowed us to perform detailed analyses of our interpretations with the ultimate goal of improving our services over time.  

COMPUTER BASED REPORTING SYSTEM

We used the same database for our screening and diagnostic studies, but developed codes that distinguished each. A sampling of the codes is listed below.

There were several fields that were automatically generated based on the patients responses to questions on the tablet. Codes reduce the amount of clutter that appears on the reporting screen.

1. Reason for the Study

a. S = Screening

b. L = Patient has a lump

c. D = Patient has a discharge

d. R = Recall from screening

2. Menopausal status

a. U = Premenopausal

b. Q = Post menopausal

The radiologist then adds the appropriate information:

3. Compare related codes

a. C= Comparison is made to the previous examinations.

b.  N=There are no previous studies for comparison.

c. O=Comparison is made to outside examinations.

d. M=The previous studies are missing.

e. T=We are trying to obtain previous outside studies.  If these can be obtained they will be compared to the present examination and an addendum will be issued.

4. Tissue pattern codes (BI-RADS letter A,B,C,D can be substituted)

a. The breast tissues are almost entirely fat.

b. The breast tissues are fat with are scattered fibroglandular densities.

c. The breast tissues are heterogeneously dense.  This somewhat lowers the sensitivity of mammography.

d. The breast tissues are extremely dense.  This somewhat lowers the sensitivity of mammography.

A full report can be constructed using these simple codes complete with a BI-RADS final assessment.  The radiologist puts in a simple set of codes into the computer:

“C   1  NEG”

This produces a full report:

“Comparison is made to the previous examinations. The breast tissues are almost entirely fat.  No masses or clustered microcalcifications are evident. There is no mammographic evidence of malignancy.

CONCLUSION:  

There is no mammographic evidence of malignancy.

BIRADS CATEGORY 1:Negative Examination.

The system also can be used to construct more complex reports with multiple findings. The majority of reports can be constructed with just 6 keystrokes.

For example: If a group of calcifications is detected on a screening examination, and additional evaluation is needed the codes are:

-NAE (for Needs additional evaluation)

-R, L, or B (for right side, left side, or both sides)

-C (for the finding of calcifications)

-M (for magnification mammography is needed)

Thus the code NAELCM produces a report that says:There is a group of calcifications in the left breast that, although likely benign, require further investigation. Magnification views are suggested.

CONCLUSION:  

Calcifications in the left breast that warrant additional evaluation as noted.  

BI-RADS CATEGORY 0: Incomplete – Additional evaluation is needed.

The codes can be organized so that when a patient is requested to return for additional evaluation, a computer routine is triggered to enter the patient into a follow-up system to ensure that she returns and the issues are resolved.

The system has multiple modules that are all linked.  This produces a database that tracks all patients. If a patient ultimately has a biopsy, the pathology results are also tracked so that the database has a complete accounting from screening through diagnosis to pathology and can even be linked to the types of therapy and outcomes.

From these databases, the results from screening can be monitored. Analysis of the results can lead to improvements in care at multiple levels.An integrated reporting system is strongly urged.