乳腺影像报告系统
筛查的目的是尽早发现有可能被治愈的乳腺癌，以减少死亡。虽然有些女性患乳腺癌的风险较高，但是每年患乳腺癌的女性中，绝大多数（约75%）患者没有已知的风险升高因素。随机对照试验（RCT）已经明确证明：早期检测可以减少40-74岁普通女性人群（参与RCT的女性年龄）的乳腺癌死亡。因此， 40-74岁的女性至少每年接受乳腺癌筛查以减少死亡。由于大量女性需要筛查，筛查必须高效且有效，这样可以使得每次筛查在15分钟或更短的时间内完成。对女性进行乳腺癌筛查不仅仅是简单的行动，了解筛查人群也很重要。比如识别可能处于高风险的女性，因为她们可能受益于使用超声或MRI的补充筛查。乳腺癌筛查也不是孤立的行动，对接受筛查的女性要进行跟踪随访，使得那些需要召回进行额外检查的女性得到明确评估。对所有参与筛查的工作人员来说，都需要根据临床结果进行学习，以确保筛查案例被正确拍摄和准确判读，并在必要时做出改进。
一个高质量的筛查项目应该是高度组织化的。时间安排、接待、患者护理、筛查以及筛查结果的解读等这些环节都应该进行周到的协调。筛查的最终报告应该是高度结构化的，以便将结果清楚地传达给患者和她的医生，从而可以进行适当的临床处理和随访。
患者信息是检查的组成部分
对筛查人群进行信息统计是筛查流程的其中一个环节。开始时，所有病人都要填写一份打印版表格，其中包括与她们的乳房健康有关的信息。这些数据随后被录入病人的电脑档案。任何乳房不适的情况都会被识别以确定病人是否需要进行诊断检查，而不仅仅是常规筛查。患者的年龄，是否绝经，是否有乳腺癌病史，活检，手术史都应该记录下来并了解清楚。后来，我们用平板电脑取代了打印版的调查问卷，女性用平板电脑更加方便地回答病史相关的问题，这样所有记录的人口统计信息就可以直接归纳到患者档案里，方便放射科医生在电脑上了解更多的研究信息。
充分培训放射技师更好地使用优质设备
筛查检查必须是高质量的，其中，乳腺X射线摄影是筛查的重要环节。用于筛查的乳腺X射线摄影系统设计应以获得最佳质量图像为首要原则，因为这是大多数女性发现早期乳腺癌的唯一机会。乳腺摆位也很重要，尽可能将尽量多的乳腺腺体置于成像视野中。负责摆位的放射技师必须经过充分的专业培训，以确保每次筛查都可以获得最多的腺体组织的影像。乳腺癌可能发生于存在腺体的任何位置，如果乳房没有完全位于系统的成像视野中，癌症就可能会被漏掉。当然，对乳腺X射线摄影影像的准确解读同样至关重要，对大多数女性而言，它是发现可治愈阶段的乳腺癌的唯一机会。
生成报告
筛查检查完成后，放射科医生需要完成评估并出具一份简洁的报告来准确、清晰且完整地说明检查结果。强烈重申一下：筛查需要高度组织化，影像解读结果需要保留在每个女性的记录中。理想情况下，应设立一个跟踪、回访受检者个人资料的系统，以上信息都应该是该系统的一部分。如果她有需要额外评估的发现，系统应该根据时间节点通知并确定她进行了检查并记录结果。最终，系统应该跟踪每个女性，通过收集结果数据，放射科医生可以确定其分析的准确性， 并在有需要时对筛查进行改进。
我们开发了一个计算机化的报告系统，以便于结果解读并生成准确报告。这样的目标是将放射科医生用于阅片的时间最大限度延长，用于出具报告的时间最大限度减少。我们的系统使用简单的代码，只需医生花很少的时间在电脑中输入，计算机会自动生成一个对所有发现进行完整描述的报告，报告可以发送给患者的临床医生，也可以同时给每位女性提供一份使用非专业术语的通俗易懂的报告。
Dr. Tabar开发了一个系统，他查看图像后会告诉助手，写明检查结果是阴性还是需要患者召回进行额外评估，这是最简单和有效的筛查报告方法。我们更倾向于采用一种稍微详细的方法，让放射科医生使用计算机生成报告，同时记录检查相关的信息，最终形成数据库，可以使得我们对报告的解读进行详细的分析，最终的目的是随着时间的推移改善我们的服务。
基于计算机的报告系统
我们使用相同的数据库进行筛查和诊断性研究，但用不同的代码予以区分， 代码示例如下所示。
有几个字段是依据患者对平板电脑上问题的解答自动生成的，代码减少了出现在报告屏幕上的杂乱无章的内容。
1.检查原因
a. S=筛查
b. L=患者有肿块
c. D=患者有分泌物
d. R=筛查后召回
2.绝经状态
a. U=绝经前
b. Q=绝经后
然后，放射科医生补充相关信息：
3.对比相关代码
a. C=与历史检查做了对比
b. N=无可比较的历史检查
c. O=与外部检查做了对比
d. M=历史检查缺失
e. T=正在尝试获取外部检查的历史信息，如获得，会与此次检查进行对比后出具一份新的报告
4. 腺体组织类型代码（可以用BI-RADS ABCD代替）
a. 乳腺内几乎全部是脂肪组织
b. 乳腺组织是脂肪，有散在纤维腺体密度区域
c. 乳腺组织不均匀致密，乳腺X射线摄影敏感性降低
d. 乳腺组织极其致密，乳腺X射线摄影敏感性降低
使用这些简单的代码和BI-RADS分类最终评估构建一份完整的报告。放射科医生只需在计算机内输入这组简单的代码：
“C 1 NEG”
这会生成一份完整报告：与历史检查进行了对比。乳腺内几乎都是脂肪组织。未见明显肿块或者成簇微小钙化。乳腺X射线摄影检查未见明显恶性肿瘤征象。
结论：
乳腺X射线摄影检查未见恶性肿瘤征象
BI-RADS 1：阴性
系统还支持创建有多个发现的更复杂的报告。大多数的报告只需6次点击就可以完成。
例如，如果在筛查中发现了成簇钙化并需要进行额外的评估时，则代码是：
- NAE（需要进行额外评估）
- R,L,or B（右侧，左侧，两侧）
- C(发现钙化)
- M(需要进行放大摄影)
代码NAELCM生成的报告是左侧乳房有成簇钙化，良性可能，建议使用放大摄影做进一步检查。
结论：
如上所述，左乳钙化，需要进一步评估
BI-RADS分类 0：不完全评估，需要额外评估
可以对代码进行组织，以便当患者被要求召回进行额外评估时，触发计算机程序，将患者归纳入随访系统，来确保患者返回并解决这些问题。
系统里的多个模块都是相互关联的，形成一个对所有患者进行持续跟踪的数据库。如果患者最后进行了活检，病理结果也会被跟踪，这样数据库里就有了从筛查到诊断到病理的完整记录，甚至可以与治疗方法和结果关联起来。
我强烈敦促对报告实行综合管理，通过数据库，我们可以监测筛查的结果，通过对筛查结果的分析，可以从多层面提升临床水平。
中英翻译
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.
