The Member Newsletter of the Society of Breast Imaging 2016 ISSUE 3

Mother lion and cubs captured by Mike Linver while on safari in South Africa following the first joint conference of the Society of Breast Imaging, Radiological Society of South Africa, and the Breast Imaging Society of South Africa on May 5-8, 2016.

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Editor’s Note

Peter R. Eby, MD, FSBI

B urnout and fatigue for radiologists and all physicians have received significant attention lately.1 Many leaders from various specialties advise cultural adjustments to promote physician wellness as much as

we promote patient wellness. Numerous habits and priorities can either support or erode our job satisfaction and performance. Technology, for example, provides tremendous opportunities to enhance our lives and connections with people through live text and chat as well as quick email and photo sharing via social media. While these advancements seem miraculous, and sometimes are, new research suggests that electronic engagement can also undermine our happiness.2,3 Some technology may facilitate seemingly efficient and helpful multitasking that in reality is slowly eating away at the time we spend with others face to face. We must remember that individual interactions with our patients generate tremendous value for them as well as for us.

When we discuss and defend screening mammography we talk about large groups of women participating in randomized controlled trials conducted across some vast geographical regions. The numbers are large, as required by scientific protocol, to demonstrate significant effect. The very first randomized controlled trial from the Health Insurance Plan of New York enrolled 62,000 women split into the control and experimental cohorts.4 The follow-up periods are also vast, stretching across decades. The Swedish two-county trial has published a 29-year follow-up and the Canadian National Breast Screening Study has reached 25 years.5,6 The upshot of these data are a solid foundation supporting screening mammography built on the experiences of hundreds of thousands of women over decades of follow-up spread across multiple continents.

The Cancer Intervention and Surveillance Modeling Network (CISNET) models, revered by the US Preventive Services Task Force, rely upon extensive population data to illustrate expected effects of screening. These models are in turn informed by additional large databases such as the Breast Cancer Surveillance Consortium and the Surveillance Epidemiology and End Results system for monitoring cancer incidence and mortality.

And yet we do not necessarily get out of bed each day to contribute to an anonymous knowledge base. The reality is in fact the opposite. We walk, bus, train, drive, cycle, ferry, and even paddle to work every day because there may be a mammogram in the pile bearing a clue that could change the life of 1 individual woman. That opportunity and that privilege are the reasons why we do what we do. So while the impersonal data support our mission, the very personal interactions give it meaning. This issue of the SBI newsletter has articles that cover both.

Beth Burnside, MD, MPH, MS, FSBI, describes how she worked within the CISNET group to provide the critical perspective and voice of radiology—she brought her personal experience to bear upon a massive anonymous database. At the population level of large data, the next article in our series from the Screening Leadership Group shines a critical eye on the Cochrane Review that dismissed nearly

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all the randomized controlled trials supporting mammography. We also begin a new series of articles on the National Mammography Database (NMD). The first, by Bhavika Patel, MD, and Cindy S. Lee, MD, describes the NMD and why we should all join.

At the individual level we have stories from members of the SBI that aren’t about patients but are rather about their unique personal experiences related to their avocation as breast imagers. Michelle Rivera, MD, created a movement to save screening with her laptop and Facebook. Perhaps you have heard of “American Women Unite for Breast Cancer Screening.” She tells us how she did it. Stephen Feig, MD, FSBI, guides us along the lifelong journey and motivation of Gerald Dodd, MD, from young doctor to champion of screening mammography. Ann Brown, MD, has interviewed Etta Pisano MD, FACR, FSBI for our series called What I’ve Learned. Mike Linver, MD, FACR, FSBI, relates the recent collaboration between the SBI, the Radiological Society of South Africa, and the Breast Imaging Society of South Africa, proving that getting on an airplane and crossing to another hemisphere can bring us closer to each other (and to elephants) than hours and hours of Skype.

These articles remind us that technology is a double-edged sword. While it may contribute to burnout if uncontrolled, it can also be helpful. We value the technology and data and all those dedicated scientists contributing to them to support our field. We also find value in social media campaigns that, when carefully crafted and striking a simple common theme, can unite people for good. And most importantly, these stories remind us that individuals and our interactions with them are the best reasons to do what we do and provide heartfelt satisfaction, recharge our souls, and alter lives of our patients for the better.

Do you have a story you would like to share? I’d love to hear it. Send me an email at peter.eby@virginiamason.org or, if it can wait, find me at the next meeting and tell me face-to-face! I’ll buy the coffee or beer.

REFERENCES

1. Peckham C. Medscape lifestyle report 2016: bias and burnout. Medscape website. http://www.staging.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=1. Published January 13, 2016. Accessed July 12, 2016.

2. Green M. Mayo study links EHRs with physician burnout. Becker’s Health IT & CIO Review website. http://www.beckershospitalreview.com/healthcare-information-technology/mayo-study-links-ehrs-with-physician-burnout.html. Published June 28, 2016. Accessed July 12, 2016.

3. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-848.

4. Strax P, Venet L, Shapiro S. Value of mammography in reduction of mortality from breast cancer in mass screening. Am J Roentgenol Radium Ther Nucl Med. 1973;117(3):686-689.

5. Tabár L, Vitak B, Chen TH, et al. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 2011;260(3):658-663.

6. Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014;348:g366.

Editor’s Note, continued from previous page

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Chief Editor:

Peter R. Eby, MD, FSBI

Assistant Editor:

Shadi A. Shakeri, MD

SBI Newsletter Committee:

Ann M. Brown, MD

Annie Ko, MD

Jiyon Lee, MD

Jessica W. T. Leung, MD, FACR, FSBI

Michael N. Linver, MD, FACR, FSBI

Vilert Loving, MD

Louise C. Miller, RT(R)(M)

Elizabeth A. Morris, MD, FACR, FSBI

Robert Nishikawa, PhD, FSBI

Liane Philpotts, MD, FSBI

Christine Puciato, RT(R)(M)(BS)

Shadi A. Shakeri, MD

Margarita L. Zuley, MD, FACR, FSBI

Graphic Design: Graphic Design Associates, Inc.

Table of Contents2 | President’s Column: Shaping Our FutureBy Elizabeth A. Morris, MD, FACR, FSBI

4 | First SBI Joint International Conference a Resounding Success!By Michael N. Linver, MD, FACR, FSBI

6 | Critical Review of the Cochrane Collaboration Assessment of Screening Mammography By Jocelyn Rapelyea, MD, FSBI; Peter R. Eby, MD, FSBI; and the Screening Leadership Group

10 | The Story of “American Women Unite for Breast Cancer Screening”By Michelle L. Rivera, MD

12 | In Memoriam Gerald D. Dodd, Jr., MD (1922-2015) 1995 Gold Medalist: Champion of Screening MammographyBy Stephen A. Feig, MD, FSBI

22 | The Future of Breast Magnetic Resonance ImagingBy Gillian Newstead, MD

25 | Reaching Across the Disciplinary DivideBy Elizabeth S. Burnside, MD, MPH, MS, FSBI

27 | The National Mammography Database: What It Is and Why You Should JoinBy Bhavika Patel, MD, and Cindy S. Lee, MD

31 | A Technologist’s Perspective of the FDA Report “Poor Positioning Responsible for Most Clinical Image Deficiencies, Failures”By Louise Miller, RT(R)(M)

34 | Breast Density Websites: Where to Send Your Patients and Referring Providers for InformationBy Jennifer Harvey, MD, FACR, FSBI

37 | Highlights of the 13th International Workshop on Breast ImagingBy Robert M. Nishikawa, PhD, FSBI

40 | New ACR Digital Mammography Quality Control Manual Now Available By Priscilla Butler, MS, FACR, FSBI

44 | What I’ve Learned: Etta Pisano, MD, FACR, FSBIBy Ann L. Brown, MD

48 | Interesting Case: Differentiating Male Breast Cancer From Nodular GynecomastiaBy Anika L. McGrath, MD; Habib Rahbar, MD, FSBI; Diana L. Lam, MD

52 | Upcoming Events

Copyright 2016. Society of Breast Imaging.

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President’s Column: Shaping Our Future By Elizabeth A. Morris, MD, FACR, FSBI

W hen I joined the SBI board 5 years ago I could not imagine how the SBI could change so dramatically to become what it is today. Many new initiatives, members, committees, and volunteers have allowed

us to grow to a vibrant and dynamic society, reaching beyond our borders to become the global voice for breast imaging. Five years ago, the board met and set goals for the society. Needless to say, we have met all of those goals and more. It is time to make new goals, and this year the board will meet again to develop strategic goals for our future. With that in mind, I will focus this column on looking forward to the next 10 years. Additionally, as we head into autumn with a presidential election in sight, addressing the political seems unavoidable.

I strongly believe that our future is dependent on our people. By that I mean not only our SBI members, board, and patients, but also our staff. As the president’s term starting next year will be curtailed to a short 1 year, it will be important for our superb SBI staff to be the keepers and bearers of our mission. Luckily, our executive director, Yasmeen Fields, is more than capable and will confidently lead us into the future with a calm hand. Regarding our patients, I was heartened to receive many responses after my last column about putting a face on breast imaging from so many people who wanted to do something. Our members amaze me in their willingness to volunteer to make a difference, like John Lewin, MD, FACR, FSBI, who is looking into having us write our own orders. I am happy to say we have finalized 2 new SBI task forces to address some of these issues: the Breast Imaging Quality and Value Task Force, chaired by Wendy DeMartini, MD, FSBI, and the Patient Care and Delivery Task Force, chaired by Toula Destounis, MD, FACR, FSBI. Both of these task forces have been populated with passionate expert members who are thought leaders about how to elevate our current practice and prepare us for the future. We are hoping that small groups of people can tackle issues they are excited about. The task forces can act as platforms to sound out ideas and develop white papers, statements, guidelines, research projects, etc, that can be promoted by SBI. We have such depth in our society with respect to individual expertise that we hope that by bringing together the expertise in a group, we can effect change more quickly and strengthen our future. We are the strongest together.

Another area in which we are moving to ensure our future is to develop an SBI Research and Education Fund. We have successfully launched Ellen’s Fund, which will support our future by providing stipends to the annual SBI/American College of Radiology Symposium for residents and fellows to present their research. Ellen Shaw de Paredes, MD, FACR, FSBI, was absolutely passionate about resident and fellow education. We are deeply grateful to be able to honor her legacy and offer these awards to ensure the success of our academic stars of tomorrow. Please consider contributing

Elizabeth A. Morris, MD, FACR, FSBI

President, Society of Breast Imaging

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to these efforts. We are lucky to have Phan Huynh, MD, FACR, FSBI, expertly leading us in this endeavor. He will be working closely with Yasmeen to develop the research and education fund over the next year, so stay tuned. Having our own fund will allow us to invest in our future, inspire our young trainees, and elevate our specialty with innovation and research. Speaking about our members in training, I am positively thrilled about the fellowship match that we will offer our residents entering breast imaging. This was truly a team effort, with many involved parties led by Gary Whitman, MD, FACR, FSBI, and a very organized Holly Suthers (Project Coordinator for the SBI), who surprised all of us with her tenacity and perseverance. Good job all around. We are at our best working in teams.

Last, I would like to talk about the politics of inclusion. Over the past few years the SBI has relaxed membership requirements to become a more international and multidisciplinary society including both radiologists and practitioners of other disciplines. We have seen our membership grow, particularly our members in training and our international members. Those looking in from the outside are no longer seeing the barriers. This is progress, as diversity in our membership will only make us stronger. By diversity I mean anything that is “other.” So reaching out to people who have different backgrounds, cultures, and ideas can only make us better. This means understanding that each individual is unique and that by including different opinions we learn and grow. We will die if we succumb to being an island and don’t diversify. With that in mind, we have made new connecting bridges with other countries and societies through our international efforts. These relationships are important to us and will continue to be in the future. As we are putting a face on breast imaging worldwide, we model what it is like to be inclusive and respectful of our imaging colleagues throughout the world. The response from the membership regarding our international efforts has been overwhelming and demonstrates that this is a very popular initiative. We are working on expanding the scope of the committee, so there is more to come on that. We have also worked hard at making our SBI committee structure open, transparent, and inclusive. We welcome all those who want to volunteer. There should be no marginalized groups. We are open to all ideas. We want you.

Looking into the future in 10 years, it is my hope that the SBI will be the society everyone involved in breast health care wants to join. By then the SBI will have conquered the 3 pillars: patient health care delivery, education, and research. It will be the home of many vibrant, inclusive teams respectfully working together. The members will be enthusiastic and respectfully engaged in collaboration with ideas and people that are “other.” Nobody achieves success alone. Let’s dream about the future successes of the SBI together.

Elizabeth A. Morris, MD, FACR, FSBI

President, Society of Breast Imaging

President’s Column, continued from previous page

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O n May 5-8, 2016, in the wine region of Stellenbosch, South Africa, a contingent of speakers from the SBI joined a similar group from the Radiological Society of South Africa and the Breast Imaging Society of

South Africa for the first collaborative breast imaging conference cosponsored by SBI with an international partner. Over 250 radiologists and technologists from all over South Africa, and some as far away as Israel and Egypt, were treated to 3 days of superb didactic sessions, as well as a preconference day of hands-on ultrasound biopsy workshops. I had the privilege of heading our SBI team of Wendy DeMartini, MD, FSBI; Jessica Leung, MD, FACR, FSBI; Reni Butler, MD; and Maxine Jochelson, MD, FSBI, with each of us presenting 6 lectures on a wide variety of subjects. We covered the basics as well as cutting-edge material on contrast mammography, molecular breast imaging, whole-breast ultrasound, tomosynthesis, and breast magnetic resonance imaging, among others. We in turn were treated to lectures on many subjects unique to the South African populace, including breast manifestations of human immunodeficiency virus and tuberculosis, as well as talks by experts in our sister specialties of surgery, oncology, pathology, and even bioethics!

Paleoanthropologist Lee Berger, the husband of one of the local speakers, gave us a special treat. He presented a talk on his discovery of a treasure trove of skeletons of Homo naledi, a new species that may be our oldest relative, near Johannesburg 3 years ago. His talk took us literally into another world, as it has for many others. He was earmarked last month by TIME Magazine as one of the 100 most influential people in the world (strangely, no one from SBI made the list!). It was a truly scintillating session!

The international flavor of the conference rubbed off on us all.

First SBI Joint International Conference a Resounding Success! By Michael N. Linver, MD, FACR, FSBI

Michael N. Linver, MD, FACR, FSBI

Back row, left to right: Maxine Jochelson, Reni Butler, Christelle Snyman (Breast Imaging Society of South Africa conference manager), conference staff member, Mike Linver. Front row, left to right: Jessica Leung and Wendy DeMartini.

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We were inundated by appreciative attendees from a host of backgrounds, eager to share their own stories with us and at the same time thanking us again and again for our contributions. The conference co-chairs, Leon von Rensburg and Eugene Jooste, were extremely gracious and hospitable, treating us to 2 delightful dinners and commodious accommodations at the Spier Estate, the conference site. They also expressed their sincere appreciation for our efforts and were genuinely pleased with the conference overall. We all left Stellenbosch surrounded by the warm glow of gratitude and friendship from our newfound colleagues in arms.

For 3 of us on the SBI faculty, that was just the beginning of our South African adventure. We were joined by Yasmeen Fields, executive director of SBI, who came to promote SBI among the conference attendees, as well as spouses and a few other friends, on a trip to the game reserves in and around Kruger National Park. Over the course of the next 4 days, we were privileged to partake of game drives to view the most wondrous wildlife in the world: prides of lions, elephant herds, leopards, rhinos, crocs (not the kind on your feet), hippos, and even a spitting cobra (we didn’t get too close)! We were spellbound, but somehow I still managed to snap about 3000 photos (those who know me well will understand). It was an experience of a lifetime.

As we departed South Africa, we all had the same magical feeling that we had taken SBI into a new era of international involvement and that this would be the first of many such endeavors. SBI has already been approached by breast imaging societies in at least 4 other countries to sponsor similar joint conferences. The breast imaging world is indeed changing at lightning speed and we should be so proud that SBI has now broadened its net in bringing these changes to countless others beyond our borders!

First SBI Joint International Conference a Resounding Success!, continued from previous page

Pictured left to right: Waishan Leung (Jessica’s sister), Jessica Leung, Michael White (Reni’s husband), Reni Butler, Mina Jo Linver (Mike’s wife), and Mike Linver.

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In a series of papers published from the Nordic branch of the Cochrane Collaboration, 2 authors, Gøtzsche and Olsen, conclude that mammography does not save lives but instead exposes women to

unnecessary surgical procedures.1, 2, 3, 4 The summary is also provided at the website (http://www.cochrane.org/CD001877/BREASTCA_screening-for-breast-cancer-with-mammography). This conclusion was based on a meta-analysis of 2 of the 8 randomized control trials (RCTs) of screening mammography. Six of the 8 studies, most of which found a significant benefit from mammography, were discounted by the authors. The remaining 2 studies, the Canadian National Breast Screening Study (CNBSS) and the Malmö trial, were judged by Gøtzsche and Olsen to have appropriate randomization and became the basis for their conclusions. The methods of Gøtzsche and Olsen should be carefully considered before adopting their results and modifying practice patterns. Limitations include the exclusion of valid studies, use of all-cause mortality to assess the effect of mammography, and inclusion of the CNBSS trial.

Many of the exclusions were based on misunderstandings of the study design. For example, Gøtzsche and Olsen dismissed the results of one of the earlier trials, New York Health Insurance Plan,1 secondary to a perceived differential exclusion of breast cancer cases in the screening group, pointing to the noticeably smaller study group population compared to the control group. However, the evidence published by Shapiro et al5 shows that exclusions were made in a balanced manner done per protocol as the study progressed.

Second, Gøtzsche and Olsen based their conclusions on the effect of screening mammography on all-cause mortality instead of breast cancer–specific mortality. None of the RCTs were designed to test a decrease in all-cause mortality. It has been estimated that to assess the benefit of screening using an all-cause mortality approach would require a trial involving more than 2.5 million women since most

Critical Review of the Cochrane Collaboration Assessment of Screening Mammography By Jocelyn Rapelyea, MD, FSBI; Peter R. Eby, MD, FSBI; and the Screening Leadership Group

Jocelyn Rapelyea, MD, FSBI

Peter R. Eby, MD, FSBI

The SBI is publishing a series of articles across multiple newsletters that summarize critical aspects of the scientific data related to screening mammography. Recognizing the constant barrage against screening, these short pieces provide concise and pivotal information. Our hope is that anyone—technologist, radiologist, sonographer—can employ these data to support screening and refute detractors. The summaries were written by members of the first class of the SBI Screening Leadership Group and reviewed and edited by the instructors. For a complete description of the Group, its inception, and its members, please see the article written by Debra Monticciolo, MD, FACR, FSBI, in the third issue of the 2015 newsletter. Visit https://www.sbi-online.org/RESOURCES/BreastScreeningLeadershipGroupResources.aspx to find the archived articles on the website.

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Critical Review of the Cochrane Collaboration Assessment of Screening Mammography, continued from previous page

women being screened do not have the disease and dying of the disease is a rare event. Although the 2 authors of the Cochrane review acknowledged that the trials were underpowered for all-cause mortality, Gøtzsche and Olsen conclude that “the reliable evidence does not indicate any survival benefit for mass screening for breast cancer.”2 This is not surprising since breast cancer accounts for less than 1% of all deaths worldwide.6 In addition, all RCTs evaluate the effect of invitation to screen rather than the screening itself. Inevitably some women will decline the invitation to screening, yet they will be counted in the experimental group to control selection bias. In effect, this further dilutes the impact of screening. For these reasons, all randomized screening trials use breast cancer–specific mortality as the end point.

Gøtzsche and Olsen judged CNBSS, a randomized study that reported no benefit from the invitation to breast screening, as having appropriate randomization and good quality. Of the 8 RCTs of screening mammography, only the CNBSS failed to demonstrate a benefit and conclude that screening is not a recommended practice (Figure 1).7 However, the CNBSS study has received a significant amount of criticism not only for inadequate randomization but also for poor-quality mammography.8,9,10,11,12 Indeed, the lead author of the CNBSS reported that screening mammography examinations were satisfactory for only 49% to 60% of cases through the first 4 years.13 Furthermore, as part of the design in the CNBSS trial, women received a clinical breast examination prior to randomization. When utilized in this manner, this initial examination may have introduced bias in the distribution of women to each arm of the trial. The data show an imbalance of 19 advanced cancers in the screening arm vs 5 in the control arm at the outset of the trial enrolling 40- to 49-year-old women. The authors felt that this approach was “not likely to have had a major influence”; however, an independent review referencing

Figure 1. Forest plot of the randomized controlled trials (RCTs) of screening mammography. The majority of RCTs reported a significant decrease in the relative risk of dying from breast cancer from an invitation to screening. The Canadian National Breast Screening Study of 40- to 49-year-olds (Canada I) and 50- to 59-year-olds (Canada II) are outliers that did not indicate a benefit. Including these 2 studies in the meta-analysis still indicates a 20% reduction in mortality for women invited to screening.7

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this imbalance finds it to be statistically significant and inconsistent with other RCTs of breast screening.14

The more recent Cochrane reviews15,16 focused on the CNBSS, Malmö, and UK Age trials as the only “adequately randomized” trials and found the absolute risk of breast cancer death in the control groups to be only 0.33%.17 However, this low death rate was due to the inclusion of the large UK Age trial, which included a younger group of women aged 39 to 41 years old. Findings suggest that 2000 women would need to be invited to screening to prevent 1 breast cancer death. The number needed to invite is very different from the number of women actually screened. As mentioned previously, women in the screening arm may refuse to undergo testing, thus diluting the effect of mammographic screening. Results from other trials (Swedish Two County) indicate that only 113 women need to be screened to prevent 1 breast cancer death.18

The Nordic Cochrane Collection 2012 review was updated to state that advances in diagnosis and treatment make mammography screening less effective today and conclude that it “no longer seems reasonable to attend” breast screening. Indeed, advancements in screening would be fruitless without effective treatment. Screening detects cancer earlier, making it possible to find small breast cancers before they metastasize, which improves survival while reducing the need for mastectomy, lymph node dissection, chemotherapy, and other imaging studies. This is consistent with the 20% reduction in mortality observed in the totality of evidence across all the randomized screening trials in women invited to screening compared to the group not invited to screening.

In summary, the Cochrane review receives disproportionate attention as a collective analysis of scientific data related to screening. However, we need only to remind ourselves and other providers that the Cochrane methods exclude nearly all RCTs showing a benefit from screening while retaining the CNBSS—an outlier result based on flawed execution.

REFERENCES

1. Gøtzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet. 2000;355(9198):129-134.

2. Olsen O, Gøtzsche PC. Cochrane review on screening for breast cancer with mammography. Lancet. 2001;358(9290):1340-1342.

3. Olsen O, Gøtzsche PC. Screening for breast cancer with mammography (Cochrane Review). Oxford: Update Software. The Cochrane Library, Issue 4; 2001.

4. Olsen O, Gøtzsche PC. Systematic Review of Screening for Breast Cancer with Mammography. 2001. http://image.thelancet.com/extras/fullreport.pdf

5. Shapiro S, Venet W, Strax P, Venet L. Periodic Screening for Breast Cancer: The Health Insurance Plan Project and its Sequelae, 1963-1986. Baltimore, MD: Johns Hopkins; 1988.

6. World Health Organization. World health report 2004 - changing history. Annex table 2: deaths by cause, sex and mortality stratum in WHO regions, estimates for 2002. http://www.who.int/whr/2004/annex/topic/en/annex_2_en.pdf?ua=1. Published 2004. Accessed July 7, 2016.

7. Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review.

Critical Review of the Cochrane Collaboration Assessment of Screening Mammography, continued from previous page

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Lancet. 2012;380(9855):1778-1786.

8. Feig SA. Effect of service screening mammography on population mortality from breast carcinoma. Cancer. 2002;95(3):451-457.

9. Cady B, Michaelson JS. The life-sparing potential of mammographic screening. Cancer. 2001;91(9):1699-1703.

10. Boyd NF. The review of randomization in the Canadian National Breast Screening Study. Is the debate over? CMAJ. 1997;156(2):207-209.

11. Cady B. The screening mammography: the continuous dilemma. Breast J. 2002;8(4):185-186.

12. Kopans DB. The most recent breast cancer screening controversy about whether mammographic screening benefits women at any age: nonsense and nonscience. AJR Am J Roentgenol. 2003;180(1):21-26.

13. Baines CJ, Miller AB, Kopans DB, et al. Canadian National Breast Screening Study: assessment of technical quality by external review. AJR Am J Roentgenol. 1990;155(4):743-747; discussion 748-749.

14. Tarone RE. The excess of patients with advanced breast cancers in young women screened with mammography in the Canadian National Breast Screening Study. Cancer. 1995;75(4):997-1003.

15. Olsen O, Gøtzsche PC. Screening for Breast Cancer with Mammography (Cochrane Review). Oxford: Update Software. The Cochrane Library, Issue 4; 2011.

16. Olsen O, Gøtzsche PC. Screening for Breast Cancer with Mammography (Cochrane Review). Oxford: Update Software. The Cochrane Library, Issue 4; 2013.

17. Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M. The benefits and harms of breast cancer screening: an independent review. Br J Cancer. 2013;108(11):2205-2240.

18. Duffy SW, Tabar L, Olsen AH, et al. Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England. J Med Screen. 2010;17(1):25-30.

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O n the morning of October 22, 2015, after reading the new American Cancer Society recommendations for screening and clinical breast examination, I felt a wave of anger and anxiety. I knew these

recommendations would be harmful to women across the nation and I felt helpless. Tears welled in my eyes.

I quickly emailed a friend who is a local news anchor and asked if she could connect several mammographers from around the country into a single videoconference so that we could tell women the truth: that these recommendations were wrong. I figured there was strength in numbers. She answered that she couldn’t help, as that was way beyond the technology of their station. I felt antsy. I needed a platform that would allow me to get this information out to large numbers of women. I wanted women to know what we as breast imagers know. I wanted to show them the articles written by experts about how yearly screening mammography beginning at age 40 for women of average risk saves the most lives. I wanted them to learn about the flaws in the studies that refute the efficacy of screening. I wanted them to be emboldened with knowledge so that they could ignore the erroneous messages that were streaming across the internet, television, and radio. I wanted them to know the truth, plain and simple, from those of us who have seen the power of screening mammography.

Enter Facebook. Within an hour, with the help of my computer, a word processing program, and a new Facebook community page, “American Women Unite for Breast Cancer Screening” was up and running, complete with a logo. https://www.facebook.com/awubcs

The process of maintaining the Facebook page is time-consuming. During very busy episodes I have spent 5 or more hours per day several times per week posting and answering messages.

After almost 8 months and many posts quoting Jay A. Baker, MD, FACR, FSBI; Wendy Berg, MD, PhD, FACR, FSBI; Kelly Broderick, MD; Daniel B. Kopans, MD, FACR, FSBI; Debra L. Monticciolo, MD, FACR, FSBI; Elizabeth A. Morris, MD, FACR, FSBI; Laszlo Tabar, MD, FACR; the Society of Breast Imaging; and members of Congress, the Facebook page “American Women Unite for Breast Cancer Screening” now has 11,100 active, mostly female followers from around the world. They regularly like, post, and share articles with friends and family and send me messages. In retrospect, I am happy that my local news station was unable to host a videoconference. That would have only been a one-time program and it would not have allowed for the continual flow of information to

The Story of “American Women Unite for Breast Cancer Screening” By Michelle L. Rivera, MD

Michelle L. Rivera, MD

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The Story of “American Women Unite for Breast Cancer Screening,” continued from previous page

thousands of people that has been made possible with Facebook. Some very interesting things have happened since I started the page.

Several breast cancer organizations have generously and graciously allowed American Women Unite for Breast Cancer Screening to cosign letters to Congress, to visit congressional staffers along with them in support of the Protecting Access to Lifesaving Screenings (PALS) Act (which is now a law), and to participate in conference calls and email chains aimed at continuing to allow women access to yearly screening mammography at age 40. Two of my op-ed pieces have been published and 15 million people heard my audio news release about the importance of screening mammography and the PALS Act. The expansion has been surprising and incredible.

The only negative so far has been 1 piece of hate mail. It was sent via regular mail, signed anonymously, and it accused me of supporting screening mammography only for personal monetary gain. I used the power of Facebook and posted the letter along with the question, “Is it really a conflict of interest for breast imagers like me to advocate for continued yearly breast cancer screening beginning at age 40?” The question alone was seen by 664 people, received 31 likes and 9 supportive comments, and was shared 3 times. No one thought it was a conflict of interest.

Facebook has been a great platform for getting this important message out quickly, easily, and cost-effectively. Posts that are formatted with a brightly colored background and concise text get the most attention. I can use the “insights” portion of Facebook and see that there are many people looking at the page. I love that anyone can see the information and that I can provide the service at no cost.

Now that the scientific information supporting screening yearly mammography for women of average risk beginning at age 40 has been on the page since October, the next wave of posts will take aim at the United States Preventive Services Task Force (USPSTF) recommendations. The focus will be on the lack of scientific data supporting their recommendations, the lack of transparency in selecting the USPSTF members, and the lack of relevant clinical experience of those members.

We already have less than 2 years to reverse the dangerous trend of later and less breast cancer screening. I urge all breast imagers to like and post comments on “American Women Unite for Breast Cancer Screening,” to start your own pages, post your comments on the pages of the American Cancer Society, and contact your congressional representatives. WE are the experts in this field and our voices are the relevant ones that need to be heard.

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S creening mammography has been one of the greatest scientific advancements of our time. Numerous randomized trials and service screening studies conducted in Europe have shown that periodic

screening can reduce deaths from breast cancer in women aged 40 years and older by as much as 50%.(1)

A greater than 30% reduction in the breast cancer death rate in the United States since 1980 has been largely due to the widespread application of high-quality mammographic technique and interpretation. For this accomplishment, women in our country can be grateful to Gerald D. Dodd, Jr., MD, who passed away in Houston, Texas, on September 25, 2015, at age 92. Through his leadership in organizations such as the American Cancer Society (ACS), the American College of Radiology (ACR), the American Board of Radiology (ABR), and the National Council on Radiation Protection and Measurements, Dodd played an indispensable role in the adoption of technical quality requirements by the ACR and the U.S. Food and Drug Administration, the Mammography Quality Standards Act (MQSA), the development of interpretive descriptors used in the ACR Breast Imaging-Reporting and Data System (ACR BI-RADS), the incorporation of breast imaging on ABR examinations, and the initiation of ACS screening mammography guidelines.

During much of his remarkably productive career, Dodd was chairman of the Division of Diagnostic Imaging at The University of Texas MD Anderson Cancer Center in Houston, Texas. He was the imaging editor for Breast Diseases: A Year Book Quarterly from its inception in 1990 until 2005, when at age 82, he recommended to S. Eva Singletary, MD, then editor-in-chief, that I assume his position. To me, Gerry Dodd was a long-time friend, a trusted mentor, and an inspiration.

Dodd was born in Oaklyn, New Jersey, on November 18, 1922. He attended Blair Academy preparatory school, participating with distinction in football, wrestling, and boxing. He received a football scholarship to Cornell University but chose Lafayette College instead, intending to pursue a

In Memoriam Gerald D. Dodd, Jr., MD (1922-2015) 1995 Gold Medalist: Champion of Screening Mammography By Stephen A. Feig, MD, FSBI

Reprinted from Breast Diseases: A Yearbook Quarterly, Vol 27, Issue 2, Stephen A Feig MD, In Memoriam: Gerald D. Dodd, Jr., MD (1922-2015): Champion of Screening Mammography, Pages 108-114, Copyright 2016, with permission from Elsevier.

Stephen A. Feig, MD, FSBI

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career in medicine. World War II interrupted his studies, and he joined the U.S. Navy as a hospital corpsman. His commanding officer recommended him to the Officer Training Program through Swarthmore College in suburban Philadelphia, and he was commissioned with the rank of ensign. After the war, he returned to Lafayette, graduating in 1945. In 1946, he married his beloved wife of 68 years, Helen Glenzing. He received his medical degree from Thomas Jefferson Medical College in Philadelphia, Pennsylvania, in 1947 and was elected to the Alpha Omega Alpha Honor Medical Society. (Many years later, he was selected for the prestigious Thomas Jefferson University Alumni Achievement Award.) In 1948, he interned at Fitzgerald Mercy Hospital in Darby, Pennsylvania. His ensuing residency in radiology at Thomas Jefferson Medical College, under Dr. Paul Swenson as chairman, ran from 1948 to 1950. During the Korean War, he joined the U.S. Air Force, rising to the rank of captain, while serving as the chief of radiology at Mitchell Air Force Base in New York.

Dodd began his highly productive career as an assistant professor at Thomas Jefferson Medical College (1952-1955). He then relocated to MD Anderson, where he served as section head of diagnostic imaging from 1955 to 1961.(2) During that time, Dodd assigned Robert L. Egan, then a resident in radiology, the task of developing a mammographic technique for the staging of breast cancer. Egan’s landmark accomplishment demonstrated that mammography can reduce errors in preoperative diagnosis and reveal unsuspected lesions.(3)

Disappointed by the lack of support for diagnostic radiology at MD Anderson at that time, Dodd returned to Jefferson in the spring of 1961 as chief of diagnosis and director of residency training. Under the leadership of Dodd and Dr. Philip J. Hodes, chairman of radiology, the department experienced a dramatic growth in the resident program.

During the 1950s and 1960s, Philadelphia was a leading center for clinical studies in the emerging field of breast imaging. Dr. Jacob Gershon-Cohen at Albert Einstein Medical Center was developing improved mammographic techniques, correlating the mammographic, pathologic, and clinical findings of breast diseases, and investigating the value of mammography for screening.(3) At Jefferson, Dodd coauthored a cooperative study of mammography at 7 Philadelphia teaching hospitals, initiated by Dr. Eugene P. Pendergrass, chairman of radiology at the University of Pennsylvania. Their results confirmed that mammography could detect clinically unsuspected breast cancer.(4)

While at Jefferson, Dodd was the first in the country to develop a preoperative needle localization technique for nonpalpable breast lesions.(5,6) This major technical innovation increased the accuracy of excisional biopsy while decreasing postoperative deformity.(7)

In 1964, Dodd and John D. Wallace, a medical physicist at Jefferson, began to assess the relationship between breast tumors and mammographic vascularity.(8) Their studies led them to evaluate thermography, a technique that depicts the infrared radiation emitted by the superficial vasculature of the breast, as a potential screening modality.(9-11)

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Despite his success in depicting advanced cancers with thermography, Dodd was always a selfless, dispassionate scientist. In 1976, he encouraged me to publish my results from a study at Jefferson on screening 16 000 women using thermography, mammography, and clinical examination.(12) My study showed that, compared to mammography, thermography had little or no value for the much smaller cancers that could be detected at that time through advances in mammographic technique. Similarly disappointing results for screening thermography were subsequently confirmed at the ACS/National Cancer Institute (NCI)-supported Breast Cancer Detection Demonstration Project (BCDDP), a nationwide multisite program involving over 280 000 women. At the urging of Dodd and others, the ACS in 1977 decided to drop thermography from the BCDDP.(13,14)

RETURN TO MD ANDERSON: 1966-1992By 1966, substantial changes had occurred in the operational aspects of MD Anderson. Through

his relationship with the Texas legislature and major donors, Dr. R. Lee Clark, president of MD Anderson, was able to offer Dodd increased space allotment and funding for staffing, equipment, and educational programs.(2) In 1966, Dodd agreed to return and was named professor and chairman of the newly constituted Department of Radiology.

Upon his return, Dodd immediately began to develop the department into an internationally renowned center for diagnosis, research, treatment, and teaching, a process that continued over the ensuing 26 years. Dodd developed an interest in the technical aspects of mammography. Together with Arthur G. Haus, a medical physicist at MD Anderson, he contributed to the development of magnification mammography and methods to improve image sharpness and reduce the radiation dose.(15-18)

At the same time, Dodd continued to build his own reputation as an outstanding radiologist in the subspecialty areas of gastrointestinal,(19) otolaryngologic,(20,21) and breast radiology.(22-24) During his career, he was the author/coauthor of 123 peer-reviewed publications, 22 book chapters, 6 monographs, 4 books, 27 other publications, and many exhibits at radiological society meetings. In 1992, Dodd retired at age 70 as the Robert D. Moreton Professor and chair of the Department of Diagnostic Radiology. He subsequently held the title of emeritus professor of radiology at MD Anderson and was the Singleton Professor of Radiology at St. Luke’s Episcopal Hospital in Houston.

Throughout the course of his long and vigorous career, Dodd unstintingly contributed his time to many medical organizations. His kindly, congenial personality, natural eloquence, and political acumen allowed him to use his numerous elected and appointed positions as means to improve and promote screening mammography on national and international levels. He always seemed to be at the right place at the right time to effect change.

In his work with the ACR, Dodd chaired the Commission on Cancer, the Breast Task Force, the

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Commission on Public Health and Radiation Protection, and the Board of Chancellors. His insights were thoughtful, but his actions were swift. He often found solutions before others recognized the problem. In the early 1980s, Dodd initiated many highly successful ACR programs, such as the first Self-Evaluation Syllabus devoted to breast imaging,(25) the first Mammography Viewbox Symposium, and the first National Breast Cancer Conference.

IMPROVING THE TECHNICAL QUALITY OF MAMMOGRAPHYIn response to findings of excessive radiation doses from mammography at U.S. facilities, Dodd, as

chair of the ACR Commission on Breast Cancer, was the first to recognize the need for the ACR to establish a Mammography Accreditation Program to ensure adequate technical quality, an acceptable radiation dose, and appropriate credentialing for interpreting physicians, medical physicists, and technologists.(26-28) This voluntary effort was the impetus and model for the U.S. MQSA, signed into law by President George H.W. Bush in 1992.

Today, every mammography facility in the United States must, by law, obtain MQSA certification from the U.S. FDA. In fact, MQSA certification requires prior accreditation through a program, such as the ACR Mammography Accreditation Program. Over the past several decades, the ACR Mammography Accreditation Program and the FDA MQSA program have been jointly responsible for substantial improvements in image quality and reduction in radiation dose.(29,30)

Dodd also initiated the development of the first ACR Mammography Quality Control Manual. Written by medical physicists, radiologists, and technologists, the manual provides quality standards for mammography equipment and examination performance. This ACR manual subsequently served as the basis for many MQSA standards.(31)

IMPROVING INTERPRETIVE SKILLS AND THE MAMMOGRAPHY REPORT

Dodd not only helped to raise the technical quality of mammography but also played a major role in elevating the level of interpretive expertise. As a member of the ABR Board of Trustees, in 1989, he convinced his fellow trustees that mammography should become a separate category on the ABR oral examination. As first chairman of the Breast Section, he pioneered the development of the first sets of breast cases used to test ABR candidates, and for many years, he organized the administration of the oral examination.

The ACR BI-RADS is another important development initiated by Dodd. He recognized that breast imaging reports should employ a common terminology and conclude with a single specific recommendation to the referring clinician. In 1989, Dodd, as chair of the ACR Breast Imaging Commission, established the first ACR BI-RADS Committee. He instructed the committee to develop sets of descriptors for imaging findings and a general format for the report. Each report would conclude with 1 of 5 highly specific final assessment categories: negative, benign, probably benign,

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suspicious for malignancy, and needs additional imaging. Selection of the appropriate descriptors allows the radiologist to arrive at an appropriate final assessment category for the patient. BI-RADS reduces ambiguity in mammography reports and facilitates more accurate diagnoses.

The first edition of BI-RADS, published in 1993, was 63 pages in length and included only mammography.(32) The current 5th edition (2013) of BI-RADS is over 600 pages long and includes mammography, ultrasound, and magnetic resonance imaging, with many illustrative examples for each descriptor. It also contains a detailed plan for monitoring screening outcome data.(33) Linkage of descriptors, recommendations, and biopsy findings is intended to facilitate a national breast imaging database. As a testament to the value of BI-RADS, the MQSA requires that a BI-RADS final assessment category be included in every breast imaging report. All major peer-reviewed medical journals now require use of BI-RADS terminology in submitted manuscripts.

SCREENING MAMMOGRAPHY GUIDELINESDodd played a key role in the adoption of the ACS Mammography Screening Guidelines and the

promotion of screening mammography. This was a major effort of his over many tumultuous decades of hope and peril for screening mammography. During the 1970s, the ACS and the NCI screened more than 280 000 women using mammography, clinical examination, and, initially, thermography at 29 BCDDP centers around the United States. The study found that almost half of all cancers and an even higher proportion of early cancers were detected by mammography alone.(13) Women with screening-detected tumors were found to have higher survival rates at 5-, 10-, and 20-year follow-up periods(13,34,35) than did the unscreened general population.(33)

The first screening mammography controversy began in 1975, when critics claimed that early detection and even longer survival did not necessarily mean improved prognosis, especially for women aged 40-49 years.(36) Some warned of a possible radiation risk from mammography.(37) Others argued that no women should be screened, or perhaps only those older than 50 years should have the examination. These controversies were widely publicized by television, newspapers, and magazines.

Throughout this critical period, Dodd used his leadership positions in the ACR, the ACS, the National Council on Radiation Protection and Measurements, the President’s Commission on Breast Cancer, and the International Union Against Cancer to encourage a reduction in radiation dose, to advocate for improvements in technical and interpretive quality, and to advise continued screening.(14,22-24) Meanwhile, the BCDDP, in United States and European randomized clinical trials, steadily accumulated more data to support screening.(1,13,38,39)

Other medical organizations issued their own guidelines, often at variance with those of the ACS. In an attempt to reduce confusion among women in the United States, in 1987, Dodd organized and chaired a multi-organizational committee charged with the development of a consensus guideline statement.(40-42) The ensuing report advised screening mammography every 1 or 2 years for

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women aged 40-49 years and annual screening thereafter. That report was a supremely ecumenical statement that only someone with Dodd’s stature and persuasive powers could have accomplished. Screening mammography seemed to be out of the woods at last. Unfortunately, this period of harmony was all too brief. In 1993, on the basis of newly reported unfavorable results from the National Breast Screening Study of Canada (NBSSC) and lack of sufficient follow-up from randomized controlled trials, the NCI removed itself from the consensus statement and no longer advised mammographic screening for women in their 40s.(36)

In response, Dodd asked Dr. Dan Kopans and me to submit our critique of the NBSSC study for publication in the American Journal of Radiology.(43) Our article clearly identified the 2 problems responsible for the unfavorable NBSSC results: 1) poor mammographic technical quality and 2) a randomization problem due to the excessive inclusion of women with advanced cancers in the study group. These were both fatal flaws that should have prevented any valid conclusion on the basis of the NBSSC results. Dodd then organized an ACS workshop to review the screening data. On the basis of presentations and discussion, the ACS reaffirmed its recommendation to continue screening women aged 40-49.(44)

By 1997, several meta-analyses of randomized controlled trials based on longer-term follow-up and new reports from 2 Swedish randomized trials finally demonstrated a statistically significant 30% reduction in breast cancer death from screening women younger than 50 years.(45-49) The NCI organized a consensus conference to review these new data. Unfortunately, to “avoid bias,” the consensus panel consisted of many individuals who were not knowledgeable about breast screening.

To the amazement and deep disappointment of most knowledgeable observers, the panel largely ignored the new data! Their majority opinion was against screening women younger than 50 years.(50) Many observers thought that politics had interfered with science. The director of the NCI, Richard D. Klausner, also strongly disagreed with the panel’s decision. He referred the issue to the National Cancer Advisory Board for a final judgment. They refuted the consensus panel decision and voted to recommend that women aged 40-49 undergo screening mammography every 1-2 years.(51)

The new data not only supported screening women in their 40s but also strongly suggested that screening would be more effective if performed annually.(1) In early 1997, the ACS, under Dodd’s leadership, organized another workshop that resulted in new ACS guidelines recommending annual screening mammography for all women beginning at age 40 years.(52) Almost simultaneously, the ACR issued an identical recommendation.(53)

In his foreword to an earlier biography of Gerry Dodd, Jack Edeiken, MD, former chair of radiology at Jefferson, a close friend of Dodd, and a mentor to me, wrote: “Advances in science usually come about when the ideas of one person are followed by many. Scientific advances require leadership, not only in terms of evaluation of scientific ideas but also in terms of the ability to convince others of

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the value of such ideas. Gerry Dodd is a leader, one who can show others the way in a compassionate, humorous, and scientifically accurate manner. His only intolerance is of ignorance. Despite his imposing physical presence, Gerald D. Dodd Jr. is a gentle man. He becomes a tiger, however, when confronted with arrogance or lack of integrity. Through his word in breast imaging, Gerald D. Dodd Jr. has, by example, set a standard for the pursuit of truth in medicine.”(54)

OTHER PROFESSIONAL AND PERSONAL ACCOMPLISHMENTSDodd also sought to make screening mammography more accessible by promoting ways to

perform the examination more efficiently and at a lower cost, such as batch interpretation.(55,56) Continuing a professional career highlighted by numerous remarkable achievements, Dodd, in his later years, was involved in planning an ACS initiative to raise breast imagers’ interpretive skills. In undertaking these national initiatives throughout his career, Dodd was a true leader, using his time and energy to set the course of national organizations in new directions for the betterment of women.

He was on the editorial boards of numerous scientific journals. He served as chairman of the board and president of the ACR, president of the ACS, president of the Texas Radiologic Society, and president of the Houston Radiological Society. He received 45 prestigious awards, including the gold medals of the ACR, the Radiologic Society of North America, the American Roentgen Ray Society, the Texas Radiological Society, the Society of Breast Imaging, and the Gilbert H. Fletcher Society. He received the Presidential Medal of the ACS, the Haughton Medal of the Royal College of Surgeons in Ireland, and the Cannon Medal of the Society of Gastrointestinal Radiologists. In 2003, the Society of Breast Imaging established the Gerald D. Dodd Lecture in his honor. This keynote address at each Society of Breast Imaging postgraduate course is presented by a scientist who has substantially advanced our knowledge of breast cancer.

Even this imposing record of accomplishments fails to reveal his entire portrait. Gerry Dodd’s warmth and generosity to his many friends and colleagues around the country and abroad was well known. At MD Anderson, he was known as a benevolent chairman who always took time to thoughtfully weigh every departmental decision. He never acted out of impulse or emotion. He was appreciative and loyal to his staff, as well as decent and considerate toward all.

At home, his highly supportive wife, Helen, “Glen”, undoubtedly was a major reason for Dodd’s ability to manage his many professional responsibilities with such calm assurance. The couple was married for 68 years until her death in 2014. Their 7 children can attest to a happy home life over many years. Grandchildren and a great-grandchild have now added additional generations to the Dodd family. One son, Gerald D. Dodd III, known as “Chip,” is professor and chair of radiology at the University of Colorado.

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A TEACHABLE MOMENT FROM THE LIFE OF DR. GERALD D. DODDIn March 1983, Dodd was in Honolulu, Hawaii, at the 21st ACR National Conference on Breast

Cancer. During the conference, the ACR arranged to have a commemorative photograph taken of Dodd, who was chairman of the ACR Breast Cancer Task Force; Dr. Eleanor Montague, professor of radiation oncology at MD Anderson, who presented the Wendell Scott Memorial Lecture; Mrs. Wendell Scott; and myself as program chair. The backdrop for this photo opportunity was a Hawaiian village mural on a wall at the Sheraton Waikiki. After returning to the U.S. mainland, we all waited expectantly for this once-in-a-lifetime photograph. By late April, it still had not arrived. Ever attentive to Dodd, the ACR staff phoned the photography studio in Hawaii again and again over the next several weeks. Each time, they were told that the photo had been lost and could not be found, even though they had searched every spot in their studio many times.

Finally, a letter was sent by the chief counsel of the ACR Legal Department stating that Dodd was getting angrier by the moment and demanding that if the photograph could not be recovered, the

Figure 1. Photo from the 21st ACR National Conference on Breast Cancer, 1983. Pictured from left to right: Dr. Montague, Ms. Scott, Dr. Dodd and Dr. Feig.

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studio had to fly all four of us back to Hawaii to be photographed once more against the same backdrop. Apparently, this final threat succeeded, because the “missing” negative suddenly and miraculously reappeared. We all received our copies via Federal Express the next week (Figure 1).

From that episode early in my career, I quickly learned that in any important medical venture, it was important to have Dodd at my side. Many major endeavors, such as the initiation of the ACR Mammography Accreditation Program and the adoption of screening mammography guidelines by most national medical organizations, owe their ultimate success to his efforts.

Thus, Dodd’s contribution to science, to medical organizations, to our patients who benefit from screening mammography, and to the development of radiology at MD Anderson, as well as his personal and family accomplishments, provide a legacy for many generations to come.

REFERENCES 1. Feig SA. Radiol Clin North Am 2014;52:455-480.

2. Dodd GD Jr, Linton OW. A History of Diagnostic Imaging. The University of Texas MD Anderson Cancer Center; 2006.

3. Egan RL. Radiology. 1960;75:894-900.

4. Gershon-Cohen J, Berger SM, Forman M, Curcio BM. Radiology. 1967;88:663-667.

5. Dodd GD, Fry K, Delany W. Percutaneous needle localization of occult carcinoma of the breast. In Nealon-TF (ed). Management of the Patient with Breast Cancer. Philadelphia, WB Saunders, 1965:88.

6. Dodd GD. Preoperative radiographic localization of nonpalpable lesions. In Gallager HS (ed). Early Breast Cancer: Detection and Treatment. New York, John Wiley, 1975:151-153.

7. Steiner RM, Kramer S. AJR Am J Roentgenol. 1996;167:561-570.

8. Dodd GD, Wallace JD. Radiology. 1968;90:900-904.

9. Dodd GD, Wallace JD, Freundlich I, Marsh L, Zermino A. Cancer. 1969;23:797-802.

10. Dodd GD, Zermeno A, Wallace JD, et al. Breast thermography: the state of the art. Curr Probl Radiol. 1973;3:1-47.

11. Dodd GD. Heat-sensing devices and breast cancer detection. In Feig SA, McLelland R (eds). Breast Carcinoma: Current Diagnosis and Treatment. New York, Masson, 1983:207-226.

12. Feig SA, Shaber GS, Schwartz GF, et al. Radiology. 1977;122:123-127.

13. Baker LH. CA Cancer J Clin. 1982;32:194-225.

14. Dodd GD. Cancer. 1977;39:2796-2805.

15. Haus AG, Cowart RW, Dodd GD, Bencomo J. Radiology. 1978;128:775-778.

16. Haus AG, Paulus DD, Dodd GD, Cowart RW, Bencomo J. Radiology. 1979;133:223-226.

17. Haus AG, Dodd GD, Paulus DD. Mammography systems characteristics: have we improved image quality while reducing dose? In Logan WW, Muntz EP (eds), Reduced Dose Mammography, New York, Masson, 1979:145-156.

18. Haus AG, Dodd GD, Paulus DD. Historical review of mammographic imaging techniques in terms of image quality and reduced radiation dose. Proc. SPIE 0173, Application of Optical Instrumentation in Medicine VII, 120 (July 6, 1979). http://proceedings.spiedigitallibrary.org/proceeding.aspx?articleid=1228177. Accessed March 10, 1979.

19. Dodd GD. Radiology. 1977;123:263-275.

20. Dodd GD, Dolan PA, Ballantyne HJ, Ibanez MJ, Chau P. Radiol Clin North Am. 1970;8:446-461.

21. Dodd GD, Jing BS. Radiology of the Nose, Paranasal Sinuses and Nasopharynx. Baltimore, MD, Williams and Wilkins, 1977.

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22. Dodd GD. Cancer. 1981;47:1766-1769.

23. Dodd GD. Cancer. 1984;53 (Suppl S3):652-657.

24. Dodd GD. CA Cancer J Clin. 1984;34:57-59.

25. Feig SA, Kalisher L, Libshitz H, et al. Breast Disease. Test and Syllabus (Professional Self-Evaluation and Continuing Education Program), vol. 24. Reston, VA, American College of Radiology, 1988.

26. Galkin BM, Feig SA, Muir HD. Radiographics. 1988;8:133-145.

27. Dodd GD. Cancer. 1989;64:2707-2709.

28. Dodd GD Jr. Cancer. 1994;74:239-243.

29. Conway BJ, Suleiman OH, Reuter FG, Antonsen RG, Slayton RJ. Radiology. 1994;191:323-330.

30. Hendrick RE, Chrvala CA, Plott CM, Cutter GR, Jessop NW, Wilcox-Buchalla P. Radiology. 1998;207:663-668.

31. Hendrick RE, Bassett L, Botsco MA, et al. Mammography Quality Control Manual. Reston, VA, American College of Radiology, 1999.

32. Kopans DB, D’Orsi CJ, Adler DD, et al. Breast Imaging Reporting and Data System (BI-RADS). Reston VA, American College of Radiology, 1993.

33. D’Orsi CJ, Sickles EA, Mendelson EB, et al. American College of Radiology BI-RADS Atlas. Reston, VA, American College of Radiology, 2013.

34. Seidman H, Gelb SK, Silverberg E, LaVerda N, Lubera JA. CA Cancer J Clin. 1987;37:258-290.

35. Smart CR, Byrne C, Smith RA, et al. CA Cancer J Clin. 1997;47:134-149.

36. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. J Natl Cancer Inst. 1993;85:1644-1656.

37. Bailar JC 3rd. Ann Intern Med. 1976;84:77-84.

38. National Council on Radiation Protection and Measurements. Mammography, recommendations of the National Council on Radiation Protection and Measurements. NCRP Report No. 66. Washington, DC, 1980.

39. Dodd GD. Cancer. 1987;60:1671-1674.

40. Dodd GD. Cancer. 1992;69:1885-1887.

41. Dodd GD. Cancer. 1993;72:1429-1432.

42. Dodd GD, Winchester D. National health professional organizations: discussion group report. Cancer. 1987;60 (Suppl S1):1694.43. Kopans DB, Feig SA. AJR Am J Roentgenol. 1993;161:755-760.

43. Dodd GD. Summary, American Cancer Society Workshop on Guidelines and Screening for Breast Cancer, October 11-13, 1991. Cancer. 1992;69 (Suppl S17):2008-2009.

44. Smart CR, Hendrick RE, Rutledge JH 3rd, Smith RA. Cancer. 1995;75:1619-1626.

45. Int J Cancer. 1996;68:693-699.

46. Hendrick RE, Smith RA, Rutledge JH 3rd, Smart CR. J Natl Cancer Inst Monogr. 1997;22:87-92.

47. Andersson I, Janzon L. J Natl Cancer Inst Monogr. 1997;22:63-67.

48. Bjurstam N, Bjorneld L, Duffy SW, et al. Cancer. 1997;80:2091-2099.

49. J Natl Cancer Inst Monogr. 1997;22:vii-xii.

50. National Cancer Institute. Statement from the National Cancer Institute on the National Cancer Advisory Board recommendations on mammography. Bethesda, MD, National Cancer Institute, March 27, 1997.

51. Leitch AM, Dodd GD, Costanza M, et al. CA Cancer J Clin. 1997;47:150-153.

52. Feig SA, D’Orsi CJ, Hendrick RE, et al. AJR Am J Roentgenol. 1998;171:29-33.

53. Feig SA. Gerald D. Dodd Jr., MD: a leader in the advancement of screening mammography. Breast Diseases: A Year Book Quarterly. 2001;12:27-32.

54. Dodd GD. Cancer. 1989;64:2667-2670.

55. Dodd GD, Fink DJ, Bertram DA. Cancer. 1987;60:1669-1670.

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1. How long will a breast magnetic resonance imaging (MRI) examination take in the future?

The answer to this question depends on whether the indication is for screening or diagnosis. The basic acquisition protocol for breast MRI has not changed greatly over the last 2 decades, and most practices today do not distinguish between screening and diagnostic studies. Going forward, a clear distinction between screening and diagnostic breast MRI examinations will become part of routine clinical practice, necessitating implementation of different acquisition protocols for these 2 indications. In general, a screening study should consist of an abbreviated protocol limiting the entire acquisition to 5 to 10 minutes or less, and a standard diagnostic examination should be acquired in approximately 15 to 20 minutes. The key technical component in any breast MRI protocol, abbreviated or full, does of course require an excellent T1-weighted (T1-W) dynamic contrast-enhanced (DCE) series with injection of a gadolinium-based contrast agent. Measures of uptake and washout of contrast media within breast lesions contain diagnostically useful information; the shape of the signal intensity–time curve has shown to be useful in the classification of enhancing lesions. With this in mind, the dynamic component of an abbreviated screening examination should be shortened to a 2- to 3-minute time frame, acquiring data in the initial phase of enhancement only, whereas a standard diagnostic examination will generally acquire both initial and delayed-phase dynamic data in a 5- to 7-minute time frame.

2. What techniques are in development that have the greatest potential to be adopted and why?

Breast MRI research efforts currently underway are aimed toward improving diagnosis. Sensitivity is already very high, and diffusion-weighted imaging and fat-suppression methods such as short tau inversion recovery and high spectral and spatial resolution imaging raise the ultimate possibility of improved diagnostic specificity and cancer detection without the use of contrast agents. In the near term, however, a new focus on improvement of the basic DCE T1-W sequence has yielded improved results. Implementation of a short sequence (abbreviated breast MRI [AB-MR]) for screening, use of ultrafast (UF) perfusion imaging in the initial dynamic phase, and use of advanced computer analytic methods for quantification of enhancement show the greatest promise.

AB-MR: Breast MRI is by far the best screening method for cancer detection. Historically, the main barriers to its use included availability, cost, and length of the examination. The need for improved screening methods for women at average to intermediate risk has come into focus in recent years

The Future of Breast Magnetic Resonance Imaging By Gillian Newstead, MD

Gillian Newstead, MD

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because of the passage of breast density legislation in over half of the United States requiring that women be informed about optional additional screening methods. Dr. Kuhl and colleagues1 have successfully pioneered an AB-MR protocol for screening women at mild and moderate risk. Early studies involving interpretations of AB-MR protocols have shown equivalent sensitivity for cancer detection when compared to a full standard breast MRI. Any standard diagnostic protocol currently used in practice can be modified to achieve a short screening acquisition. Generally, a T2-weighted (T2-W) sequence and a DCE T1-W series with 1 or 2 postcontrast sequences obtained within 10 minutes will suffice. The AB-MR series will not provide contrast washout data, and only measures of the initial uptake rates of enhancing lesions are obtained. Nonetheless, diagnostically useful information can be extracted by using computerized analysis of the initial enhancement slope.

3. Will we move to UF MRI? Or will we abandon kinetics altogether?We will move to UF imaging in the first 40 to 60 seconds of the T1-W dynamic series for both

screening and diagnostic protocols, but we will certainly not abandon kinetic analysis.

UF breast MRI: New protocols referred to as ultrafast or accelerated imaging are distinct from AB-MR methods and are based on imaging and sampling early kinetic data at a faster rate, with continuous 2 to 8 seconds per time point over the first minute for a bilateral scan. The UF sequence replaces the standard first post-contrast 60-second acquisition in the common dynamic series used in both screening and diagnostic protocols.2 Lesion conspicuity in UF images is often greatest within the first 30 seconds after contrast media injection, when background parenchymal enhancement (BPE) is minimal, even when later series may show marked BPE. UF methods allow measurement of the rate of lesion enhancement with respect to the time of initial arterial enhancement rather than time of injection, thus reducing dependence on global variables such as cardiac output. Kinetic analysis will include display of the slope of initial enhancement and time to enhancement of each lesion compared to the time of initial aortic enhancement.

Regarding kinetic analysis: UF techniques have the potential not only to improve MR imaging methods but also to provide quantitative measurements of perfusion parameters such as arterial input function and the volume transfer coefficient, both essential for development of prognostic and predictive image-based biomarkers. Breast cancer subtypes are now increasingly classified based on tumor genotype and demonstrate significant intra- and intertumor variability in biological aggressiveness. Breast cancer regression models of computer-extracted DCE MR image-based tumor phenotypes (known as radiomics), combined with genomic features (known as radiogenomics), are aimed toward better understanding of genetic variability in cancers and the prediction of prognosis and response to therapy.3 The following questions are currently leading these research efforts: Can MR imaging features predict important genomics features? Could integration of MR imaging and genomics features lead to higher predictive power of therapeutic outcomes? Could MR imaging serve in lieu of biopsy?

The Future of Breast Magnetic Resonance Imaging, continued from previous page

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4. What are the current recommendations for the average/general radiologist who wishes to participate in the evolution of breast MRI?

Simplify it all! Breast MRI has become much too complicated. Concentrate on achieving 1 simple screening series and 1 standard diagnostic series with excellent technique, rather than chasing the tail of exotic new sequences. Streamline your breast protocols based on proven reliable DCE MRI technology. All that is needed for excellent results are a T2-W sequence and a T1-W DCE MRI series, including 1 sequence without fat suppression. Streamline workflow, particularly for women undergoing screening. Select dedicated technologists for breast MR imaging and include them in educational programs and audit functions. We all need to include AB-MR in our practices. The challenge will be to develop a streamlined, efficient workflow for rapid screening at a lower cost. Keys to this process will be a faster MRI protocol, efficient throughput, and advanced training for radiologists in the interpretation of MRI screening studies.

REFERENCES

1. Kuhl CK, Schrading S, Strobel K, Schild HH, Hilgers RD, Bieling HB. Abbreviated breast magnetic resonance imaging (MRI): first postcontrast subtracted images and maximum-intensity projection—a novel approach to breast cancer screening with MRI. J Clin Oncol. 2014;32(22):2304-2310.

2. Pineda FD, Medved M, Wang S, et al. Ultrafast bilateral DCE-MRI of the breast with conventional Fourier sampling: preliminary evaluation of semi-quantitative analysis. Acad Radiol. 2016;pii: S1076-6332(16)30077-0.

3. Li H, Zhu Y, Burnside ES, et al. MR imaging radiomics signatures for predicting the risk of breast cancer recurrence as given by research versions of MammaPrint, Oncotype DX, and PAM50 gene assays. Radiology. 2016;152110.

The Future of Breast Magnetic Resonance Imaging, continued from previous page

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R eaders of this article are undoubtedly passionate about minimizing the burden of breast cancer for women in the United States and beyond. We chose this field of breast imaging because we believe in the impact

of high-quality image-based screening and diagnosis. Fortunately, we have the support of both randomized clinical trials and observational studies that demonstrate a mortality benefit. In this article, I address the importance of engaging in transdisciplinary discussions in our local, regional, and national communities. My primary hypothesis: we can most powerfully advance the goal of improving breast cancer outcomes by actively participating in—or leading—these multidisciplinary conversations about breast cancer care, particularly with those who hold different views.

Our community is currently (and perhaps will always be) engaged in discussions with colleagues, practices, and institutions about breast cancer screening guidelines and other components of breast care. These conversations often involve a diverse group of individuals. Typically specialists in breast care like surgical, medical, and radiation oncologists and radiologists are having these conversations frequently as we care for patients in our day-to-day work. The committees that formulate institutional policies and national guidelines are often composed of primary care physicians, administrators, and individuals with population health or epidemiology backgrounds. Ideally, specialists in breast care are invited to participate in these conversations. It’s crucially important that radiologists are “at the table.” Fostering relationships based on trust, respect, and professionalism is the best way to get an invitation. Sometimes these conversations can be contentious and emotionally charged. Focusing on data and advocating for breast imaging quality and patient-centered care are key.

I have had the opportunity to serve on an initiative that embodies these concepts of multidisciplinary collaboration. Over the last 4 years, I have participated as the radiologist consultant on the Cancer Intervention and Surveillance Modeling Network (CISNET), a group supported by grants from the National Cancer Institute. CISNET is a collaboration of 6 distinct simulation modeling groups that investigate the impact of screening and treatment on breast cancer outcomes. This group has been influential in screening guidelines primarily authored by the US Preventive Services Task Force (USPSTF). I was invited to participate in CISNET by an epidemiologist. I had to be approved by the group and then written into the grants that support this initiative. Two other consultants participate: a pathologist and a medical oncologist. Sometimes other specialties participate on an ad hoc basis. In my role, I have advised modelers about imaging. My duties include reviewing the data that support breast cancer screening with mammography, conveying the limitations of our technology, and summarizing the emerging evidence regarding new modalities as the data become available. The 6 principal investigators of these models make the final decisions about the modeling assumptions and

Reaching Across the Disciplinary Divide By Elizabeth S. Burnside, MD, MPH, MS, FSBI

Elizabeth S. Burnside, MD, MPH, MS, FSBI

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Reaching Across the Disciplinary Divide, continued from previous page

techniques. My input does not always influence every model. Each modeling team has its own unique tendency to adopt consulting advice from any source. My point: I believe being at the table is crucially important.

Other local, national, and international opportunities to engage in these conversations exist. For example, the American College of Obstetrics and Gynecology (ACOG) convened influential groups in the mammography screening debate to publish a consensus statement to illustrate the points on which diverse groups agree. These groups include the National Comprehensive Cancer Network (NCCN), the American College of Radiology (ACR), the American Cancer Society, the USPSTF, the American College of Surgeons, the American College of Physicians, and the American Association of Family Physicians. Each group selected 2 representatives to participate in a dialogue to reinforce the areas of agreement and then publish these in a consensus statement. Influential leaders in our community were included in this conversation: Edward Sickles, MD and Debra Monticciolo, MD (the ACR representatives) and Mark Helvie, MD (an NCCN representative). I believe this admirable effort by ACOG to look beyond differences to emphasize areas of agreement will benefit women and represent a pioneering example of multidisciplinary cooperation.

I encourage you to participate in these fundamental conversations. Whether these conversations happen at the water cooler, at your local institution, or on a larger scale, I urge you to be at the table. This involvement requires not only being ready with data but also listening to opinions with which you may not agree. As we know, there’s a wide range of belief as to the effectiveness of breast cancer screening. Sometimes, to everyone’s surprise, available data can be used on many sides of the debate. A statesman once said, “A consensus means that everyone agrees to say collectively what no one believes individually.”1 When we actively participate in dialogues that cross disciplinary divides, the consensus will not perfectly reflect our views with crystal clarity, but supported by scientific data and with the patient in mind, our voices can influence the outcome.

REFERENCES

1. Quote: Abba Eban. BrainyQuote website. http://www.brainyquote.com/quotes/keywords/consensus.html. Accessed June 23, 2016.

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T he National Mammography Database (NMD) is the largest mammography database in the United States, containing over 12 million mammograms as of May 2016. Established in 2009, the NMD is

a part of the American College of Radiology (ACR) National Radiology Data Registry.1 It is self-sustaining, supported by the ACR and participating facilities. The database, which is housed at the ACR in Reston, VA, gathers data that radiology facilities already collect per federal mandate under the Mammography Quality Standards Act (MQSA), including patient demographic information, clinical findings, mammography interpretations, management recommendations, and biopsy results. All NMD data and associated reporting have strict procedures for masking patient identifiers and sharing limited radiologist information for confidentiality. As a quality improvement activity that uses data related to patient care, the NMD registry is institutional review board exempt and the requirements of patient privacy laws are compliant with the Health Insurance Portability and Accountability Act.

The primary purpose of the NMD is to help radiologists and radiology groups improve their performance using standardized objective audit measures alongside average values across all registries, as well as Breast Cancer Surveillance Consortium (BCSC) benchmarks. There is also a potential financial benefit. The NMD is approved by the Centers of Medicare and Medicaid Services as a Quality Clinical Data Registry for the Physician Quality Reporting System (PQRS) and Value-Based Modifier programs. In other words, radiology practices that satisfactorily participate in 2016 PQRS through the NMD may avoid the 2018 payment penalty of 2%.2 Moreover, participating in the NMD can also help fulfill the practice quality improvement component of the American Board of Radiology Maintenance of Certification program.3 As of May 2016, 410 mammography facilities across the United States have registered to be part of the NMD (Figure 1).

Participants in the NMD receive useful national and regional benchmarking data with detailed comparisons at the individual and practice levels every 6 months and shorter feedback reports every 3 months, including measures that are eligible for the PQRS. Each NMD feedback report summarizes recent radiologist and group performance using key metrics such as cancer detection rate, recall rate, and positive predictive values (Figure 2). Prior to the NMD, the BCSC served as the main source of national benchmarking and outcomes data for mammography facilities and radiologists in the United States.4 The BCSC is a federally funded research collaborative network by the National Cancer Institute consisting of several regional population-based mammography registries and a Statistical

The National Mammography Database: What It Is and Why You Should Join By Bhavika Patel, MD, and Cindy S. Lee, MD

Bhavika Patel, MD

Cindy S. Lee, MD

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The National Mammography Database: What It Is and Why You Should Join, continued from previous page

Coordinating Center analyzing mammographic and pathologic data. It has been a successful and valuable resource for research on risk assessment, screening disparity, delivery, and quality of breast cancer screening in the United States. However, the scope of BCSC data collection has changed because of different funding priorities, with declining data collection since 2009. Although it is not possible to perform direct statistical comparison between NMD and BCSC performance metrics because of different registry design and data reporting, the NMD can generate measures parallel to those of BCSC.5

Through the NMD, MQSA-compliant quality reporting is automatically generated and participants receive detailed semiannual performance reports. NMD reporting functionality is integrated with most commercial breast reporting software and therefore requires limited additional work to generate actionable reporting. Similar to our practices, many NMD participants have found that the data-driven reporting has improved their overall breast imaging practices by starting a conversation

Figure 1. Map of NMD facilities in the United States

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on quality and process, by highlighting training needs, and by building confidence in interpretative skills. NMD participation also allows practices to objectively measure the impact of specific quality initiatives and to provide ongoing, current feedback on new initiatives.

In this era of health care quality improvement and pay for performance, NMD is a great way for radiology practices to document their quality improvement efforts for interested third parties. Practices can distinguish themselves from others by demonstrating a commitment to continuous improvement. This objective, up-to-date comparison tool facilitates implementation of quality measures and helps identify and target areas for improvement, which in turn improves patient outcomes.

The NMD allows participants to advance their specific mammography practices while also contributing to our collective mission to improve patient outcomes. The good news is that if your facility is an ACR Breast Imaging Center of Excellence, the registration fee is waived and it is now free

The National Mammography Database: What It Is and Why You Should Join, continued from previous page

Figure 2. Screenshot of NMD semiannual feedback report. You can compare your practice’s recall rate to the national NMD and BCSC benchmarks as well as to your peers in a similar geographic region, practice type, and location.

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The National Mammography Database: What It Is and Why You Should Join, continued from previous page

to join. If you are not already a participant, we hope that your practice capitalizes on this powerful tool that allows breast imagers to easily track and benchmark key metrics. Please refer to Dr Leung’s article in the next issue of the SBI newsletter on how to join the NMD.

You can find more information by visiting http://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/National-Mammography-DB or emailing nrdr@acr.org. Sample reports for facilities and individual physicians can be found at:

http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/NRDR/NMD/NMDSampleFacilityReport.pdf

http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/NRDR/NMD/NMDSamplePhysicianReport.pdf

The authors can be reached at: Patel.Bhavika@mayo.edu

Mayo Clinic Arizona, Department of Radiology, 5777 E. Mayo Blvd, Phoenix, AZ 85054.

Cindy.Lee3@ucsf.edu

University of California San Francisco, Department of Radiology and Biomedical Imaging, Box 0628, San Francisco, CA 94143.

REFERENCES

1. Patti JA. The national radiology data registry: a necessary component of quality health care. J Am Coll Radiol. 2011;8(7):453.

2. 2. Qualified clinical data registry reporting. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html. Updated June 16, 2016. Accessed June 24, 2016.

3. NMD ABR PQI project description. National Radiology Data Registry/American College of Radiology website. https://nrdr.acr.org/Portal/NMD/Main/page.aspx. Accessed June 24, 2016.

4. Rosenberg RD, Yankaskas BC, Abraham LA, et al. Performance benchmarks for screening mammography. Radiology. 2006;241(1):55-66.

5. Lee CS, Bhargavan-Chatfield M, Burnside ES, Nagy P, Sickles EA. The National Mammography Database: preliminary data. AJR Am J Roentgenol. 2016;206(4):883-890.

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R ecently I received a call from a radiologist asking me to provide 8 hours of positioning training for his technologists. They had failed American College of Radiology (ACR) accreditation for positioning and needed to

document the training in order to resubmit new images, which were due in a week. A side note here: if you fail, get help EARLY. When I met the radiologist in his office on the morning of the training, he began to tell me that his techs obviously didn’t know how to position correctly. This is a common assumption that is not entirely untrue. I met with the techs, who were all experienced mammographers with varying years of experience. I presented a lecture on standardized positioning and correlational anatomy and then gave a hands-on demonstration with a model. Almost all were surprised by the way I positioned, which was based on the tenets of consistency, reproducibility, and sound ergonomics. I learned these principles way back in the 1990s and have modified them to accommodate the changes in technology over the years. They all laughed nervously because none of them positioned this way. In fact, their positioning techniques were all different from each other’s. This is a scenario I see in hundreds of facilities throughout the country. I started asking myself, “What has changed? What did they miss that I did not?” These were all women who were proud of their work and were often embarrassed by their failure. They were doing the best they knew how. Fortunately, most technologists want to learn techniques, and they want to improve and do their best possible work for the patients. These technologists were lacking essential training updates for positioning or had insufficient initial training using a standardized method.

Back in the day (1980-2000), mammography technology came charging along and all the female techs in the department suddenly had to perform mammography. There were no application specialists, no mammography courses, and certainly no online classes because there was no “online.” Fortunately, several pioneers of mammography, including Daniel B. Kopans, MD, FACR, FSBI; Edward A. Sickles, MD, FACR, FSBI; and Lawrence W. Bassett, MD, FACR, FSBI emphasized the importance of standardized positioning and supported the team approach to learning, where technologists and radiologists attend hands-on positioning courses together. One of my favorite memories is that of a middle-aged, bald male radiologist who, while positioning a “perfect” model, looked up nervously with his hands shaking and sweat dripping from the top of his head and said to me, “Wow, this is not that easy.” But we all learned together. The ACR held positioning classes at their annual breast imaging conference, a positioning video was made, and we all understood that this was the way to

A Technologist’s Perspective of the FDA Report “Poor Positioning Responsible for Most Clinical Image Deficiencies, Failures” By Louise Miller, RT(R)(M)

Louise Miller, RT(R)(M)

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A Technologist’s Perspective of the FDA Report “Poor Positioning Responsible for Most Clinical Image Deficiencies, Failures,” continued from previous page

position. As standards changed, mostly because of the implementation of the Mammography Quality Standards Act (MQSA), technologists scrambled to get 40 hours of required education (not training) in mammography. Conferences were held throughout the country where equipment vendors would send machines for hands-on positioning training. We learned and we taught. The MQSA was an incredible step in improving the quality of mammograms.

Here are some interesting points that I think deserve consideration, given the positioning crisis as defined by the US Food and Drug Administration (FDA).

1. The MQSA does not specify that the 40 hours of mammography education must include hands-on positioning. (One can actually get all 40 hours of credit online!)

2. The MQSA does not require that hands-on training be included in the 15 continuing education units in mammography that techs must obtain every 3 years. Most credits are obtained online. Although the articles may be interesting and informative, they cannot correct positioning problems.

3. Images sent to the ACR for accreditation every 3 years for each mammography unit may represent the work of only 1 or 2 technologists in facilities where thousands of exams are performed by multiple technologists. This is the only real evaluation of positioning, and as the FDA report shows, it’s not going so well.1

4. Aside from the ACR images, the only feedback techs get on positioning is from our radiologists, who often have very little familiarity with the positioning process. Technologists may be informed of inadequacies in their positioning, such as insufficient pectoralis muscle or inframammary fold (IMF), but they may not know how to correct the problems. We need to be taught proper technique. A technologist who over-rotates a skull image knows exactly how to fix it. This is not necessarily the case with mammography. Our education needs to focus on problem-solving and include the principles of correlational anatomy and physiology.

5. The lack of current (stated) standardized methods of positioning makes it very difficult for students to learn these techniques. This is prevalent in most mammography facilities where bad habits are passed on to future generations of technologists.

6. The variability and inconsistency of proven positioning techniques in mammography is in clear contrast to techniques that technologists use for positioning other body parts. Every technologist worldwide performs a spine, wrist, ankle, and pelvis radiograph in the same way, using the same imaging sequences. Not so in mammography. The lack of consistency and reproducibility of positioning techniques affects everything about an imaging study when compared year to year. Are you able to easily tell which of your techs produced which mediolateral oblique image? You should not be able to see those individual differences.

7. Improper body ergonomics resulting in workplace injuries are a growing problem and affect

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A Technologist’s Perspective of the FDA Report “Poor Positioning Responsible for Most Clinical Image Deficiencies, Failures,” continued from previous page

the overall morale and finances of a department. Look around your department. How many techs have back, wrist, and shoulder problems that have required surgeries? Many are a result of using poor positioning techniques. If your techs are sitting down to position their mediolateral oblique images, get ready for some rotator cuff issues. This can be avoided! Technologists must understand correlational anatomy used for positioning and image analysis. For example, what should they do if they don’t get the pectoralis muscle down to the posterior nipple line? If they are missing the IMF on the image, what specifically can they do to include it?

8. The last positioning study was published in 1993. Yes, 1993. The study conducted by Bassett et al followed 6 technologists who underwent standardized positioning training.2 68% of the examinations were improved after training!

9. Although positioning techniques are similar for digital and film screen mammography, my experience is that because of the marked increase in image receptor and face shield size, accommodations must be made when positioning patients on digital formats.

I believe most mammography technologists want to do excellent work. Unfortunately, many have not received the appropriate foundational education, which I believe should include mandatory hands-on positioning updates. When we know better, we do better. But with the rapid advances in breast imaging and the decline of hands-on positioning opportunities, we must work together to ensure that we have the knowledge we need to meet these important goals.

As the FDA has noted, “The consequences of poor positioning can be very significant not just for individuals but for mammography facilities as well....To achieve and maintain proper positioning, both training and communication are essential.” Please support your technologists in the endeavor to provide the best in image quality and patient care.

REFERENCES

1. US Food and Drug Administration. Poor positioning responsible for most clinical image deficiencies, failures. www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/FacilityScorecard/ucm495378.htm. Updated April 11, 2016. Accessed July 8, 2016.

2. Bassett LW, Hirbawi IA, DeBruhl N, Hayes MK. Mammographic positioning: evaluation from the view box. Radiology. 1993;188(3):803-806.

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G oogle “dense breasts” and at least 10 relevant websites will come up. Unfortunately, the best ones are not at the top of the list. This article provides a review of the content of multiple online sources (in

alphabetical order) of information for radiologists and patients.

American College of Radiology The American College of Radiology has a PDF brochure (http://www.acr.

org/News-Publications/~/media/180321AF51AF4EA38FEC091461F5B695.pdf ) that can be downloaded for patient use and also provides brief, clear, and reasonably balanced information.

American Cancer Society The American Cancer Society has a very clear 2-page PDF file (http://www.cancer.org/acs/groups/

content/@editorial/documents/document/acspc-039989.pdf ) on breast density. Patients are clearly the intended audience. No data are provided but pros and cons of ancillary screening are at least touched upon.

Are You Dense: Exposing the Best-Kept Secret This website (http://www.areyoudense.org) represents a 501(c) charitable organization founded by

Nancy Cappello, PhD. Dr Cappello detected her breast cancer by palpation months after a normal screening mammogram. She went on to learn about breast density and advocate for patient education and notification, resulting in the first state (Connecticut) legislation on this issue. The website provides patient-level information about breast density and primarily focuses on masking through numerous patient stories. Most stories are from women with large or advanced-stage disease presenting shortly after a normal mammogram, presumably because of dense tissue. The site instructs women to talk with their doctors about more screening tests and states that these are covered in Connecticut. It then directs women to the advocacy site for more information for their state. The site is very passionate in its approach, but other websites provide more comprehensive information on breast density. The board of directors does not include any MDs.

Breastcancer.org Breastcancer.org is a comprehensive nonprofit site with a professional advisory board including

radiologists. It is dedicated to all aspects of breast cancer, from diagnosis to treatment to survivorship. The site includes a single page (http://www.breastcancer.org/risk/factors/dense_breasts) providing information on breast density. The information is limited and focuses on reducing risk through diet,

Breast Density Websites: Where to Send Your Patients and Referring Providers for Information By Jennifer Harvey, MD, FACR, FSBI

Jennifer Harvey, MD, FACR, FSBI

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Breast Density Websites: Where to Send Your Patients and Referring Providers for Information, continued from previous page

healthy body weight, etc. Links to possible ancillary screening lead to general information on ultrasound and magnetic resonance imaging, rather than data or pros and cons. Not very helpful for this topic.

Breast Density Info This site (http://www.breastdensity.info) was organized in 2013 by the California Breast Density

Information Group—composed almost entirely of radiologists from California—to provide information primarily to providers in response to their breast density notification legislation. Patients may benefit as well. The site provides a good review of breast density knowledge and is easy to navigate. The site has flowcharts for providers. Information about ancillary screening is provided but only in generalities. Numerical data to support decision-making would be helpful. The downside is that information does not appear to have been updated since it was first launched. For example, the website states, “Breast tomosynthesis (‘3D mammography’) is being offered in addition to screening mammography in some centers,” and no current data about tomosynthesis in dense breasts are provided. The most recent reference is from 2013. Overall this site is very user-friendly and has good information for radiologists and nonradiologist providers but could benefit from inclusion of numerical data and an update.

Dense Breast Info I need to disclose that I am one of many scientific advisors for this site.

This website (http://densebreast-info.org) is the most comprehensive and easy to navigate. It was created as a 501(c) and the advisors are all MDs. It is also supported by some breast imaging and biopsy-related vendors (http://densebreast-info.org/educational-supporters.aspx). In the center of the home page are tabs “For Patients,” “For Healthcare Providers,” “Technology,” and “Legislation.” The first 2 are similar in content, covering breast density knowledge and implications for care. The site includes a risk form that can be downloaded for patients to bring to their healthcare providers to help guide discussion. The site discusses ancillary screening but is not heavy-handed. I appreciate this statement: “You need to consider your own tolerance for false positives compared to the potential benefit of improved cancer detection when deciding whether or not to have additional screening.” Technology information is up-to-date and even includes evolving technologies such as contrast-enhanced mammography. The site provides a table that includes information on interval increase in

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cancer detection and false-positives. In addition, the legislation tab indicates which states have density notification laws and details of the legal nature and wording. For example, the recent law effective July 1, 2016, in Indiana has no specific language or criteria for notification. Navigation of the site is quite manageable. Of note, this website does not appear until page 3 of a Google search for “dense breasts,” so many people will not find it on their own.

Komen Komen (http://ww5.komen.org/Breastcancer/Highbreastdensityonmammogram.html) is familiar to

all of us and is frequently the first website to be listed in a search. Although the site states that they support national legislation on breast density notification, they are very soft and even negative in the discussion of ancillary screening. For example, the site states, “Digital may offer screening benefits over film mammography for women with dense breasts.” No data are provided and several links are broken or lead to a different page. Not recommended.

There are many other sites that discuss breast density. Many are located within an institution, such as Memorial Sloan Kettering (https://www.mskcc.org/blog/diagnostic-radiologist-carol-lee-discusses-what-women-should-know-about-breast-density) and the Mayo Clinic (http://www.mayoclinic.org/tests-procedures/mammogram/in-depth/dense-breast-tissue/art-20123968). These sites are simple, with basic information that provides a good starting point for patients and providers. Others, such as Cancer Treatment Centers of America (http://www.cancercenter.com/discussions/blog/breast-density-becoming-an-important-predictor-of-breast-cancer-risk/), simply reiterate information from Komen.

In summary, the most up-to-date, comprehensive site for breast density knowledge is the Dense Breast Info site, with easy-to-navigate information for patients and providers. Again, note that this does not come up at the top of the search, so patients and providers will need direction to find it. Breast Density Info provides a comprehensive and well-written review of density in response to California legislation in 2013. It is aimed primarily at providers and could benefit from an update. For a starting point for discussion with patients, the American College of Radiology and American Cancer Society have nice PDFs that can be downloaded for distribution at your facility.

Breast Density Websites: Where to Send Your Patients and Referring Providers for Information, continued from previous page

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Every other year in June approximately 200 researchers interested in breast imaging meet to discuss the latest technical developments and clinical results for different breast imaging modalities. The meeting

consists of a mixture of invited talks, proffered talks, and posters. This year, the meeting was held in Malmö, Sweden, and was hosted by Anders Tingberg, PhD, Kristina Lång, MD, PhD, and colleagues from Lund University in Sweden. https://www.malmokongressbyra.se/iwdm2016_-_13th_international_workshop_on_breast_imaging.

The conference started with an invited talk by Sophia Zakrisson, MD, PhD, who summarized the results of the Malmö Breast Tomosynthesis Screening Trial. The Malmö study compared digital mammography with digital mammography and a single tomosynthesis mediolateral oblique view. They found an increase in cancer detection rate but also an increase in recall rate for tomosynthesis compared to digital mammography. They were unsure why the recall rate was higher for tomosynthesis. Emily Conant summarized some of the findings from the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) trial, which imaged women with 2-view tomosynthesis and digital mammography over consecutive years. The study examined whether the performance of tomosynthesis can be maintained over time. The PROSPR trial found that the trend in cancer detection rate increased over a 4-year period, with concomitant increase in positive predictive value. The interval cancer rate decreased over the first year, but more follow-up is needed to complete the analysis for subsequent years.

Several groups working on virtual clinical trials (VCTs) presented excellent anatomical models of the breast and breast cancers. The goal of VCT is to model the breast and breast lesions, the imaging system, and the radiologist so that an imaging trial could be conducted in silico. A VCT could also be used compare several different tomosynthesis reconstruction algorithms or to determine the best scan angle to image microcalcifications. An example of a partial VCT presented at the meeting (they did not model radiologists) was described for characterizing different display devices. The designers showed that an advanced 12-megapixel display was better at detecting simulated lesions in realistic mammographic backgrounds than the 5-megapixel display used in standard clinical settings.

There were several talks on computer-aided diagnosis (CAD) systems. Much of the work examined the use of deep learning or convolution neural networks to produce results superior to existing clinical CAD systems. Such approaches can produce a CAD system with a very low false-positive rate comparable to that of radiologists (assuming a 10% recall rate).

Highlights of the 13th International Workshop on Breast Imaging By Robert M. Nishikawa, PhD, FSBI

Robert M. Nishikawa, PhD, FSBI

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Highlights of the 13th International Workshop on Breast Imaging, continued from previous page

The breast density session began with an invited talk by Per Hall, MD, PhD, who gave an overview of the Karolinska mammography project for risk prediction of breast cancer (KARMA). The goal of the research is to create the world’s best-characterized breast cancer cohort and use it to reduce mortality and incidence of breast cancer, focusing on prevention. They use breast density as a marker for breast cancer risk. They have over 70,000 participants and continue to accrue women at a rate of 2500 per month. One sub-project, KARISMA, is a randomized clinical trial to identify an optimal tamoxifen dose for reducing the risk of breast cancer. They have found that within 3 months of starting tamoxifen they are able to measure a difference in breast density. Importantly, the data in KARMA are available to other researchers upon request as long as there is no overlap with an existing project.

Eva Fallenberg, MD, from Charité in Berlin, gave an excellent overview of spectral and contrast-enhanced mammography (CEM). She summarized several studies showing that compared with dynamic contrast-enhanced magnetic resonance imaging, CEM has similar sensitivity but superior specificity. In particular, higher spatial resolution was important for imaging microcalcifications. Spectral imaging is a method to record not only the number of photons hitting the detector but to some extent the energy of the photons. By configuring the detector to count the number of photons above and below some energy threshold, it is possible to implement dual-energy imaging using a single exposure, saving time and dose and eliminating image registration problems. This is particularly valuable in CEM. A novel application of spectral imaging is to distinguish cysts from solid lesions using mammography. In a simulation study, it was shown that 99% sensitivity with 26% specificity was possible in differentiating solid lesions from cysts. That is, if the lesion is actually solid, the technique has a very high positive predictive value. The simulation method can be used to optimize the imaging system. A spectral photon-counting tomosynthesis system was also shown to be able to make very accurate and precise measurements of volumetric breast density in a pilot clinical study. Such a system may be better suited to monitor changes in breast density on an individual basis than other methods, and therefore it has an advantage in monitoring response to treatments such as tamoxifen.

Still very much in the laboratory stage of development, phase-contrast mammography is an x-ray–based modality that relies on both x-ray attenuation and diffraction of the x-ray beam. There are several potential advantages of phase-contrast imaging. First, soft-tissue contrast is enhanced. Second, interfaces between tissue types are also enhanced with the appearance of edge enhancement. The images are somewhat reminiscent of xerography but without the loss in large area contrast. Further, because phase contrast is not dependent on x-ray absorption, the radiation dose can potentially be reduced by using higher x-ray energies. At the conference, Marco Stampanoni, PhD, ETH Zürich (Swiss Federal Institute of Technology in Zürich), gave an invited talk that provided an overview of the technique. He showed images that highlighted the potential to

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provide more diagnostic images compared to conventional mammography. Several other talks on the topic examined image quality and dose issues, and a collaborative group from Trieste, Italy, and Melbourne, Australia, described a clinical phase-contrast computed tomography system for the breast. They showed impressive images of phantoms and excised breast tissue that were taken on their system.

This was truly an international conference. Authors from 20 countries presented papers and all continents (except Antarctica) were represented. I encourage all interested breast imagers to attend future meetings. Between 5% and 10% of attendees are radiologists from many different countries: the United States, Canada, Germany, Sweden, Belgium, and more. A higher representation of radiologists would enhance the meeting and help move the field forward more quickly. Radiologists get to learn about cutting-edge research and may influence the direction of new technologies and innovations to maximize clinical impact. The next meeting will be in 2018, hosted by Elizabeth Krupinski, PhD, from Emory University. I am sure you will see a few SBI fellows who regularly attend the meeting. Hope to see you there.

Highlights of the 13th International Workshop on Breast Imaging, continued from previous page

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T he 2016 American College of Radiology (ACR) Digital Mammography Quality Control (QC) Manual is now available in electronic format. The new manual is a collaborative effort among medical physicists,

radiologists, mammography technologists, and industry representatives. Written by the ACR Subcommittee on Mammography Quality Assurance (Eric Berns, PhD [chair]; Jay Baker, MD, FACR, FSBI; Lora Barke, DO; Lawrence Bassett, MD, FACR, FSBI; R. Edward Hendrick, PhD, FACR, FSBI; Debra Monticciolo, MD, FACR, FSBI; Doug Pfeiffer, MS, FACR; Margarita Zuley, MD, FACR, FSBI; Christine Adent, RT(R); Shelli Dixon, RT(R); John Sandrick, PhD [Medical Imaging & Technology Alliance (MITA)]; Robert Uzenoff, BS [MITA]; Moustafa Zerhouni [MITA];

Priscilla Butler, MS, FACR, FSBI [ACR staff]; Marion Boston, RT(R) [ACR staff]; and Pamela Platt, BSRT(R) [ACR staff]), the manual provides user-friendly instructions to perform and document QC across all manufacturers and types of digital mammography equipment. The objective of the manual is to ensure high-quality digital mammograms while keeping radiation doses low.

In February 2016, the Food and Drug Administration (FDA) approved the ACR’s new Digital Mammography QC Manual and Digital Mammography QC Phantom as alternative standards for use in routine QC of digital mammography equipment. Currently, the FDA requires digital mammography facilities to perform QC for approved imaging systems according to their respective manufacturers’ quality control manuals. This alternative standard allows mammography facilities, including QC technologists and medical physicists, to use the new ACR manual in lieu of their

New ACR Digital Mammography Quality Control Manual Now Available By Priscilla Butler, MS, FACR, FSBI

Priscilla Butler, MS, FACR, FSBI

Figure 1. New ACR Digital Mammography Phantom and Schematic of Specifications

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Test Minimum Frequency Corrective Action TimeframeTechnologist Tests1. ACR Digital Mammography Phantom Image Quality Weekly Before clinical use2. Computed Radiography Cassette Erasure

(if applicable) Weekly Before clinical use

3. Compression Thickness Indicator Monthly Within 30 days

4. Visual Checklist Monthly Critical items, before clinical use; less critical items, within 30 days

5. Acquisition Workstation Monitor QC Monthly Within 30 days; before clinical use for severe defects

6. Radiologist Workstation Monitor QC Monthly Within 30 days; before clinical use for severe defects

7. Film Printer QC (if applicable) Monthly Before clinical use8. Viewbox Cleanliness (if applicable) Monthly Before clinical use9. Facility QC Review Quarterly Not applicable10. Compression Force Semiannually Before clinical use

11. Manufacturer Detector Calibration (if applicable) Manufacturer recommendation Before clinical use

Optional - Repeat Analysis As Needed Within 30 days after analysis

Optional - System QC for Radiologist As Needed Within 30 days; before clinical use for severe artifacts

Optional - Radiologist Image Quality Feedback As Needed Not applicableMedical Physicist Tests1. Mammography Equipment Evaluation (MEE):

Mammography Quality Standards Act Requirements MEE Before clinical use

2. ACR Digital Mammography Phantom Image Quality MEE and Annually Before clinical use3. Spatial Resolution MEE and Annually Within 30 days4. Automatic Exposure Control System Performance MEE and Annually Within 30 days5. Average Glandular Dose MEE and Annually Before clinical use

6. Unit Checklist MEE and Annually Critical items, before clinical use; less critical items, within 30 days

7. Computed Radiography (if applicable) MEE and Annually Before clinical use

8. Acquisition Workstation Monitor QC MEE and Annually Within 30 days; before clinical use for severe defects

9. Radiologist Workstation Monitor QC MEE and Annually Within 30 days; before clinical use for severe defects

10. Film Printer QC (if applicable) MEE and Annually Before clinical use11. Evaluation of Site Technologist QC Program Annually Within 30 days12. Evaluation of Display Device Technologist QC

Program Annually Within 30 days

MEE or Troubleshooting: Beam Quality (Half-Value Layer) Assessment MEE or Troubleshooting Before clinical use

MEE or Troubleshooting: kVp Accuracy and Reproducibility MEE or Troubleshooting MEE, before clinical use;

troubleshooting, within 30 days

MEE or Troubleshooting: Collimation Assessment MEE or Troubleshooting MEE, before clinical use; troubleshooting, within 30 days

Troubleshooting: Ghost Image Evaluation Troubleshooting Before clinical useTroubleshooting: Viewbox Luminance Troubleshooting Not applicable

Table 1. New ACR Digital Mammography Quality Control (QC) Tests

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New ACR Digital Mammography Quality Control Manual Now Available, continued from previous page

manufacturers’ QC manuals. The FDA’s alternative standard approval specifies that the new manual may be used only for full-field digital mammography systems without advanced imaging capabilities (eg, tomosynthesis and contrast enhancement).

The ACR’s original Committee on Mammography Quality Assurance, chaired by Gerald Dodd, MD, first published its Mammography Quality Control Manual in 1990 to provide QC procedures for screen-film mammography. Three subsequent versions were published, the latest in 1999 under the chairmanship of R. Edward Hendrick, PhD, FACR, FSBI. In 2000 the first full-field digital mammography unit was approved by the FDA for clinical use. Since then, the FDA has required that facilities perform QC for approved digital mammography systems according to their respective manufacturers’ QC manuals. The new manual and phantom will aid in ensuring uniformity of QC testing.

The manual consists of 3 sections: Radiologist, Radiologic Technologist, and Medical Physicist. The latter 2 sections contain detailed instructions and procedures for quality control tests without being too rigid, allowing for differences among digital manufacturers (see table of QC tests). Action limits are given for each test.

New to this release are tests and ways to run a QC program resulting from the evolution of modern digital mammography (Table 1). Today, facilities include networks with multiple machines, monitors, picture archiving and communication systems, and, most significantly, locations. Every QC test in the manual has been adapted for digital mammography. The move from film display to softcopy display has presented a new challenge for QC and documentation. The concept of a QC team with the radiologist included in a formal QC review test is new to this manual.

Additionally, a new, larger phantom that resembles the previous ACR accreditation mammography phantom has been introduced to optimize for artifact evaluation while maintaining the ability to measure dose according to FDA requirements. Test object scoring is similar to the old phantom so that users of the new phantom will not have a steep learning curve (Figure 1). In order to ensure that all ACR mammography phantoms manufactured and sold for accreditation purposes are consistent and meet ACR specifications, the ACR has established a testing process to evaluate and approve manufacturers of the new ACR Digital Mammography Phantom. Approved manufacturers of the ACR Digital Mammography Phantom are listed on the ACR website at http://www.acraccreditation.org/Modalities/Mammography.

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New ACR Digital Mammography Quality Control Manual Now Available, continued from previous page

A link was sent to all mammography facilities accredited by the ACR (or those in the process of accreditation) to download the new manual at no charge. These facilities should forward the manual to their medical physicists responsible for annual surveys and technologists responsible for QC. Individuals not associated with ACR-accredited facilities may purchase the manual from the ACR catalog at http://www.acr.org/Education/Education-Catalog.

The new ACR Digital Mammography QC Manual and ACR Digital Mammography Phantom will go into effect in 2017 for those facilities that choose to use the new manual for QC. This means that facilities will not be able to submit images of the new phantom or QC testing results with the new manual for ACR accreditation until 2017. However, the ACR encourages mammography facilities to start using the new manual alongside existing QC prior to that time to become familiar with the changes. Free webinars are being developed to aid technologists and medical physicists in the use of the new QC manual and phantom. For more information, visit the ACR Digital Mammography Quality Control Manual Frequently Asked Questions at http://www.acraccreditation.org/~/media/ACRAccreditation/Documents/Mammography/DMQCFAQs_3-11-16.pdf?la=en.

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What I’ve Learned: Etta Pisano, MD, FACR, FSBIBy Ann L. Brown, MD

Dr. Etta Pisano, MD,FACR, FSBI, has made an indelible mark on the breast imaging world. She seems to embody all that a radiologist, scientist, community leader, and mother can do. Naturally, when choosing

whom to profile for this piece, I gravitated towards her. The following interview with Dr Pisano allows us a first-hand look into her life, work, and lessons learned.

Your work has contributed significantly to the evolution of our field. How have you seen breast imaging change since you began practicing?

When I came out of training in 1988, people around the country were beginning to do stereotactic and ultrasound core biopsies but it wasn’t widely disseminated and we certainly weren’t doing digital mammography or tomosynthesis. I always say in our field if you stop learning when you graduate, you’re behind. Our field just evolves so quickly. And I was involved in a lot of it—the transition from surgical biopsy to core biopsy and film mammography to digital mammography. It’s very gratifying to be part of that evolution.

You have a long list of accomplishments as a radiologist and scientist. What has given you the greatest satisfaction thus far in your career?

I would say the work that I’ve done on behalf of women, both professional women—to help the advancement of women—and women patients. At UNC [University of North Carolina], I was very active in getting the campus to adapt to women. There was no maternity leave policy and it was really hard to get promoted as a woman. Even though I had already had my maternity leaves and been promoted, I spent a lot of energy advocating for other women. It was important for me to do that work.

Who influenced you the most in your career?

The two most important people that helped me were Ferris Hall at Beth Israel [in Boston] and Bob McClellan at UNC [in Chapel Hill]. Ferris was a role model to me when I was a resident. He was

Much of what we know has been validated by scientific investigation and published in web-accessible journals for all to see. But there is so much more we learn through daily experience and interaction with our colleagues and patients. Where is that stored? How can we access it? If we are lucky, a talented veteran colleague will impart wisdom at opportune moments. We introduce a series of articles in the SBI Newsletter called “What I’ve Learned.” Our goal is to transmit the experience of our leaders far beyond the halls of their own breast centers to the many young dedicated custodians of the future of breast imaging.

Etta Pisano, MD, FACR, FSBI

Ann L. Brown, MD

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ahead of his time in talking to patients, which was unusual for a radiologist to do in those days, and he taught me how to read mammograms. Bob mentored me and supported me through all of my early grant writing and introduced me to hundreds of people, which had a big influence on me. They are both still dear friends.

What is your recipe for a successful career in research?

I was a philosophy major in college. It was hugely useful training for me because I learned how to write and think clearly and I learned how to construct arguments logically. It is the exact same process in research. The things I tell people if you want a scientific career are that you have to learn how to argue and write clearly. The other thing I always tell people is that you have to be willing to fail and then try again and again and again. You have to be dogged, because if you’re willing to give up after one try, you’re not going to be a scientist.

You mention failure. What is an example of something you have failed at and how did you bounce back?

The biggest thing recently is the company that I founded. One of the things I worked very hard on was a new technology called diffraction imaging. I tried for almost a decade to bring it to market and I still think it would be very useful but I couldn’t commercialize it. Something like 90% of all start-ups fail so I’m not devastated by it. If you’re not failing sometimes, you’re not trying enough. I’m a pretty resilient person and an optimistic, can-do person so it doesn’t bother me when I fail.

Where do you draw your strength?

I came from a very strong family. My father is a radiologist and my mother was an electrical engineer. My father was very confident in me and gave me a lot of positive strokes growing up. Also, I lost my mom when I was 15. I was the oldest of 7 and she died suddenly so it was a real maturing experience. You just learn how to get things done when you’re thrown into those kinds of circumstances. I had a lot of opportunities to be strong and so you learn that you are strong. Then in college I met my husband and he has been like a rock for me.

You and your husband have raised 4 children together. As a working mother, how did you strike a balance between your family and work?

First off, we are so lucky as radiologists to have the resources that we do. I always look at women who are cashiers, secretaries, and waitresses—they have a much harder time because they don’t have the resources that we have. My husband and I are both doctors so we were very privileged and we used the resources that we had. The whole time our kids were growing up we had in-home help. I worked part-time for 5 years because I had little kids. Jan and I were partners and we did everything equally. It wasn’t a chore to me—it was a joy to me.

What I’ve Learned: Etta Pisano, MD, FACR, FSBI, continued from previous page

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What is your best advice to a young radiologist like myself who is just starting out?

I’ve had a lot of opportunities to give a lot of advice over the years and what I always tell people is to figure out what you want. If you don’t understand where you want to go, you can’t get there. So know your goals and then go for it! Don’t be half-hearted. ‘Life’s too short to be shy’ is something we always tell our kids. It’s important to think big. Don’t just think about the next 5, 10, or 15 years…. You really need to think about what you’re going to say about your life at the end of your life. If you do that, then a lot of things become obvious. I would also say that if you’re interested in academics as a career, saying yes to most things people ask you for is the right thing. You can decide no after you’ve tried something.

On the flip side, what is your advice to a more senior radiologist considering retirement?

It’s the same thing. I’ve known people who have waited too long to retire. That’s kind of sad because I think that the retirement years can be a period of great joy and fulfillment. I have a hard time imagining myself as completely retired, but I feel that you shouldn’t forgo that period of your life. Many of my role models, family, and friends have had lovely retirements. You should think about what your values are. There are some people who want to work and that’s all they want to do. I have enough other things in my life that I could see myself doing those things with a lot of joy, so I’m hoping that I get to do that some day.

What do you believe is the biggest challenge facing breast imaging?

I don’t think that this issue of whether breast cancer screening works or not is going to go away on its own. People are going to continue questioning whether what we do is of value to patients. We’ve got to find a way to develop more evidence that what we do is of value, because we’re arguing about studies that are 30 to 40 years old. What people who don’t believe in mammography are worried about is that we’re finding things that don’t matter and that we don’t need to find things so early with the new therapies that exist. We’ve got to address these questions because they’re not going away. If anything, the attacks on breast imaging are becoming more serious as the studies get older and older, the therapies get better and better, and our tools become more sensitive.

What do you predict for the future of our specialty?

I actually think we are going to have blood biomarkers for cancer. It may take 30 years, but I think we’re going to find pieces of RNA or DNA or protein fragments that will be highly suggestive of malignancy in a patient. That will lead to an incredibly detailed workup of the body from head to toe. People worry that imagers are going to become obsolete but of course we’re not. They’re not going to know where the cancer is, but we will have more individually adjusted screening criteria. I think we’re heading towards a different paradigm for how to screen. It means radiologists will have to change, but we can do that.

What I’ve Learned: Etta Pisano, MD, FACR, FSBI, continued from previous page

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Dr. Pisano is Dean Emerita of the Medical University of South Carolina College of Medicine. She served as Principal Investigator of the largest clinical trial ever run by a radiologist, the Digital Mammographic Imaging Screening Trial. She is a past president of the Association of University Radiologists and American Association for Women Radiologists and received Gold Medals from the Radiological Society of North America, the American Roentgen Ray Society, and the Association of University Radiologists. She recently returned to her former training grounds in Boston as the Vice Chair of Research at Beth Israel Deaconess Medical Center. She lives in Cambridge with her ophthalmologist husband, Jan, and together they have 4 successful children—Carolyn, Jimmy, Schuyler, and Marijke—and 1 adorable grandson, Abe. When they are not traveling or visiting family, she enjoys solving puzzles, learning to cook, and taking walks with their 2 Labrador retrievers, Wiggles and Libby.

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A 77-year-old man presented with a left breast mass. A

mammogram with tomosynthesis was performed (Figure 1). How would you interpret these images?

A mammogram of the right breast was negative, without evidence of gynecomastia. Spot-magnification views and targeted ultrasound of the left breast mass were performed.

Spot-magnification views confirmed the presence of an oval-shaped, subareolar, high-density mass with microlobulated margins (Figure 2). Ultrasound showed a hypoechoic mass with an irregular shape and angular margins at the site of the mammographic mass. Final BI-RADS assessment was a

Interesting Case: Differentiating Male Breast Cancer From Nodular Gynecomastia By Anika L. McGrath, MD; Habib Rahbar, MD, FSBI; Diana L. Lam, MD

Figure 1. Left breast craniocaudal (CC) (a) and mediolateral oblique (MLO) (b) diagnostic views show an oval-shaped mass in the subareolar position. MLO (c) tomosynthesis view confirms the presence of a high-density mass with posterior microlobulated and spiculated margins.

The SBI Newsletter Committee is excited to provide interesting cases for our members. Our hope is that interesting cases will illustrate one or more valuable teaching points for a scenario or combination of findings that may emerge in any type of daily practice. We are happy to accept an interesting case from any individual or group. The description of a single extremely rare entity (case report) is discouraged unless there is an important aspect to the workup or imaging or clinical picture that merits discussion and can be more widely applied. Please contact the chief editor of the newsletter for questions or submissions at Peter.Eby@virginiamason.org.

Anika L. McGrath, MD Habib Rahbar, MD Diana L. Lam, MD

1 2 3

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suspicious abnormality (BI-RADS Category 4). Ultrasound-guided biopsy was recommended and tissue sampling revealed invasive ductal carcinoma.

This case illustrates a potentially difficult scenario of differentiating male breast cancer from nodular gynecomastia. Male breast cancer is uncommon, accounting for less than 1% of all breast cancers.1 Risk factors include age, family history, chronic estrogen exposure, prior chest radiation, BRCA mutations, and Klinefelter syndrome. The majority of cases (85%) are invasive ductal carcinoma, followed by ductal carcinoma in situ and papillary carcinoma.2,3

Gynecomastia, on the other hand, is the most common male breast abnormality and often presents as unilateral or bilateral soft, tender, mobile masses in the subareolar breast. While most gynecomastia can be diagnosed clinically, imaging may be needed for equivocal cases. For such

Differentiating Male Breast Cancer From Nodular Gynecomastia, continued from previous page

Figure 2: CC (a) and MLO (b) spot-magnification views confirm the high-density, oval, subareolar mass has microlobulated margins. There is associated nipple retraction.

2a 2b

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cases, the American College of Radiology Appropriateness Criteria recommend initial evaluation with ultrasound for men less than 25 years old and bilateral diagnostic mammography for men greater than 25 years old.1 This is because mammography can quickly exclude a mass in most cases, whereas ultrasound can be challenging since gynecomastia may appear as an irregular mass with angular margins and posterior acoustic shadowing, as seen in this case.

Gynecomastia has 3 subtypes or phases: nodular, dendritic, and diffuse. Nodular type is the earliest phase, in which there is florid intraductal hyperplasia without fibrosis. It can mimic a subareolar malignancy. Dendritic type represents chronic fibrotic changes and appears as a triangular flame-shaped density in the subareolar region with interdigitating fat. Diffuse type has both nodular and dendritic components, mimicking the pattern of a heterogeneously dense female breast.

While both the dendritic and diffuse phases of gynecomastia typically can readily be identified with mammography, it can be difficult to distinguish nodular gynecomastia from a solid mass. Key differentiating features for cancer include a location eccentric to the nipple (rather than subareolar), the presence of mass-specific shapes (eg, round, oval, or irregular), margins (eg, circumscribed, microlobulated, or spiculated), and unilaterality. Cancer rarely presents as bilateral synchronous masses, whereas gynecomastia is commonly bilateral and asymmetric. When trying to distinguish gynecomastia from a mass, close attention to the posterior aspect of the finding (particularly on the mediolateral oblique views for the presence of interdigitating fat) can be especially helpful to confidently report the finding as benign.

Conversely, the presence of secondary signs such as nipple retraction, skin thickening, and axillary adenopathy support a diagnosis of cancer. It is important to note that calcifications are rare in male

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Figure 3: Ultrasound demonstrates a solid hypoechoic mass with angular margins in the subareolar region, with associated nipple retraction.

3a 3b

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breast cancer and, if present, appear coarser and potentially more benign when compared to female equivalents.2

In general, solid masses (including those with cystic elements in males) should be biopsied, regardless of morphologic features. This is because lobular proliferation, which accounts for the majority of benign masses in women, is typically absent in men. As a result, a probably benign assessment (BI-RADS Category 3) is generally not appropriate for male breast masses.

In this example, mammography revealed an oval-shaped subareolar mass with microlobulated and spiculated margins. Although the location favored gynecomastia, the patient’s age, clinical history, presence of a definable mass, suspicious margins, nipple retraction, and unilaterality warranted further evaluation with ultrasound. Suspicious features were confirmed on ultrasound and subsequent biopsy showed invasive ductal cancer.

REFERENCES

1. Mainiero MB, Lourenco AP, Barke LD, et al. ACR Appropriateness Criteria evaluation of the symptomatic male breast. J Am Coll Radiol. 2015;12(7):678-682.

2. Lattin GE Jr, Jesinger RA, Mattu R, Glassman LM. From the radiologic pathology archives: diseases of the male breast: radiologic-pathologic correlation. Radiographics. 2013;33(2):461-489.

3. Nguyen C, Kettler MD, Swirsky ME, et al. Male breast disease: pictoral review with radiologic-pathologic correlation. Radiographics. 2013;33(3):763-779.

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2016

September 8-11, 2016 – Barcelona, Spain 2nd World Congress on Controversies in Breast Cancer (CoBrCa)

September 8-10, 2016 – San Francisco, CAAmerican Society of Clinical Oncology (ASCO) Breast Cancer Symposium 2016

September 17-18, 2016 – San Diego, CA Case-Based Review & Advanced Breast Imaging: Digital Breast Tomosynthesis - (Last time it will be offered as a dedicated Weekend Course)

September 23-24, 2016 – Paris, FranceEuropean Society of Breast Imaging (EUSOBI) Annual Scientific Meeting

November 8, 2016 International Day of Radiology

November 27-December 2, 2016 – Chicago, IL RSNA 2016

April 6-9, 2016 – Los Angeles, CA SBI/ACR Breast Imaging Symposium 2017

For a listing of other society events please check out the SBI Calendar of Events at www.sbi-online.org

THIS IS THE LAST TIME THIS COURSE WILL BE OFFERED AS A DEDICATED WEEKEND COURSE!

Register now to get the eight hours of initial training in DBT, including the unique features of the Hologic, GE, and Siemens DBT systems, required by the FDA.

The Member Newsletter of the Society of Breast ImagingClick on this bar to return to Table of Contents