indications for breast imaging tests

�  Indications for breast imaging tests ›  Mammography, ultrasound, MRI

�  Ontario Breast Screening Program (OBSP)

�  BIRADS

�  Rapid diagnostic unit

�  Case examples

� Goal is to find breast cancer early √  Better chance of treating successfully √  Less likely to spread √ May have more treatment options

�  Breast cancer mortality in Ontario has declined between 1990 and 2009 ›  37% ages 50-74 ›  31.5 % for all ages ›  Due to screening and improved treatments

�  Cancer Care Ontario ›  50-74 years of age every 2 years1

�  Canadian Task Force on Preventive Health Care ›  50-74 years of age every 2-3 years2

�  American College of Radiology ›  40-74 years of age every 1 year3

1 - https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9514 2 - http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast-cancer/systematic-review/ 3 - https://acsearch.acr.org/list

� Non-OBSP ›  Physician referral required

� OBSP ›  No referral required ›  Women aged 50-74 can call their nearest

OBSP screening location to make an appointment

https://www.cancercare.on.ca/pcs/screeening/breastscreening/obsp

�  Inviting women to participate in screening �  Reminding patients of next screening test �  Notifying participants of screening results �  Tracking participants through the screening

processes �  Evaluating program quality and

performance �  Screening sites accredited by the Canadian

Association of Radiologists’ Mammography Accreditation Program

�  50-74 years old* �  No acute breast symptoms �  No personal history of breast cancer �  No current breast implants �  No mammogram within the last 11 months * Over age 74, personal decision for

screening. MD can provide referral to OBSP for screening past this age.

�  Started in Ontario in 2011

�  Annual mammography and MRI at a high risk screening centre (list on CCO website)

�  Physician referral required (SB High-Risk Breast Clinic 416-480-6835)

�  Eligibility for high risk screening ›  Age 30-69 ›  BRCA1/2 positive ›  1st degree relative of mutation carrier and have declined

genetic testing ›  ≥ 25% lifetime risk of breast cancer ›  Chest radiation before age 30, at least 8 years previously

�  0.4 mSv to each breast for mammography

� Chest x-ray 0.1 mSv

� CT head 2 mSv

� Natural background radiation 3 mSv

�  Breast symptoms including ›  New palpable lump ›  Nipple discharge ›  Redness of the skin that does not resolve ›  Tethering of the skin ›  Nipple inversion ›  Other symptom/sign suspicious for breast cancer

�  Work-up of mammographic findings on screening mammogram- “call back”

� Masses

� Asymmetry

� Distortion

� Calcifications

�  Extra views performed to assess findings on routine 2 views

›  Spot compression views for masses and asymmetries

›  Magnification views for calcifications

›  Other specialized views for specific situations

Lat mag CC mag

Stereotactic biopsy: Ductal carcinoma in situ

CC spot MLO spot

Invasive ductal carcinoma Lymph node neg

�  1st method for women <30 yo or pregnant �  Work-up of mammographic findings �  Breast symptoms including ›  New palpable lump, breast or axilla ›  Nipple discharge ›  Redness of the skin that does not resolve ›  Tethering of the skin ›  Nipple inversion ›  Other symptom/sign suspicious for breast cancer

�  Rule out abscess

�  2nd look after MRI

�  Known malignancy, multifocal or multicentric?

�  Known malignancy, evaluation of axillary or supraclavicular nodes

�  Male patient with palpable lump

�  Imaging guidance for intervention

� Whole breast and axilla ›  Suspicious mammographic finding or a

suspicious sonographic lesion found

�  Targeted breast ultrasound ›  Screen detected isolated finding ›  Follow-up ultrasound for probably benign

lesions

�  Not performed routinely at academic institutions ›  Data is lacking for general population screening ›  Operator dependent ›  Time consuming

�  Will perform in high risk patients who have contraindications to breast MRI

�  Offered at some clinics

IDC

�  Indications ›  Unilateral breast nipple discharge ›  Clear or bloody ›  Single duct ›  Reproducible

� Causes include ›  Intraductal papillary lesion ›  DCIS ›  Invasive ductal cancer

CC MLO

�  Screening in high risk patients or screening of contralateral breast in patients with breast cancer

�  Extent-of-disease �  Problem solving �  Post-lumpectomy with positive margins �  Neoadjuvant chemo (before, during, after) �  Assess for disease recurrence �  Occult breast cancer (axillary

lymphadenopathy) �  Implant integrity

�  Enhancement in the breast ›  Focus ›  Mass ›  Non-mass

� Other findings ›  Skin and nipple evaluation ›  Chest wall ›  Axillary lymph nodes

IDC LN pos

September 2014 June 2013

IDC

February 2015 June 2014 February 2015 June 2014

MLO views CC views

Pectoralis Invasion

�  Performed for lesions not detected by either mammography or ultrasound

� ACR Guidelines: ›  For all centers performing MRI of the breast-

important to offer MRI guided biopsy

›  If no biopsy capability- relationship with a facility that provides MR biopsy

�  BIRADS – Breast imaging reporting and data system

BIRADS

0 – Further work-up required

1 – Normal examination

2 – Benign findings

3 – Probably benign finding (≤2% chance of malignancy)

4 – Suspicious finding (2 to 95% chance of malignancy)

4a: >2 to ≤10%, 4b: >10 to ≤50%, 4c: >50 to <95%

5 – Highly suspicious finding (>95% chance of malignancy)

6 – Patient has biopsy proven malignancy

�  6 month follow-up recommended �  If stable, further 6 month, then 1 year follow-up

for a total of 2 years �  Will remain BIRADS 3 until 2 year stability shown,

then becomes BIRADS 2 (benign mass)

� Outpatient service �  Single point of access for diagnostic

services �  RDUs: ›  Concentrate and coordinate diagnostic

services ›  Provide information and support to patients ›  Help family doctors get access to diagnostic

tests for their patients ›  Expedite diagnosis and/or time to treatment

�  Any individual with an imaging abnormality or clinical finding that is highly suspicious for malignancy may be referred to the RDU

�  BIRADS 4 or 5 on imaging, suspicious breast lump, clinical findings of inflammatory cancer, etc.

�  Launched May 2011 �  976 patients �  Decrease in median

wait time from referral to diagnosis

58 days 10 days

Referral Process Suspicious Finding

Patient arrives at RDU

Imaging and Core Biopsy

Communicating the Diagnosis

Pathology Analysis

Patient has consult in RDU

Patient’s imaging & core biopsy completed

Core specimen obtained

Pathology analysis complete

Pathology results available

Diagnosis communicated to patient by surgeon or surgical GPO & RN present with patient

Next Day Diagnosis

Sunnybrook Breast Rapid Diagnostic Unit (RDU): Work Flows

October 2011//al

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�  Nursing assessment ›  Clinical history ›  Screened for distress ›  Clinical breast exam ›  High risk assessment ›  Patient education

�  Breast Imaging ›  Mammogram ›  Ultrasound ›  Core biopsy ›  FNA (if required)

�  Follow up instructions

�  Pathology result available the next afternoon

�  Breast radiologist will review pathology result and dictate addendum with rad-path concordance for the surgeon prior to patient’s appointment

�  Patient returns that day to Breast Centre

�  Receives diagnosis from breast surgeon or breast physician

�  Preliminary discussion re: treatment options

�  See Sunnybrook website for referral form:

www.sunnybrook.ca search “breast RDU” �  Contact Emily Walker

in NPB office - ext. 7938

�  Contact RDU Nurse Navigator at ext. 85047