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Breast Imaging: Current Utilization, Trends, and Implications

¹ Iris Cantor Center for Breast Imaging, Radiology Department, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Rm. 165-47, Los Angeles, CA 90095.

Received May 16, 2007; accepted after revision May 18, 2007.

 
Address correspondence to L. W. Bassett.

Presented as the Keynote Address at the 2007 annual meeting of the American Roentgen Ray Society, Orlando, FL.

Keywords: ARRS annual meeting • breast cancer • breast cancer screening • breast imaging • practice of radiology • residency training

Introduction

Top Introduction Patient Contact Exciting New Technologies References

 
In 1975, pursuing a career in musculoskeletal radiology, I was appointed Assistant Professor of Radiology at the University of California at Los Angeles (UCLA). My appointment also required spending at least 1 day a week working in the one-room "mammo" section. Due to the increased utilization of mammography, in 1976 I was appointed Director of Mammography—who else would do it? At that time, residents did not rotate through the mammography section, verifying its low priority in academic radiology departments.

However, in the late 1970s, research studies had begun proving that mammography screening was effective in reducing breast cancer mortality, and those findings were verified by more studies in the 1980s. The American College of Radiology (ACR) responded by developing several programs focused on breast imaging, including a Committee on Breast Imaging (1983), the Mammography Accreditation Program (1987), and the Breast Imaging Reporting and Data System (BI-RADS) (1992). In 1990, the American Board of Radiology (ABR) added breast imaging (category 10) to the ABR oral board examination. As a result of these accomplishments, many of my national colleagues and I became full-time breast imagers. In 1992, the U.S. Congress passed the Mammography Quality Standards Act (MQSA), which set minimal requirements for radiologists interpreting mammograms. Over this time frame, breast imaging had become a required rotation for radiology residency training programs.

Finally, in 2005, the ACR established the Breast Imaging Commission with a seat on the ACR Board of Chancellors, under the leadership of Carol Lee, MD, from Yale University. Although it took a long time, the creation of the Breast Imaging Commission was an exciting and rewarding accomplishment for so many of us who had now devoted our careers to breast imaging. However, we still faced many difficult challenges.

More than 50% of American women 40 years old are now self-referring or being referred for screening mammograms. However, multiple studies conducted by the ACR and government agencies indicate that there are not enough MQSA-qualified radiologists to serve this growing population of women seeking mammography screening [1]—let alone to perform diagnostic workups for abnormal screening examinations.

These studies reported job vacancies for breast imagers in 30% of radiology practices. Facilities with job openings for breast imagers had long waiting times for screening examinations. Breast imaging practices face physician shortages, financial constraints, increased workload, and a steady increase in the population of women 40 years old and older who present for screening.

Obviously, the answer to the dilemma is to recruit young trainees in radiology training programs into the field of breast imaging, but residents were not pursuing breast imaging. Three years ago there were 53 breast imaging fellowship training programs in the United States, but only 43 recruits: Why?

My colleagues and I held telephone interviews with fourth-year radiology residents in all training programs in the United States and Canada [2]. More than 65% of the residents reported that they would not consider a fellow-ship in breast imaging if one were offered to them. The leading reason they gave was that breast imaging was "not an interesting field" (translated into "not high tech"), followed by "fear of lawsuits" and "too stressful."

However, I firmly believe that due to the advances in breast imaging we can now attract residents into breast imaging for these primary reasons: patient contact and exciting new technologies.

Patient Contact

Top Introduction Patient Contact Exciting New Technologies References

 
Breast imagers have become the gate-keepers for patients with breast problems. Many of our residents have told me that they missed patient contact, and they found it fulfilling during their rotations in breast imaging to talk with patients about their imaging findings and recommendations for follow-up protocols or biopsy. They also found fulfillment in participating in the management of patients from the time of their screening examination to imaging workups, imaging-guided biopsies when indicated, and postbiopsy management.

Exciting New Technologies

Top Introduction Patient Contact Exciting New Technologies References

 
New technologies include advanced imaging-guided interventional procedures (95% of breast biopsies are now performed by breast imaging radiologists), digital mammography (with interpretations at workstations rather than at viewboxes), the promise of digital tomosynthesis, computer-aided detection, state-of-the-art high-resolution sonography, and the increasing use of MRI. Breast imaging is now very high tech. It is no longer "not an interesting field." This increase in interest in breast imaging is verified by the 11 abstracts and scientific presentations on breast MRI presented by residents and fellows in breast imaging at the 2007 American Roentgen Ray Society's 107th Annual Meeting in Orlando, FL.

References

Top Introduction Patient Contact Exciting New Technologies References

 

1. Farria DM, Schmidt ME, Monsees BS, et al. Professional and economic factors affecting access to mammography: a crisis today, or tomorrow? Results from a national survey. Cancer 2005;104 : 491-498[CrossRef][Medline]
2. Bassett LW, Monsees BS, Smith RA, et al. Survey of radiology residents: breast imaging training and attitudes. Radiology 2003;227 : 862-869[Abstract/Free Full Text]

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