Interdisciplinary Breast Care: Essential Information for the Treatment Team

Comprehensive Breast Diagnostic Evaluation 

The comprehensive breast diagnostic evaluation should include the patient’s pertinent breast history and results from the clinical breast examination and appropriate imaging to accurately determine the size and extent of the patient’s underlying breast cancer. Current primary prognostic indicators for breast cancer include tumor size, tumor type, tumor grade, nodal status, and presence of systemic metastasis. Tumor size alone can act as a governor for tumor grade through dedifferentiation with time, nodal status, and potential for metastatic disease.

At most institutions, and certainly at mature interdisciplinary comprehensive breast centers, image-guided needle core biopsy (ie, ultrasound, stereotactic, and MRI) is now preferred over surgical biopsy for obtaining definitive tissue diagnosis for most breast problems. This has resulted in even greater responsibility for radiologists, who now must not only determine which patients require biopsy for tissue diagnosis, but also must recommend the most appropriate means for biopsy. The decision regarding the mode of image-guided biopsy, needle size, and number of core samples required for an accurate diagnosis is very important to the care of the patient, and also is a key determinant of the cost for the biopsy. Not only is image-guided core needle biopsy more cost-effective than open surgical biopsy, it is also more time-efficient and results in less patient morbidity. With open surgical biopsy, the surgeon typically assumes the primary responsibility of establishing clinical–pathologic concordance. However, the radiologist providing image-guided core needle biopsy should be the physician to assume responsibility for confirming clinical–radiographic–pathologic concordance. We do not have an ultrasound technologist in our Center because we recognized the importance of direct patient contact, which allows the radiologists to directly correlate the patient history, physical examination, and imaging findings. Likewise, it provides an opportunity to answer the patient’s questions and to provide additional information, while immediately providing the results of our examinations.

In addition to establishing the diagnosis of breast cancer with image-guided biopsy, the radiologist should determine tumor focality, nodal status, and evaluation of the contralateral breast based on clinical examination and appropriate imaging. At many comprehensive breast centers, ultrasound is the primary means of image-guidance for biopsy. Therefore, the ultrasound examination provides an excellent opportunity for the radiologist to complete a bilateral clinical breast examination aided with ultrasound that includes evaluation of the nodal regions (ie, axillary, internal mammary) at the time of the biopsy. Understanding that ultrasound is more sensitive in detecting adenopathy than is physical examination, a larger percentage of patients with adenopathy at the time of diagnosis of their primary breast cancer can be more accurately and efficiently staged. Ultrasound-guided biopsy provides an excellent means to sample lymph nodes that are suggestive of metastasis. When the diagnosis of axillary metastasis can be established before surgery, sentinel lymph node mapping and biopsy can be avoided, therefore eliminating the additional cost and time necessary to complete these procedures during surgery.

Biplanar Specimen Radiography 

Breast specimen radiography was introduced in the 1960s, initially as a means to confirm that a clinically occult lesion was removed during an open surgical biopsy. The intent was to confirm capture of the lesion in the surgical specimen, with limited regard for surgical margins. Today image-guided biopsy has largely replaced open surgical biopsy for the purpose of establishing definitive tissue diagnosis, so surgery is reserved primarily for tumor treatment with complete therapeutic resection. Thus, specimen radiography should be used not only to confirm capture of the tumor within the specimen, but also to help assess whether the tumor encroaches the surgical margins, signifying a very close or involved margin. When a specimen radiograph in a single plane is obtained, two of the six surgical margins will not be properly assessed. Therefore, biplanar radiography should be employed to evaluate all six specimen margins (ie, superior, inferior, anterior, posterior, medial, lateral) of surgical specimens submitted during breast-conserving surgery. After completion of the first specimen radiograph, the specimen is rotated 90° and properly oriented for the second orthogonal view. It is important that the specimen margins are clearly marked (ie, clips, sutures, ink) and properly identified by the surgeon immediately after resection because this anatomical orientation is used to orient and mark the margins during the biplanar specimen radiography and during subsequent histologic sectioning and final evaluation by the pathologist. If any of the tumor involves—or is extremely close to—a surgical margin as identified with biplanar specimen radiography, the surgeon is notified and can choose to remove additional tissue during the initial surgery. Biplanar specimen radiography has been demonstrated to reduce the number of patients requiring additional surgery due to positive surgical margins.3, 4 Whether for ductal carcinoma in situ (DCIS) or invasive carcinoma, tumor margin status is critical in determining the potential for local tumor occurrence. Digital imaging, along with picture archiving and communication systems (PACS), makes it possible to obtain and transmit the biplanar specimen radiograph into the operating and pathology suite, allowing for immediate review and consultation by the radiologist providing timely information for their surgeons and pathologists.

Large surgical specimens from breast-conserving surgery (and from most mastectomies) frequently undergo random sectioning, with only a relatively small portion of the entire specimen processed and submitted for histologic evaluation. Therefore, after tissue sectioning of a large specimen, specimen radiography can aid the pathologist in selective subsectioning of tissue for microscopic evaluation, especially when a mammographically detected lesion remains occult on gross histologic inspection. Although reported as early as 1918 by Albert Saloman, a surgeon from the University of Berlin,5 it is the report by Rosen and coworkers6 in 1970 describing this technique of serial specimen radiography that spawned its use at centers in the US and Europe.

Communication of Examinations and Procedures 

Most radiologists communicate primarily through medical reports, although within interdisciplinary breast centers, radiologists are frequently in direct contact with breast pathologists, surgeons, and oncologists. At Gundersen Lutheran Medical Center, a reporting protocol has been established to be used as the conclusion of the biopsy reports. According to this protocol, the conclusion must contain essential information required by the treatment team for subsequent management (Fig. 1; see also the article by Julio Ibarra, MD, in this issue). A brief medical history is recorded, which includes the patient’s age, family history of breast cancer, whether the lesion is palpable or nonpalpable, and the mode of biopsy. Tumor size, lesion location, focality, nodal status, and the status of the contralateral breast are important in preoperative planning. Tumor size is usually based on clinical examination, mammography, ultrasound, and/or MRI. Although the recorded tumor size can vary when using different means of measurement, the size recorded in the report should reflect the most accurate size of the viable tumor. Berg and coworkers7 have reported that tumor sensitivity and extent are best measured with a combination of clinical breast examination, mammography, and MRI (Table 1, Table 2). However, tumor sensitivity and extent determination are dependent on breast density for mammography and tumor type for the various examinations. In their study, as a single modality in determining tumor extent, MRI was most accurate for invasive ductal carcinoma, ultrasound for invasive lobular carcinoma, and mammography for DCIS. However, tumor size and extent was not demonstrated to be significantly different for invasive cancers when comparing ultrasound with MRI. Accurate tumor location with the patient in the supine position is important because this is the position in which the surgeon will likely examine the patient and perform surgery. With mammography, tumor location is affected by the patient’s upright position and by the breast being compressed between the mammography paddles. Likewise, with MRI the breasts are in a dependent position while the patent is lying prone. Therefore, breast ultrasound performed in a supine position most accurately reproduces the position the patient will assume during surgery, with the breast dependent on the chest wall. During the ultrasound examination in the supine position, the lesion location in terms of o’clock position, distance from the nipple, and depth from the skin can be recorded. Tumor size, location, and focality are also important as they may determine whether a patient would be a reasonable candidate for breast conservative therapy and radiation brachytherapy. Although there are no universal definitions for multifocal and multicentric breast cancer, definitions frequently recorded in the literature for multicentricity include: (1) separate independent cancer foci involving more than one quadrant of the same breast, or (2) separate independent cancer foci separated by at least 2 or 5 cm.8, 9, 10 Multifocal disease implies cancer confined to the same quadrant or separated by less than 2 or 5 cm. Regardless of definition, it should be recognized that multifocal disease implies cancer associated with a single duct network, whereas multicentric diseases are composed of independent cancer foci originating from separate ductal lobes or segments, frequently from different quadrants of the breast. Regardless of the definition used, a common lexicon should be employed, especially among physicians (radiologists, pathologists, surgeons, and oncologists) directly involved in the care of patients with breast cancer within the same institution.

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Figure 1. Report conclusion protocol for imaging-guided ultrasound, stereotactic, or MRI needle core breast biopsy.

Table 1. Tumor Detection

		IDC⁎	ILC†	DCIS‡
	Mammo	89/110(81%)	10/29(34%)	21/38(55%)
	US	104/110(94%)	25/29(86%)	18/38(47%)
	MRI	105/110(95%)	28/29(96%)	34/38(89%)

Derived with permission from Table 1 in Berg WA, Gutierrez L, NessAiver MS, et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology 233:830–849, 2004.

⁎ IDC, Invasive ductal carcinoma. † ILC, Invasive lobular carcinoma. ‡ DCIS, Ductal carcinoma in situ.

Table 2. Tumor Size Accuracy

		IDC⁎	ILC†	DCIS‡
	Mammo	40/72(56%)	5/12(42%)	6/12(50%)
	US	53/72(74%)	8/12(67%)	4/12(33%)
	MRI	61/72(85%)	7/12(58%)	5/12(42%)

Derived with permission from Tables 4, 5, and 6 in Berg WA, Gutierrez L, NessAiver MS, et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology 233:830–849, 2004.

⁎ IDC, Invasive ductal carcinoma. † ILC, Invasive lobular carcinoma. ‡ DCIS, Ductal carcinoma in situ.

Current practice varies widely with regard to preoperative diagnostic breast evaluations for patients diagnosed with breast cancer, ranging from physical examination and mammography to physical examination, mammography, ultrasound, and MRI. Decisions about which of the various imaging modalities to use may be guided by patient age, breast density, family history, tumor type, and by whether findings—usually of physical examination and/or mammography—are suggestive of multifocal/multicentric disease. Both breast ultrasound and MRI have been reported to increase the detection of additional foci of breast cancer when compared with physical examination and mammography alone.11, 12, 13, 14, 15 The pathologist’s histologic evaluation and report after the initial biopsy provide essential information about the tumor type, grade, and receptor status. The results of the receptor status for estrogen and progesterone help determine the potential utility of hormonal therapy (eg, tamoxifin, raloxifene, anastrozole, letrozole, exemestane). Likewise, human epidermal growth factor receptor (HER-2neu) status helps determine the potential utility of selective chemotherapeutic agents (eg, Trastuzumab). A clear disposition provides essential information to include which physician will direct the patient’s subsequent care, recommendations by the radiologist, and perhaps subsequent scheduled appointment(s) in follow-up care. Radiologists managing patients in the early detection and diagnostic phases of breast cancer must engender trust and confidence in their judgment and performance—both in their patients and in referring physicians. Aided by the annual breast-imaging audit, radiologists can objectively demonstrate their performance and value to their interdisciplinary colleagues as well as their direct impact on patient morbidity and mortality as reflected in the primary prognostic indicator for each patient at the time of cancer detection. In addition, annual audits not only allow radiologists to monitor their performance but also provide key educational information that likely will enhance the levels of care and performance for subsequent audits. At Gundersen Lutheran Medical Center, not only is the performance recorded and reviewed in screening mammography and diagnostic evaluations/procedures, but a significant amount of time is spent reviewing the interval cancers (patients diagnosed with breast cancer within 12 months of a screening mammogram with a Breast Imaging and Reporting Data System—ACR BI-RADS®—score of 1-3). This has proven to be a very important exercise in further understanding and recognizing the presentation of subtle findings for invasive carcinomas.

Clinical breast radiologists have the potential to make a significant impact—not only in patient outcomes but also in the overall financial cost of breast care (Fig. 2). The size and subsequent stage of breast cancer at diagnosis has a significant impact on the type of treatment to be considered and provided by surgeons and oncologists. The potential benefits of adjuvant forms of therapy after definitive surgery are frequently reduced to the level that many patients with favorable tumors (based on patient age, tumor size, tumor type, tumor grade, receptor status, angiolymphatic spread, and surgical margin status) elect—after appropriate education and consent—not to receive radiation therapy or chemotherapy after lumpectomy. Screening mammography recall rates, mode of biopsy for initial tissue diagnosis, and use of adjuvant forms of therapy have a significant impact on the global cost of breast cancer care. Likewise, efficient use of space, time, support personnel, and equipment can have a significant impact on the productivity of the radiologist in terms of both patient care and revenues. The screening mammography reading rooms were designed to be ergonomically efficient, interruption-free, and acoustically sound, with light emanating only from the rolloscope. The support staff understands that during the interpretation of screening mammography, the radiologist should not be interrupted unless truly urgent. Appropriate support from clinic staff (technologists, nurses, assistants)—to include patient preparation, retrieval of prior examinations and reports, and preparation of image-guided procedures and examinations—is essential.

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Figure 2. Impact of early detection on treatment costs ($). (Reference—Kolb Breast Health Management Inc.)

Interdisciplinary Breast Care Team 

The interdisciplinary breast care team at the Norma J. Vinger Center for Breast Care at Gundersen Lutheran Medical Center is composed of the medical staff (radiologists, pathologists, surgeons, medical oncologists, radiation oncologists, plastic surgeons), support staff (eg, technologists, nurses, medical assistants, office assistants, genetic counselors, dietitians, social workers), and administrative staff (chief executive officer, division vice presidents, division administrative directors, clinical managers). The primary strength is the willingness of a very dedicated core group of physicians and support staff to establish a patient-centered, interdisciplinary breast cancer center that is horizontally and not vertically oriented in terms of medical practice and patient care (ie, no pecking order). The hospital executive committee wisely assigned codirectors who are practicing clinicians (a radiologist and a surgeon). Their primary mission is to help facilitate the needs of their interdisciplinary breast care team, in addition to providing direct leadership. Likewise, early in our inception, the interdisciplinary team established the mission and vision statements, reviewed the strengths, weaknesses, opportunities, and threats, and developed key operating strategies that are in alignment with those of our institution.

Many policies and procedures, including physician credentialing and privileges, have been established with the aid of national policies such as those of the American College of Radiology, the American College of Pathologists, the American Cancer Society, the National Comprehensive Cancer Network, and the American Society for Therapeutic Radiology and Oncology. The development and dissemination of our request form for the Diagnostic and Interventional Breast Clinic (Fig. 3), along with appropriate patient triage for initial diagnostic evaluation and biopsy, has had a significant impact on timely patient scheduling and streamlined care among the interdisciplinary physicians. Whether the patient needs additional evaluation due to a finding on screening mammography or has a clinical concern that was detected by the patient or their general practitioner, patients generally are first triaged to the clinical breast radiologist, who is responsible for determining what examinations and procedures are required for the diagnostic evaluation. Likewise, the use of pathology reporting templates by our pathologists for initial core biopsy and definitive surgical resection has been extremely helpful. The weekly radiographic–pathologic conference, the breast cancer prospective treatment conference, and the codirector’s meeting have helped to foster a collegial working environment and rapid dissemination of information in addition to providing coordinated, interdisciplinary patient care. Of the 25 radiologists, only 3 function as clinical breast radiologists, providing services in our Diagnostic and Interventional Breast Clinic and interpreting the majority (>95%) of the screening mammograms. This degree of subspecialization has been instrumental in improving the level and consistency of care provided for our patients.

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Figure 3. Center for Breast Care screening and diagnostic services request form.

Shared clinical space is used by the clinical breast radiologists, breast surgeons, and nurse navigators for the initial diagnostic evaluation and biopsy, as well as for initial patient consultation after breast cancer diagnosis. The nurse navigators and medical assistants are vital to the overall mission and are not assigned to a particular department; rather, they provide cohesive patient care across the traditional departments of radiology, surgery, and oncology. The nurse navigators and medical assistants become involved at the beginning of the patient’s initial diagnostic evaluation to provide timely education and support, in addition to basic medical nursing needs. Having patients wait until their first scheduled appointment with the surgeon or oncologist before they receive a breast cancer diagnosis or support from nurses specializing in breast care frequently results in increased patient anxiety and loss of valuable time for patient education, counseling, and completion of pretreatment examinations.

Audit Information 

At Gundersen Lutheran Medical Center, the screening mammography services are separated from the diagnostic and interventional breast imaging services. Like many institutions, there are several sites where screening mammography is conducted, but the screening examinations are batch-read at a single location. An extensive list of metrics is recorded, to include metrics requested by the ACR for the annual audit. This information is benchmarked to the prior year’s performance as well as to the practice guidelines provided by Basset and coworkers16 and Tabar and coworkers17 and reported national performance benchmarks for screening and diagnostic mammography by Sickles and coworkers18 (Table 3). Metrics of greatest interest are: (1) total screening volume, (2) recall rate from screening mammography, (3) mean and median size of the screening-detected invasive breast cancers, (4) number of cancer cases detected per 1000 patients, (5) positive biopsy rate (ACR-defined PPV3), and (6) interval cancer detection rate. These six essential metrics must be reviewed collectively because any single performance metric, when reviewed in isolation, can be misleading. However, the measures of greatest importance in terms of reducing mortality are the mean and median size of the invasive tumors diagnosed through screening because tumor size can be used as a surrogate for mortality rate. Therefore, to determine the effect of screening for a given population in terms of reduction in mortality, the median size of the invasive tumors detected for women participating in screening compared with that for women not participating in screening can be used.19, 20

Table 3. Gundersen Lutheran Breast Cancer Screening Performance Compared with National Benchmarks

	Metric⁎	1994 AHCPR Guidelines	2005 BCSC Screening†	BCSC Screening: Unpublished‡	2005 BCSC Palpable Lump†	Ellis et al, Gundersen Lutheran: Screening
						2002§	2003‖	2004¶
	PPV2	25–40%	25%	–	48%	49%	55%	53%
	Tumors, 0 or 1	50%	82%	71%	40%	97%	95%	96%
	Min. Ca’s	30%	62%	49%	18%	55%	53%	43%
	Node pos.	<25%	16%	21%	34%	16%	20%	16%
	Ca Dx/1000	2–10	30.8	4.1	49%	4.5	4.5	4.1
	Recall rate	≤10%	12.3%	9.3	10.5%	6.4%	4.3%	5.0%
	Sensitivity	85%	86%	80%	84%	92%	87%	83%
	Invasive tumor size [median/mean]		11mm/ 14.3mm			11mm/ 11.5mm	11mm/ 11.5mm	12mm/ 12.6mm

⁎ Metrics, defined as follows: PPV2: positive biopsy rate for breast cancer [PPV = TP/TP + FP]. Tumors, Stage 0 & 1: DCIS and invasive tumors 1–20 mm. Min. Ca’s: minimal cancers, [ie, DCIS and invasive tumors 1–10 mm]. Node pos.: frequency of screen-detected tumors with associated axillary adenopathy. Ca Dx/1000: number of breast cancers detected per 1,000 screening patients. Recall: percentage of women asked to return for additional evaluation after a screening mammogram. Sensitivity: ability of radiologist interpreting screening mammography to identify a breast cancer [sensitivity = TP/TP + FN]. † Sickles EA, Miglioretti DL, Ballard-Barbash R, et al: Performance benchmarks for diagnostic mammography. Radiology 235:775–790, 2005. ‡ BCSC = Brease Cancer Surveillance Consortium (Dianna L. Miglioretti, PhD, personal communication). § Total 2002 screening volume = 15,783. ‖ Total 2003 screening volume = 16,314. ¶ Total 2004 screening volume = 17,748.

It is important to recognize and understand the difference between quality-of-care metrics that affect patient outcome in terms of mortality and metrics that measure process of care. Although important, quality-of-care metrics that measure process of care should not be confused with, nor should they replace, metrics that measure patient outcome. Quality-of-care metrics that measure process of care include type of biopsy and surgery, patient satisfaction score, pathology report turnaround time, and lumpectomy/mastectomy ratio. The annual metrics also have been very important in determining what improvement, if any, might be gained with the addition of CAD to the screen detection of small (<16 mm) invasive breast cancers.21 As a group, we also share our annual performance with the interdisciplinary clinical and administrative staff. We hope to use this information as part of the Wisconsin Collaborative for Health Care Quality (www.wchq.org) to inform Wisconsin residents, and for medical contract negotiations with third-party payers.

Conclusions 

Radiologists specializing in breast care play a pivotal role and provide important leadership for interdisciplinary breast care centers. Given the paradigm shift in the detection of breast cancer while predominantly clinically occult, radiologists subspecializing in breast care should assume primary responsibility for the early detection and diagnostic management phases for breast cancer. During the diagnostic evaluation of patients with signs or symptoms suggestive of breast cancer, it is important for the radiologist to combine clinical history, physical examination, appropriate imaging studies, and the image-guided core needle biopsy when appropriate in providing a comprehensive diagnostic evaluation. This information is extremely important for the treatment team members of the interdisciplinary breast care clinic in the subsequent management and treatment of patients diagnosed with breast care. Likewise, radiologists need to be reminded that largely through their efforts with screening mammography, breast cancer morbidity and mortality have been reduced dramatically. To continue to improve the level of care offered to our patients, it is important to obtain, analyze, and make appropriate changes based on essential information obtained from our annual audits.