Author: Logan Young

_{Published August 5, 2022}

Gary J. Whitman

2022–2023 ARRS President

Every year, medical students, early in their educational journeys, are encouraged by deans and other high-ranking medical school administrators to consider primary care (internal medicine, family medicine, or pediatrics) as a career choice. Most of us chose a different, more specialized route and wound up in radiology.

Now, I would like to encourage you to be a primary radiologist. By saying primary radiologist, I am not encouraging you to go into primary care, but rather to be the best radiologist that you can be. Primary radiologists are leading radiologists—working at a very high level, communicating clearly and effectively with referring physicians and patients, and keeping up to date with new developments in imaging and medicine. Most practices or groups have a primary radiologist—the highly accurate radiologist who is consulted on the most difficult cases and who is always available to help.

The primary radiologist’s role is based heavily on earning the respect of others. A primary radiologist is the one you and others turn to when you need an expert opinion. Oftentimes, a colleague will ask, did you show the case to Dr. _____? Alternatively, one may want an opinion on how Dr. _____ would approach a difficult procedure.

It is difficult to be a primary radiologist. There are ongoing global stressors, like the COVID-19 pandemic, and stressors affecting radiologists, including high burnout rates and an ever-increasing workload. Bhargavan et al. noted that when 2006–2007 data was compared to 2002–2003 data, the annual workload per full-time equivalent radiologist increased by 7%. When 2006–2007 data was compared to data from 1991–1992, the annual workload per full-time equivalent radiologist increased by 70.3%! Now, 2006–2007 seems like a long time ago, and, undoubtedly, workloads have continued to rise over the last 15 years. 

How do we become primary radiologists in the current milieu? When we think of doing a great job, we need to define success. Success may be defined differently by deans, hospital administrators, chairs, section heads, and individual radiologists. As many of us are working very hard these days, it makes sense to think about what success means. John Wooden served as the basketball coach at the University of California, Los Angeles (UCLA) from 1948 to 1975. During that time, he led the UCLA Bruins to 10 National Collegiate Athletic Association (NCAA) basketball championships. I like John Wooden’s definition of success. Coach Wooden stated that “success is peace of mind which is a direct result of self-satisfaction in knowing you did your best to become the best that you are capable of becoming.”

In Coach Wooden’s Pyramid of Success, industriousness and enthusiasm are major cornerstones. Regarding industriousness, I don’t see radiologists’ workloads diminishing any time soon.  In our current world of radiology, I agree with Coach Wooden, who noted that “there is no substitute for work. Worthwhile results come from hard work and careful planning.” When discussing planning and preparation, Coach Wooden stated that “failing to prepare is preparation for failure.” This important maxim applies to individual cases and procedures, as well as to our overall growth and development.

As we strive to be primary radiologists, our continued growth and development is based on self-assessment and identifying educational opportunities to rectify our perceived deficiencies. As we head into a new academic year and try to find top-notch educational content to fill our gaps, I suggest looking into the vast portfolio of educational offerings from our American Roentgen Ray Society. On ARRS.org, you will find information on the 2023 ARRS Annual Meeting in Honolulu, Hawaii, upcoming Live Symposia, Online Courses, Web Lectures, Quick Bytes, and Global Partner Education, including American Journal of Roentgenology (AJR) articles with credit, AJR Webinars, Author Videos, Podcasts, Tweetchats, Visual Abstracts, and much more. Whatever you are looking for, it is very likely that you will find it on the ARRS website and various social media channels.

In our quest to become primary radiologists, a key ingredient is enthusiasm. Coach Wooden noted that enthusiasm “brushes off upon those with whom you come in contact.” He continued, noting that “you must truly enjoy what you are doing.” Being enthusiastic about an unrelenting onslaught of work can be challenging, but we should try to be enthusiastic toward those who really need our services—our patients and our referring providers—and our team members. In general, our teams will function at a higher level if we treat everyone with enthusiastic, professional respect.

In addition to enthusiasm and industriousness, I think that in today’s topsy-turvy world, adaptability is critical. If we are going to be at the top of our game and really be the primary radiologists that we are capable of becoming, we must be able to adapt to new and sometimes unforeseen situations. Coach Wooden defined adaptability as “being able to adjust to any situation at any given time.”  Just think of how different October 2019 (pre-COVID) was compared to March 2020 (early in the COVID-19 pandemic). The first COVID-19 outbreak was reported in Wuhan, Hubei, China in November of 2019, and by March 11, 2020, we were involved in a major pandemic with 118,465 confirmed cases of COVID-19 and 4,295 deaths worldwide. As we enter a new academic year, I want to encourage you to be the best radiologist that you can be—to be your best version of a primary radiologist. It won’t be easy, but with industriousness, enthusiasm, and a lot of adaptability, I think that we can do it and enjoy the journey!

_{Published August 1, 2022}

Jonathan Kruskal, MD, PhD

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

Lea Azour, MD

Clinical Assistant Professor, Department of Radiology, NYU Grossman School of Medicine
Director of Wellness, Department of Radiology

Jonathan Goldin, MD, PhD

Professor of Radiology, Medicine, and Biomedical Physics, UCLA David Geffen School of Medicine
Executive Vice Chairman, Department of Radiological Sciences, UCLA David Geffen School of Medicine

The epidemic of stress and burnout among physicians in our imaging field continues unabated, with many commitments, remedies, websites, apps, financial resources, meetings, meals, committees, retreats, articles, and other tactics directed at mitigating the expanding repertoire of undesirable, harmful, and even tragic consequences. The constellation of recognized detractors contributing to our widespread lack of wellness and professional fulfillment continues to grow, and will do so, until an effective and collective strategy is implemented.

Mitigation tactics have been tried—improving practice efficiency amid amassing volumes, personal wellness invocations in times of increased isolation, and efforts to cultivate individual and even practice resilience. Many of these have been Band-Aid attempts to right perceived wrongs, to keep up with current trends, or to respond to newly recognized symptoms. These efforts have had short-term impacts, at best.

There have been broad-based recommendations for addressing the epidemic of languishing, which struck unexpectedly, followed by post-traumatic recovery efforts, which were never fully understood; together, we’ve raised our voices at the so-called moral insults and associate injuries repeatedly cast in our direction.

One tactic after another. One mole whacked to unearth another. One new personal solution. One new app. And nothing seems to have improved. Our trend lines are heading downwards.

Moving the Wellness Dial?

Most certainly, we have started to move the radiology wellness dial—we have discovered what works and what doesn’t, we have started to recognize the spectrum of manifestations of stress, we have started to explore different personal and practice approaches to wellness, we have started to acknowledge the impact of effective leadership, communities and connections, of having voices heard, of removing the many pebbles from our shoes, and we have started to speak louder and louder about the need for a more organized approach. We have commenced our wellness journey. 

There is no better time than now to define where we want to go, how to get there, and how to remove current and future obstacles along the way.

Our efforts have been diverse and well-intended: various manners of resilience-building have been explored, personal wellness strategies were introduced, organizational contributors were recognized, the value of high-functioning teams extolled, as was understanding of the complex preferences of our wonderful multicultural and multigenerational team members. Practices slowly started listening to the voices of their team members. Listening, yet not quite hearing. Conversations slowly started transforming from burnout to wellness, to professional fulfillment, and voices were now being listened to and heard.

Yet the stress and symptoms of emotional exhaustion, detachment, disengagement, and disillusionment persisted, and a great resignation commenced. New challenges emerged, which have become our contemporary opportunities: supporting and sustaining remote teams and flexible work patterns, a staffing challenge like few can recall, rethinking productivity and compensation models, calls for greater transparency, wellness-driving compensation plans and reading environments, and reimagining what a day’s work should look like. The Great Resignation inspired the Great Exploration and Reshuffling, and now the Great Renegotiation—of why and how we work.

So, where does that leave us today? For the past several years, we have responded to the epidemic of burnout by changing the conversation to a more positive focus on wellness, yet our many very well-intended efforts have been largely tactical, rather than strategic.

We have been playing wellness whack-a-mole by responding with tactics to each newly recognized symptom or contributor, rather than thinking strategically.

It’s not too late. As a medical subspecialty, we have the opportunity to change that now, and must. We certainly have the skilled team members, advocates, resources, voices, passions, and energy to do that, and we need to start now. Together, we can and must build a blueprint for wellness that will guide and sustain our efforts towards improved wellness.

How do we do this? To expand on the oft quoted ice-skating analogy relating to the renowned hockey player Wayne Gretzky, we need to convene all voices of the House of Radiology to better understand the challenges, impacts and contributors, to define where our proverbial puck will be, and then to define a path that will guide us to meet that puck. 

This April, please join us in Honolulu, Hawaii for the ARRS Radiology Wellness Summit during the 2023 ARRS Annual Meeting, where all of these will be addressed.

We need to hear your voice; we want to hear your voice.

What Will the ARRS Radiology Wellness Summit in Hawaii Address?

There are moral, ethical, and business imperatives that should drive wellness, and we will explore what strategies are working and which are not. How do we design workflow for wellness, rethink productivity metrics, and explore shift-based comp plans? What does a new day’s work look like for a radiologist? How can one hop off and stay off the hamster wheel that many workplaces have become? What might your AI efficiency wish list look like? What do your wellness numbers and trends reveal? Do you know your current numbers? What are you measuring?

While one might need to measure in order to manage, to quote Albert Einstein, “not all that counts can be counted, and not all that is counted, counts.” Collectively, we have a lot to talk about.

How do we go about stemming the tide of the Great Resignation, or can we, or should we? What are you doing to show appreciation to your faculty who might feel undervalued? What does your peer support program look like? How are you sustaining your talented multigenerational team through different career and life stages? Is your communication strategy effective? How are you introducing appreciative enquiry and positive psychology into your practice? What is your equivalent of a wellness booster clinic, and what are you doing to rediscover the joy and meaning that first led you into radiology? Have you considered coaching, storytelling, micropractices, mindfulness, music, or art? Is your team functioning like Ted Lasso is the coach? How did you train your Chief Wellness Officer and your wellness change agents? 

Our inaugural ARRS Radiology Wellness Summit will bring together radiologists across subspecialties and practices to address the many contemporary issues that are top of mind in our postpandemic terrain, with the goal of defining a wellness roadmap that will guide our House of Radiology forward to better navigate the anticipated stormy seas ahead. Together, we plan to transform from a tactic-driven approach to one that is thoughtful, intentional, and strategic. We hope you’ll join us in Honolulu this April for the undertaking. We want your imprint in this timely, necessary, and important effort. 

_{Published August 2, 2022}

Robert M. Barr, MD, FACR

Dr. Barr is a private practice neuroradiologist with Mecklenburg Radiology Associates PA in Charlotte, North Carolina, and incoming President of the American Board of Radiology.

The five years since I joined the Board of Governors has been a period of remarkable change as the American Board of Radiology (ABR) has evolved in response to new requirements and improved stakeholder engagement. The biggest change was the introduction of Online Longitudinal Assessment (OLA) in 2019 to supplant the previous model of recurring high-stakes exams as part of Continuing Certification. The platform has both formative and summative functions and, as a result, satisfies the parts of our social contract as medical professionals that relate to lifelong learning and self-assessment. It positions the ABR as one of the leaders in adopting the American Board of Medical Specialties (ABMS) Standards for Continuing Certification released last November.

In early 2020, recognizing the challenges resulting from the pandemic, we embarked on an aggressive development plan to deliver our Initial Certification exams in a virtual environment. Our early experience with OLA was crucial in guiding the design and implementation of remote exams. In 2021, we successfully administered over 5,000 exams (including both qualifying and certification exams) across all four disciplines (diagnostic radiology, interventional radiology, medical physics, and radiation oncology) and anticipate this will remain an enduring model for Initial Certification.

In addition to the introduction of remote exams and accelerated exam administration, 2021 saw the implementation of a new residency leave policy designed to balance the need for standardization with flexibility to address life events that individuals face during training. We were fortunate to benefit from the vigorous engagement of numerous stakeholders during the development of this policy, including dozens of conversations with trainees and program faculty. Beginning with the 2021–2022 academic year, residents with total time away from residency averaging less than eight weeks (40 workdays) per academic year are eligible for Initial Certification without an extension of training.

Although the programs mentioned above are the most visible to our candidates and diplomates, the behind-the-scenes efforts of our volunteers have been critical in supporting the continuous improvement of our exam content and delivery. We now offer exam candidates increased flexibility in many elements of the qualifying exams, as well as additional dates for the oral exams in medical physics, radiation oncology, and interventional radiology. Several months ago, we embarked on a comprehensive evaluation of the certification exams for diagnostic radiology; as of this writing, external discussions have provided a broad range of perspectives and extremely useful suggestions for potential modifications.

Our executive team and staff have made significant strides in streamlining our administrative processes and improving efficiency, with the goal of mitigating costs. We have reduced redundancy and non-core initiatives and terminated our lease for the Chicago testing center as part of our transition to remote exams. We’ve reduced the cost of some of our products, particularly subspecialty certification exams, and will continue to focus on fee reduction when possible. We are fortunate to maintain healthy capital reserves, which have helped offset investments in technology and software development during the past few years of transition. We continue to maintain our recognition for financial transparency with Platinum Status (per Candid®, formerly GuideStar®).  

As I assume the role of ABR president, I look forward to working with our volunteers, staff, and stakeholders to support the ABR’s mission to provide a credential that indicates a high level of professional achievement and commitment to clinical excellence. The ABR Board of Governors, volunteers, and staff remain committed to improving the relevance and value of our exams and programs while avoiding increased costs and unnecessary complication for our candidates and diplomates.

_{Published May 13, 2022}

Victoria L. Mango

Department of Radiology, Memorial Sloan Kettering Cancer Center

Lars J. Grimm

Department of Radiology, Division of Breast Imaging, Duke University School of Medicine

Jennifer A. Harvey

Department of Imaging Services, University of Rochester Medical Center

Donna M. Plecha

Department of Radiology, University Hospitals Cleveland Medical Center

Emily F. Conant

Department of Radiology, Division of Breast Imaging, Perelman School of Medicine, University of Pennsylvania

Abbreviated breast MRI (AB-MRI) has been shown to maintain the high sensitivity of longer or full breast MRI protocols while decreasing operational costs. The clinical implementation of an AB-MRI program requires collaboration of multiple stakeholders, including administrative, operational, financial, technical, and clinical providers. Institutions must define patient eligibility and imaging protocols and monitor performance metrics to ensure high-quality patient care. The improved efficiency and maintenance of accuracy of AB-MRI may allow more women to access this important supplemental screening modality.

MRI is the most sensitive imaging modality for breast cancer detection [1], and its role as an adjunct to mammographic screening for women at high risk for breast cancer (i.e., a lifetime risk > 20%) is well accepted [2–5]. Although demographic and genetically based risk assessment models are often used to determine breast cancer risk, increased mammographic density increases breast cancer risk and decreases mammographic sensitivity through the obscuration of cancer by adjacent dense breast tissue [6]. Increasing awareness of the impact of increased breast density on patient outcomes has driven the adoption of state and federal legislation mandating that women be notified of their breast density. In response to this increasing awareness, there is growing interest in supplemental screening for breast cancer with breast MRI, which shows improved breast cancer detection for women with dense breasts and otherwise average risk [7]. To accommodate the increasing demand for supplemental breast MRI screening, abbreviated (or fast) breast MRI protocols have been developed that reduce costs, improve workflow, and increase patient access. This article provides details regarding the current literature supporting the utilization of AB-MRI for supplemental screening and the numerous administrative, operational, financial, techni­cal, and clinical elements that must be considered in the imple­mentation of a clinical AB-MRI program.

Review of Abbreviated Breast MRI Outcome Data

The first AB-MRI study, which was published in 2014 by Kuhl et al. [8], included 443 women with a “mildly to moderately in­creased risk of breast cancer.” The study showed that a 3-minute AB-MRI acquisition that consists of only one unenhanced and one contrast-enhanced sequence has diagnostic accuracy in breast cancer screening that is equivalent to that of a full breast MRI pro­tocol. Multiple studies have since been published, including a pro­spective multicenter trial [9] and at least three systemic reviews or meta-analyses supporting the use of AB-MRI [10–13] (Table 1).

These studies confirm that the combination of mammography and MRI screening yields the highest cancer detection rate. In addi­tion, cancers detected with MRI are more likely to be invasive and higher grade, compared with cancers detected with mammography [14], and therefore have the potential for greater impact on patient morbidity and mortality.

Because MRI offers improved cancer detection rates and can detect more clinically relevant disease, AB-MRI has been inte­grated into clinical practice at numerous institutions. Clinical implementation of an AB-MRI program requires consideration of patient eligibility requirements, imaging protocols, and appropri­ate performance metrics to ensure high-quality patient care.

Patient Selection and Screening Interval

At present, most supplemental screening with AB-MRI is re­served for women with dense breasts, given the superior sensi­tivity of breast MRI for cancer detection [15]. This recommen­dation is supported by multiple studies of women with dense breasts, including women who underwent screening with AB-MRI after having negative or benign mammography and ultra­sound findings [8], and by a prospective screening study that showed significantly higher rates of invasive breast cancer detection with AB-MRI, compared with digital breast tomosynthesis (DBT) (11.8 vs 4.8 cancers per 1,000 women) [9]. For women with an average risk of breast cancer who have dense breasts and a nor­mal DBT, AB-MRI has shown a breast cancer detection rate of up to 27.4 can­cers per 1,000 women [12]. The possible role of AB-MRI in detecting breast can­cer in women with nondense breasts who are at intermediate risk for breast cancer has not yet been established.

Although there currently are no data to guide the frequency of AB-MRI screening, given current screening para­digms and the recommendation that high-risk women should undergo annual MRI screening [16], one could consider screening women of average risk who have dense breasts with AB-MRI every 1–2 years [7]. AB-MRI should be performed in addition to an annual mammography examination, and this screening may be performed at the same time as mammog­raphy or offset between mammographic screenings.

Imaging Technique

AB-MRI protocols remain institution-dependent; however, consideration should be given to minimizing the total scanning duration and thus the time that the pa­tient spends on the table (i.e., table time). Published AB-MRI acquisition times range from 1.1 to 12 minutes [17, 18], but addi­tional time not related to acquisition must also be allocated to allow the patient to enter and exit the room and to be positioned on the table. The AB-MRI protocol should use parameters similar to those of the full breast MRI protocol, such as magnet field strength, axis of image acquisition, and patient orientation, to facilitate interpretation and comparisons between full and AB-MRI examinations. Postprocessing of sequences, such as subtracted images, maximum-in­tensity-projection (MIP) images, and mul­tiplanar reconstructions, does not increase actual scanning time and may be performed after the patient has been taken off the table, further improving table-time efficiency.

Published AB-MRI protocol sequenc­es vary greatly but most commonly use an unenhanced T1- and/or T2-weighted sequence, plus one contrast-enhanced sequence [8–11, 19]. A single contrast-enhanced sequence enables generation of subtracted and MIP images but does not provide kinetic information. Despite AB-MRI protocol variation, a systematic re­view/meta-analysis showed no significant difference in the sensitivity or specificity of AB-MRI versus full breast MRI in stud­ies with 1–2 years of follow-up [12].

Interpretation

The time needed for interpretation of AB-MRI varies depending on the number of protocol sequences [20]. AB-MRI has higher sensitivity than DBT (95% vs 39%) but lower specificity (87% vs 97%) [9]. Improving specificity through minimizing false-positive results should be prioritized when implementing an AB-MRI program.

For interpretation of AB-MRI, it is advised that one first evaluate the MIP im­age to assess background parenchymal enhancement (BPE) and the symmetry of the breasts and to identify any unique fo­cal findings. AB-MRI interpretation may be more difficult when BPE is moderate or marked [21, 22]. Identification of a unique finding requiring additional evalu­ation should be based on the morphology of the finding and whether it differs from surrounding or BPE. If available, comparison with prior MIP images will enable determination of whether a finding is new. Correlation with findings on prior mammograms and ultra­sounds may also help determine whether the unique finding is benign.

Recognizing benign patterns of BPE may help improve specificity when inter­preting screening AB-MRI. Such patterns include multiple scattered foci of enhance­ment, symmetric regional enhancement, multiple foci with larger enhancing areas, and a picture frame distribution of enhancement along the periphery of the breast [23]. BPE may be asymmetric or, conversely, increased in patients who recently stopped taking antiestrogen medication [24].

Utilization of a T2-weighted sequence in an AB-MRI protocol can assist in the characterization of foci and masses be­cause increased T2 signal intensity, plus a benign morphology, help support a benign diagnosis [25, 26]. T2-hyperintense mass­es with benign morphologic characteris­tics, such as round or oval shape, circum­scribed margins, dark internal septations, homogeneous enhancement, or a combi­nation of these characteristics, should at most be assessed as a BI-RADS category 3 finding. Inclusion of a T2-weighted sequence in the AB-MRI protocol can decrease BI-RADS category 3 utilization by 37.7% [8]. This is further supported by a retrospective review of T2-hyperintense masses without suspicious features, which had a malignancy rate of 2% [26]. Given that cancers may also show T2 hyperintensity, biopsy should be recommended if a T2-hyperintense finding shows suspicious morphology.

A unique nonmass enhancement (NME) should be biopsied if it is linear, segmental, clumped, heterogeneous, or has clustered ring enhancement (Fig. 1).

If NME is dif­fuse or regional with internal homogeneous enhancement with associated T2 fibrocystic changes, it should be considered benign.

Auditing Your Practice

As with auditing any breast MRI prac­tice on the basis of imaging indication (i.e., high-risk screening, diagnostic problem solving, cancer staging), auditing of AB-MRI should be done separately. Performance measures should include, but should not be limited to:

• cancer detec­tion rate per 1,000 women;
• PPV2 (based on recommendation for tissue diagnosis) and PPV3 (based on results of biopsies actu­ally performed);
• outcomes of BI-RADS final assessment categories 0, 3, 4, and 5;
• overall sensitivity and specificity.

Complete medical audit data for screen­ing MRI are outlined in BI-RADS 5th edition [27]; however, it is important to note that the benchmarks in BI-RADS 5th edition were based on analyses of prospec­tive, full-protocol screening MRI trials of women with a hereditary predisposition for breast cancer.

In auditing any breast MRI program, BI-RADS category 0 should be used spar­ingly, reserved for requests of prior imaging that may not have been available at the time of initial interpretation. For example, it may be necessary to correlate MRI findings with those from mammography and/or ultrasound to en­sure the stability of MRI findings, such as probable fibroadenomas, lymph nodes, fat necrosis, or a surgical scar. Those MRI findings with benign mammographic or so­nographic correlates may be downgraded to BI-RADS category 2 (benign). Careful comparison with prior imaging ultimately helps improves the specificity of MRI and thus patient outcomes.

Although no benchmarks have yet been established for short-term follow-up or the use of BI-RADS category 3 for breast MRI, early outcome data suggest that the limited imaging provided by AB-MRI may increase the rate of short-term follow-up recommendations, compared with full breast MRI protocols [28]. In reporting their first 2 years of experience with AB-MRI, Marshall et al. [28] found that in the first 4 months, their BI-RADS category 3 rate was 14.2%. In an effort to decrease the BI-RADS category 3 rate, they required that all BI-RADS category 3 cases be re­viewed by at least two other breast radi­ologists and that their group would review such cases weekly. After the interventions, the group’s use of BI-RADS category 3 decreased to 8.3% in their first year [28]. As with any breast MRI study, when BI-RADS category 3 is assigned, the next rec­ommendations should clearly be stated in the report.

For cases where an MRI-directed ultrasound is recommended for further evaluation of a mass, the MRI report should provide recommendations for next steps, if a follow-up ultrasound shows no finding. If MRI-directed ultrasound shows a probably benign mass, follow-up of the mass can be performed with ultrasound in 6 months, instead of with MRI. In addition, if follow-up with MRI is recommended, it should be an AB-MRI, not a full-protocol examination, to maintain operational costs and facilitate comparison across similar protocols. A final assessment of BI-RADS category 3 should never be used for an enlarging or new solid mass. Benchmarks are well established for outcomes for BI-RADS categories 4 and 5, as well as for PPV2 and PPV3 [29]. Access to the audit data of each individual reader, as well as to the combined data of the group, is essen­tial, so radiologists can compare their outcomes to those of others and seek ad­ditional training as needed.

As expected, there is a learn­ing curve to the interpretation of any new imaging modality or protocol. Auditing al­lows the identification of outliers among a group of radiologists and may help target individuals for additional training. As with any new imaging modality, a practice may also consider limiting the number of ra­diologists reading AB-MRI cases early in the implementation, later expand­ing the number of readers as the volume of examinations increases and a teaching set of images with known outcomes has been collected for sharing across the group. Furthermore, as outcome data from AB-MR studies continue to evolve, benchmarks will be established for best practices.

Financial Considerations

Because there currently is no Current Procedural Terminology (CPT) code for AB-MRI, women must self-pay for their examinations without insurance being billed [15]. According to recent reviews of AB-MRI implementation at sites across the United States, out-of-pocket charges vary from $250 [28] to $500 [30]. When appro­priate pricing is considered, the cost of the gadolinium-based contrast agent and table time must be considered [31], as must the costs of any downstream MRI-guided biop­sies that may or may not be covered by the patient’s insurance. It should be noted that the out-of-pocket payment may be a barrier for some patients, leading to disparities in access to AB-MRI screening. In a recent survey of 508 patients with dense breasts who were undergoing screening mammog­raphy, 67% of patients cited the cost of adjunct screening as the primary deterrent [32], which was independently associated with younger age [33]. A possible solution could include adjustment of the self-pay­ment costs based on financial need.

To determine appropriate pricing based on cost benefit, Mango et al. [34] used a Monte Carlo simulation to analyze a 30-year screening period in which a hypotheti­cal group of 2.5 million women would un­dergo either digital mammography annually or MRI every 3 years (selected on the basis of no interval cancers being identified dur­ing this time frame in another study [35]). At 24 years, MRI became as cost-effective as mammography ($13.02 billion vs $13.03 billion, respectively). When a lower cost of $400 was used for MRI (vs $640 for the full diagnostic protocol), MRI screen­ing became more cost-effective in less than 6 years ($3.41 billion vs $3.65 billion for mammography). However, the comparison of AB-MRI with 2D mammography rather than DBT limits generalizability [34].

Bundled payment models, which in­clude all costs from screening to breast cancer diagnosis over a 364-day period, have been created to control costs and increase value. If AB-MRI reduces over­all costs for breast cancer screening (as a triennial examination performed without mammography), compared with digital mammography by 6 years, as suggested by the Monte Carlo simulation [34], bundled payments may be reasonable for incident AB-MRI screening at the cost of $400 per study. The societal costs of screening once every 3 years must also be considered.

With no current insurance coverage for AB-MRI, institutions must engage mul­tiple stakeholders when initiating an AB-MRI program. Certainly, the downstream revenues to the institution from breast can­cers detected using AB-MRI are an impor­tant consideration. Institutional financial support may be needed, with expectations of downstream revenues.

Implementation of Abbreviated (or Fast) MRI in Your Clinical Practice

A clear protocol that defines which pa­tients should be offered AB-MRI is need­ed, especially in the early phase of imple­mentation. Additionally, because triage of patients will be needed to ensure appro­priateness, it may be prudent to limit the number of schedulers involved in book­ing AB-MRI examinations, until a smooth process is developed. A telephone script for schedulers can help to ensure that ap­propriate eligibility is determined before scheduling [7].

Preferably, AB-MRI examinations should be scheduled in time slots that are signifi­cantly shorter than the time slots needed for full-protocol breast MRI, which takes longer to perform. To increase operational efficiency for an abbreviated protocol, it will be important to work with MRI tech­nologists to limit the time that patients are positioned on the table to match the abbre­viated protocol. For example, it will be im­portant to emphasize that for the greatest efficiency, the processing of reconstructed images (subtracted and MIP images) by technologists should be done after the patient has been removed from the MRI table and imaging room. AB-MRI exami­nations can also be scheduled sequentially to reduce the time needed to set up and take down the breast coil. This attention to ef­ficient use of the room and table time will optimize operations and allow more rapid turnover of the room for the next patient study, resulting in less downtime for room use [31].

To start a successful program of sup­plemental AB-MRI screening, it is es­sential to engage referring health care providers with educational programs that address who may be appropriate for supplemental AB-MRI screening and what the implications of additional screening may be for patients. One of the best methods of educating both patients and providers is lecturing at patient-facing symposia or departmental grand rounds to discuss the implications of increased breast density on both the masking of cancers on mam­mography and the risk of breast cancer developing. Also, it is helpful to create informational cards on supple­mental screening with AB-MRI that can be provided to appropriate patients in ei­ther the breast imaging or primary care clinics [7]. As uptake of the new protocol increases and significant results, such as supplemen­tal cancer detection rates and subtypes of cancers detected, become available, fol­low-up educational sessions should be provided to referring providers and, if possible, consumers.

Future Directions

The imaging sequences for breast MRI protocols, including AB-MRI protocols, are constantly evolving. For example, given the limited temporal information re­garding many AB-MRI protocols, several exploratory efforts have included ultra­fast sequences [36–39], which may have lower spatial resolution but may include images acquired every 1–10 seconds dur­ing the first two minutes after injection of contrast medium. Therefore, while maintaining an abbreviated protocol, measurements of both maximum slope of enhancement and rate of enhancement are possible to help discriminate benign from malignant lesions [39, 40]. There have also been efforts to develop unen­hanced abbreviated breast MRI protocols because screening MRI could potentially be performed routinely over many years and because there have been concerns surrounding cumulative deposition of gadolinium [41]. A recent study by Bickelhaupt et al. [42] showed that the perfor­mance of unenhanced DWI and AB-MRI was comparable (sensitivity, 0.92 vs 0.85, respectively; specificity, 0.94 vs 0.90, re­spectively). Although acquisition of DWI is time-consuming, the possibility of DWI replacing contrast imaging is appealing, if performance is maintained [42]. How­ever, according to a recent study that included both DWI and contrast imag­ing, inclusion of DWI in the abbreviated protocol achieved performance compa­rable to that of a full protocol (sensitivity, 100% vs 100%, respectively; specificity, 95.0% vs 96.8%, respectively); however, scanning time was extended, and contrast medium was still used [43]. Ideally, DWI will advance so that performance of an abbreviated DWI protocol will rival that of an abbreviated contrast study.

AB-MRI may improve access to high-sensitivity screening breast MRI and de­crease overall cost. Successful clinical implementation requires the thoughtful collaboration of multiple stakeholders and ongoing monitoring of performance met­rics. Additional data and experience are re­quired to facilitate standardization across institutions. With improved efficiency and maintained accuracy, AB-MRI may enable more women to access this important sup­plemental screening modality.

A multimodality review—everything from routine ultrasound and mammography to the latest DBT and AI applications—ARRS’ Breast Tumor Imaging Online Course delivers the interpretive, technical, and systems knowledge that practicing radiologists need to provide quality breast cancer screening. Additional lectures address pathology, the BI-RADS lexicon, and even the history and economics of breast cancer, all critical for improving overall care disparities and patient outcomes.

Read faculty excerpts from the contrast-enhanced mammography sessions on InPractice.

References

1. DeMartini W, Lehman C. A review of current evidence-based clinical applications for breast magnetic resonance imaging. Top Magn Reson Imaging 2008; 19:143–150
2. Sardanelli F, Boetes C, Borisch B, et al. Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group. Eur J Cancer 2010; 46:1296–1316
3. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57:75–89
4. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultra- sound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010; 7:18–27
5. Mann RM, Balleyguier C, Baltzer PA, et al. Breast MRI: EUSOBI recommendations for women’s information. Eur Radiol 2015; 25:3669–3678
6. Saftlas AF, Hoover RN, Brinton LA, et al. Mammographic densities and risk of breast cancer. Cancer 1991; 67:2833–2838
7. Grimm LJ, Mango VL, Harvey JA, Plecha DM, Conant EF. Implementation of abbreviated breast MRI for screening: AJR expert panel narrative review. AJR 2021 Aug 11 [published online]
8. 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; 32:2304–2310
9. Comstock CE, Gatsonis C, Newstead GM, et al. Comparison of abbreviated breast MRI vs digital breast tomosynthesis for breast cancer detection among women with dense breasts undergoing screening. JAMA 2020; 323:746–756
10. Baxter GC, Selamoglu A, Mackay JW, Bond S, Gray E, Gilbert FJ. A meta-analysis comparing the diagnostic performance of abbreviated MRI and a full diagnostic protocol in breast cancer. Clin Radiol 2021; 76:154
11. Hernández ML, Osorio S, Florez K, Ospino A, Diaz GM. Abbreviated magnetic resonance imaging in breast cancer: a systematic review of literature. Eur J Radiol Open 2020; 8:100307
12. Geach R, Jones LI, Harding SA, et al. The potential utility of abbreviated breast MRI (FAST MRI) as a tool for breast cancer screening: a systematic review and meta-analysis. Clin Radiol 2021; 76:154.e11–154.e22
13. Weinstein SP, Korhonen K, Cirelli C, et al. Abbreviated breast magnetic resonance imaging for supplemental screening of women with dense breasts and average risk. J Clin Oncol 2020; 38:3874–3882
14. Sung JS, Stamler S, Brooks J, et al. Breast cancers detected at screening MR imaging and mammography in patients at high risk: method of detection reflects tumor histopathologic results. Radiology 2016; 280:716–722
15. Marshall H, Pham R, Sieck L, Plecha D. Implementing abbreviated MRI screening into a breast imaging practice. AJR 2019; 213:234–237
16. Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol 2018; 15:408–414
17. Mori N, Sheth D, Abe H. Nonmass enhancement breast lesions: diagnostic performance of kinetic assessment on ultrafast and standard dynamic contrast-enhanced MRI in comparison with morphologic evaluation. AJR 2020; 215:511–518
18. Heacock L, Melsaether AN, Heller SL, et al. Evaluation of a known breast cancer using an abbreviated breast MRI protocol: correlation of imaging characteristics and pathology with lesion detection and conspicuity. Eur J Radiol 2016; 85:815–823
19. Heacock L, Lewin AA, Toth HK, Moy L, Reig B. Abbreviated MR imaging for breast cancer. Radiol Clin North Am 2021; 59:99–111
20. Harvey SC, Di Carlo PA, Lee B, Obadina E, Sippo D, Mullen L. An abbreviated protocol for high-risk screening breast MRI saves time and resources. J Am Coll Radiol 2016; 13:R74–R80
21. DeMartini WB, Liu F, Peacock S, Eby PR, Gutierrez RL, Lehman CD. Background parenchymal enhancement on breast MRI: impact on diagnostic performance. AJR 2012; 198:[web]W373–W380
22. Ray KM, Kerlikowske K, Lobach IV, et al. Effect of background parenchymal enhancement on breast MR imaging interpretive performance in community-based practices. Radiology 2018; 286:822–829
23. Giess CS, Yeh ED, Raza S, Birdwell RL. Background parenchymal enhancement at breast MR imaging: normal patterns, diagnostic challenges, and potential for false-positive and false-negative interpretation. RadioGraphics 2014; 34:234–247
24. Li J, Dershaw DD, Lee CH, Joo S, Morris EA. Breast MRI after conservation therapy: usual findings in routine follow-up examinations. AJR 2010; 195:799–807 [Erratum in AJR 2010; 195:1043]
25. Ha R, Sung J, Lee C, Comstock C, Wynn R, Morris E. Characteristics and outcome of enhancing foci followed on breast MRI with management implications. Clin Radiol 2014; 69:715–720
26. Grimm LJ, Enslow M, Ghate SV. Solitary, well-circumscribed, T2 hyperintense masses on MRI have very low malignancy rates. J Breast Imaging 2019; 1:37–42
27. Ikeda DM, Hylton NM, Kuhl CK, et al. BI-RADS: magnetic resonance imaging, 1st ed. In: D’Orsi CJ, Mendelson EB, Ikeda DM, et al. Breast Imaging Reporting and Data System: ACR BI-RADS—breast imaging atlas. Reston, VA: American College of Radiology, 2003
28. Marshall HN, Plecha DM. Setting up an abbreviated breast MRI program: our two-year implementation experience. J Breast Imaging 2020; 2:603–608
29. Lee JM, Ichikawa L, Valencia E, et al. Performance benchmarks for screening breast MR imaging in community practice. Radiology 2017; 285:44–52
30. Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. Screening algorithms in dense breasts: AJR expert panel narrative review. AJR 2021; 216:275–294
31. Borthakur A, Weinstein SP, Schnall MD, Conant EF. Comparison of study activity times for “full” versus “fast MRI” for breast cancer screening. J Am Coll Radiol 2019; 16:1046–1051
32. Miller MM, Repich K, Patrie JT, Anderson RT, Harvey JA. Preferences and attitudes regarding adjunct breast cancer screening among patients with dense breasts. J Breast Imaging 2021; 2:119–124
33. Miller MM, Repich K, Patrie JT, Anderson RT, Har- vey JA. Patient characteristics associated with patient-reported deterrents to adjunct breast cancer screening among patients with dense breasts. AJR 2021;217: 1069–1079
34. Mango VL, Goel A, Mema E, Kwak E, Ha R. Breast MRI screening for average-risk women: a Monte Carlo simulation cost-benefit analysis. J Magn Reson Imaging 2019; 49:e216–e221
35. Kuhl CK, Strobel K, Bieling H, Leutner C, Schild HH, Schrading S. Supplemental breast MR imaging screening of women with average risk of breast cancer. Radiology 2017; 283:361–370
36. van Zelst JCM, Vreemann S, Witt HJ, et al. Multireader study on the diagnostic accuracy of ultra- fast breast magnetic resonance imaging for breast cancer screening. Invest Radiol 2018; 53:579–586
37. Goto M, Sakai K, Yokota H, et al. Diagnostic performance of initial enhancement analysis using ultra- fast dynamic contrast-enhanced MRI for breast lesions. Eur Radiol 2019; 29:1164–1174
38. Milon A, Vande Perre S, Poujol J, et al. Abbreviated breast MRI combining FAST protocol and high temporal resolution (HTR) dynamic contrast enhanced (DCE) sequence. Eur J Radiol 2019; 117:199–208
39. Mann RM, Mus RD, van Zelst J, Geppert C, Karssemeijer N, Platel B. A novel approach to contrast- enhanced breast magnetic resonance imaging for screening: high-resolution ultrafast dynamic imaging. Invest Radiol 2014; 49:579–585
40. Abe H, Mori N, Tsuchiya K, et al. Kinetic analysis of benign and malignant breast lesions with ultrafast dynamic contrast-enhanced MRI: comparison with standard kinetic assessment. AJR 2016; 207:1159– 1166
41. Runge VM. Critical questions regarding gadolinium deposition in the brain and body after injections of the gadolinium-based contrast agents, safety, and clinical recommendations in consideration of the EMA’s Pharmacovigilance and Risk Assessment Committee recommendation for suspension of the marketing authorizations for 4 linear agents. Invest Radiol 2017; 52:317–323
42. Bickelhaupt S, Laun FB, Tesdorff J, et al. Fast and noninvasive characterization of suspicious lesions detected at breast cancer x-ray screening: capability of diffusion-weighted MR imaging with MIPs. Radiology 2016; 278:689–697
43. Chen SQ, Huang M, Shen YY, Liu CL, Xu CX. Abbreviated MRI protocols for detecting breast cancer in women with dense breasts. Korean J Radiol 2017; 18:470–475