The American Roentgen Ray Society (ARRS) was but a teenager when the city of Boston, MA, first hosted an ARRS Annual Meeting. Dr. Henry Khunrath Pancoast (of “Pancoast lung tumor” fame) presided over that 1913 convocation in Boston, and North America’s first radiological society would return to the cradle of liberty for six more meetings before the 20th century was over.

The 2024 ARRS Annual Meeting at Boston’s John B. Hynes Veterans Memorial Convention Center delivered the same clinically relevant experience for which this society has long been heralded. From Sunday, May 5 to Thursday, May 9, radiologists of each practice type and every training level relished world-class instruction from trusted experts spanning every subspecialty.

Pioneers in asynchronous education a decade before COVID-19 changed everything, ARRS continues to offer both in-person and virtual registrants the most flexible meeting experience in radiology. From Instructional Courses and Scientific Sessions to Categorical Courses and Online Posters, all #ARRS24 attendees retain on-demand access to the complete program for an entire calendar year, learning and earning CME well into 2025. 

And speaking of 2025, ARRS looks forward to delivering yet another singular experience at the Marriott Marquis Marina in San Diego, CA, next April 27–May 1.

After voting “yea” on a bylaw amendment to streamline the selection of committee chairs, the ARRS membership officially installed Angelisa Paladin, MD, of the University of Washington in Seattle as the 124th president of ARRS. Joining Dr. Paladin are the following newly elected ARRS officers for 2024–25: president-elect Deborah A. Baumgarten, MD, MPH; vice president Christine M. Glastonbury, MD; and secretary-treasurer Reginald F. Munden, MD, DMD, MBA.  

Dr. Paladin succeeds Erik K. Paulson, MD, who presented this year’s coveted ARRS awards. The first laurels of the morning went to Philip Costello, MD, who was awarded the 2024 ARRS Gold Medal. The highest distinction bestowed by ARRS, our Gold Medal has been honoring distinguished service to radiology for more than four decades. Gaveled in as ARRS President during the 2018 Annual Meeting in Washington, DC, presently, Dr. Costello chairs the six vital scholarship programs of ARRS’ own Roentgen Fund®.

David M. Neager, MD, was then recognized as the 2024 ARRS Distinguished Educator. An engaging presence who motivates and impacts learners and colleagues alike, he exhibits his commitment to ARRS’ own educational initiatives—especially the Clinician Educators Development Program and Radiology Review Track—with attention to the needs and diversity of our members.

Next, ARRS was proud to recognize two recipients of 2024 ARRS Scholarships: Ian Mark, MD, of Mayo Clinic Minnesota and Evan Calabrese, MD, PhD, of Duke University Medical Center. Also provided by the Roentgen Fund, the ARRS Scholarship supports early-career faculty members pursuing radiological research that promises to change how medical imaging is practiced. A two-year grant totaling $180,000, the ARRS Scholarship aims to advance emerging scholars, as well as prepare them for positions of leadership. 

Stephen Keevil, BIR President, Named Honorary Member

Professor Stephen F. Keevil, president of the British Institute of Radiology (BIR)—the oldest medical imaging society in the world—was recognized with honorary membership as part of ARRS’ Global Partner Society (GPS) program. Keevil served on the faculty for the 2024 ARRS Annual Meeting Global Exchange, “Screening Patient Pathways Across the Pond: Highlights and Challenges for Radiology in the UK and USA.” The GPS program was established to build long-standing relationships with key leaders and societies in the global imaging community to enhance understanding, raise awareness, and increase participation in programs and services. The Annual Meeting Global Exchange incorporates one partner society annually into the educational and social fabric of the meeting, with ARRS reciprocating at the partner society’s meeting that year.

2024 AJR Luncheon with Figley and Rogers Journalism Fellows

During the American Journal of Roentgenology (AJR) Luncheon on Monday afternoon, Francis Baffour, MD, of Mayo Clinic in Rochester, MN, was honored as the 2024 Melvin M. Figley Fellow in Radiology Journalism, while Hyun Soo Ko, MD, of the Peter MacCallum Cancer Centre and Epworth Medical Imaging in Melbourne, Australia was recognized as the 2024 Lee F. Rogers International Fellow in Radiology Journalism. 

Named for two distinguished Editors Emeriti of AJR, the Melvin Figley and Lee Rogers Fellowships offer practicing radiologists an unparalleled opportunity to learn the tenets of medical publishing via “the yellow journal”—the world’s longest continuously published radiology journal. Through hands-on experience with ARRS staff and AJR personnel—as well as personal apprenticeship with AJR’s 13th Editor of Chief, Andrew B. Rosenkrantz—Drs. Baffour and Ko will receive expert instruction in scientific writing and communication, manuscript preparation and editing, peer review processes, journalism ethics, and digital production and publication.

With Distinction: Award-Winning Scientific Research

The 2024 ARRS Annual Meeting hosted hundreds of electronic exhibits and abstracts presenting leading-edge research. Below are three highlights from our 2024 Scientific Program. 

Mammograms Reveal Hidden Clues to Heart Health

According to the Summa Cum Laude Award-Winning Online Poster presented during the 2024 ARRS Annual Meeting, fat-enlarged axillary nodes on screening mammograms can predict high cardiovascular disease (CVD) risk, Type 2 diabetes (T2DM), and hypertension (HTN).

“Incorporating fat-enlarged nodes into CVD risk models has the potential to improve CVD risk stratification without additional cost or additional testing,” said Jessica Rubino, MD, from Dartmouth Hitchcock Medical Center in Lebanon, NH. “Fat-enlarged axillary lymph nodes visualized on screening mammography may increase the ability to identify women who would benefit from CVD risk reduction strategies and more intensive risk assessment with coronary artery CT.”

Rubino et al. reviewed patients (women, 40–75 years) without known coronary artery disease who had a routine screening mammogram and cardiovascular risk factors available in the EMR within 1 year of the index mammogram (January 1, 2011–December 31, 2012). Evaluating major adverse cardiovascular events (MACE) within 10 years of the index mammogram, the researchers used clinical parameters at the time of the index mammogram to determine high estimated CVD risk via the pooled cohort equation (PCE) —defined by the American Heart Association as more than a 7.5% likelihood of MACE within 10 years. Two breast imagers evaluated screening mammograms to measure the length of the largest visible axillary LN in each breast in the mediolateral oblique view, analyzing the largest visible node for each patient. Logistic regression then examined associations between lymph node size, 10-year CVD risk, MACE, T2DM, HTN, low density lipoprotein (LDL), age, and BMI. 

Ultimately, among 1,216 women included in this ARRS Annual Meeting Summa Cum Laude Scientific Poster, 907 (74.6%) had a visible axillary LN on the index mammogram, and 232 (19.1%) women had fat-enlarged nodes—defined as larger than 20 mm in length due to an expanded fatty hilum. Women with fat-enlarged nodes had a high risk of CVD defined by PCE (OR = 2.6, 95% CI 1.5–4.2), as well as a higher prevalence of T2DM (OR = 4, 95% CI 2.1–7.7) and HTN (OR = 2.5, 95% CI 1.6–4.0). Fat-enlarged nodes were also associated with a trend toward higher risk of MACE (OR = 1.7, 95% CI 0.9–3.1) and LDL (OR = 1.4, 95% CI 0.9–2.1).

“These results support further investigation of fat-enlarged lymph nodes,” Rubino added, “particularly with studies leveraging AI evaluation of mammographic fat-enlarged LNs and cardiometabolic disease.” 

Detecting Accessory Infraglenoid Muscle in Teres Minor Fatty infiltration

The Magna Cum Laude Award-Winning Online Poster presented during the 2024 ARRS Annual Meeting showed a high prevalence (89%) of accessory infraglenoid muscle (AIGM) in patients with teres minor fatty infiltration (TMFI)—compared to those without (30%). Additionally, within the TMFI cohort, many AIGM abutted the axillary nerve with concomitant axillary neuropathy. 

“These results stress the importance of looking for AIGM in the setting of TMFI, as TMFI on preoperative MRI has been associated with poor postsurgical outcomes,” said Jennifer Padwal, MD, from Stanford University Medical Center in California. “And the presence of AIGM on shoulder MRI could negate the need for additional imaging to evaluate the cause of TMFI.” 

Padwal et al.’s institutional review of all shoulder MRIs yielded 100 patients with documented TMFI (76 men, 24 women; mean age, 58.6 years). For comparison, a respective sample of 100 shoulder MRIs in patients without TMFI (53 men, 47 women; mean age, 56.4 years) was obtained. All scans were consensus evaluated by two radiologists (one musculoskeletal attending with 25 years of experience, as well as a 4th-year radiology resident) for an AIGM with diagnostic confidence, noting muscle origin and insertion. In patients with TMFI, the distance between the AIGM and axillary nerve was measured, documenting any abnormal axillary nerve signal. TMFI was then graded via Goutallier classification, while the presence of atrophy and/or edema was noted. 

Ultimately, in the ARRS Annual Meeting Magna Cum Laude Online Poster, TMFI was grade 1 in 33%, grade 2 in 32%, grade 3 in 13%, and grade 4 in 14%, with intramuscular edema in 33 and atrophy in 21 patients. AIGM was seen in 89/100 patients with TMFI; 30/100 patients without TMFI. In all cases, the AIGM originated from the inferior glenoid neck and inserted onto the humeral neck/proximal humeral diaphysis. The inferior margin of the AIGM in patients with TMFI touched the axillary nerve in 39 (46%), with abnormal signal in 23 (27%) patients.  

Noncontrast Fluoroscopy Images Chronic Hypertension 

The Cum Laude Award-Winning Online Poster presented during the 2024 ARRS Annual Meeting found that the noncontrast x-ray pulsatility index (XPI) method to evaluate and monitor pulmonary blood flow could improve clinical efficiency as a screening or diagnostic test, provide substantial financial benefits, and improve patient satisfaction.

“Additionally,” said Matthew Smith, MD, from Vanderbilt University Medical Center in Nashville, TN, “this easy-to-implement method can be performed by an x-ray technologist in an outpatient setting,”

Smith et al. enrolled volunteers suspected of chronic thromboembolic pulmonary hypertension (CTEPH) based on pulmonary scintigraphy and/or CTA. Fluoroscopic acquisition (70 kV, 30 frames/s) over an 8-second breath hold was performed in either RAO (30°) or LAO (40°) for the right and left lung, respectively. The temporal signal from each pixel was decomposed into individual frequency components via Fourier transform. The researchers then isolated heart rate signal oscillation using a band-pass filter and amplitude XPI mapped to form an image. Immediately following each fluoroscopic acquisition for spectral analysis, digital subtraction pulmonary angiography was performed with catheter-injected contrast in the same projection using standard protocols. Perfusion maps were segmented using a blinded manual technique, as well as a semi-automated threshold and region-growing method, while segmentation maps were compared using the Dice similarity coefficient—a statistical measurement of overlap.

Ultimately, in this ARRS Annual Meeting Cum Laude Scientific Poster, where noncontrast (XPI) and contrast pulmonary angiography images were obtained in 11 different lungs, all patients were able to perform satisfactory breath hold, despite moderate to severe disease. Direct comparison of segmentation maps revealed an average Dice score of 0.77, suggesting excellent agreement between XPI and pulmonary angiography maps in depicting regions of blood flow and, more importantly, lack of blood flow.

The American Roentgen Ray Society (ARRS) proudly recognizes four emerging radiologists, as well as their institutions and research projects, with the 2024 ARRS Resident/Fellow in Radiology Awards:

Jessica T. Wen, MD, PhD | Stanford University
ARRS Melissa Rosado de Christenson Award 
“Alpha-Fetoprotein Response Patterns After Y-90 Radioembolization for Intermediate-to-Advanced Hepatocellular Carcinoma Predicts Disease Progression and Survival”

Melina Hosseiny, MD | University of California, San Diego
ARRS President’s Award
“Multi-task Ensemble Deep Learning for Differential Diagnosis of Pneumonia and Pulmonary Edema on Chest Radiograph”  

Ahmed Taher, MD | University of Texas Health Science Center at Houston
ARRS Executive Council Award

“Safety and Efficacy of Zilretta Administered to Patients with Greater Trochanteric Bursitis”

Hana L. Haver, MD, MSc | Massachusetts General Hospital

ARRS Executive Council Award
“Large Language Models to Assist Breast Imaging Reporting: A Comparison of GPT-3.5 Versus GPT-4 in Assigning BI-RADS Final Assessment Categories”

Supported by The Roentgen Fund®, the ARRS Resident/Fellow in Radiology Awards are available to all ARRS In-Training Members in imaging and allied sciences research to acknowledge their work and present their results during the ARRS Annual Meeting. ARRS Resident/Fellow in Radiology Awards are based on the competence and promise of the candidate in radiological research, education, or administration and the scientific merit and potential impact of the candidate’s research.

Stay tuned—an application call for the 2025 ARRS Resident/Fellow in Radiology Awards will be announced later this year.

Clinician Educator Development Program Supports 30 Radiologists

Each year, CEDP recipients are selected to receive a travel grant to attend a specialized workshop during the ARRS Annual Meeting. With a curriculum offering increased proficiency in teaching skills, as well as educational activity design, ARRS’ CEDP remains a highly interactive day of learning. Focusing on new and emerging pedagogical tools, while improving already acquired clinical acumen, over half of this expertly curated syllabus consisted of hands-on learning. 

Offering a unique opportunity to interact with fellow enthusiastic clinician educators the Saturday before the meeting begins, attendees engaged further with the esteemed faculty ARRS convened: 2024 Distinguished Educator, David M. Naeger, MD; longtime CEDP instructors Judith A. Gadde, DO, and Travis S. Henry, MD, first-time CEDP leader Sherry Wang, MD; as well as the 2021 AJR Melvin M. Figley Fellow in Radiology Journalism, Omer A. Awan, MD.

Chairpersons and program directors at medical schools, affiliated hospitals, and clinical research institutions are invited to nominate two candidates per institution for the 2025 ARRS Clinician Educator Development Program. For full details, please visit ARRS.org/CEDP.

Honorary Lectures Hone In On Cardiothoracic Interpretation, Chest Radiography

On Monday, May 6, and Tuesday, May 7, Ballroom A of John B. Hynes Veterans Memorial Convention Center in Boston witnessed not one, but two must-see Roentgen Fund Honorary Lectures.

Former Roentgen Fund chair Melissa Rosado de Christenson, MD, sponsored and helped to deliver “Great Cardiothoracic Interpretations From Our Practices.” Presented in memory of Robert D. Pugatch, MD, Dr. Rosado de Christenson, was joined by Drs. Jeffrey Klein and Caroline Chiles. These three luminaries of chest imaging—all past presidents of the Society of Thoracic Radiology—discussed the great cases that they have seen in their own clinical practices.

In honor of Drs. Rosado de Christenson and Gerald Abbott, 2024 ARRS Gold Medalist Philip Costello, MD, graciously underwrote “Chest Radiography: Pearls from the Experts.” A high-profile presentation in four high-impact parts, Dr. Abbott, himself, opened, pointing out pearls and pitfalls alike when interpreting chest radiographs. Saurabh Agarwal’s presentation on focal lung disease followed, with Tami J. Bang offering a much need primer for cardiac devices. The last session of this year’s slate of Honorary Lectures concluded with Ioannis Vlahos’ guidance regarding dual-energy chest radiographs.

Since 1990, The Roentgen Fund has granted millions of dollars to hundreds of imaging professionals for both research pursuits and professional development. Today, through six vital scholarship and fellowship programs, the generosity of The Roentgen Fund’s donors is channeled to every corner of the globe—establishing dual foundations in innovation and leadership for a true diversity of radiology’s next generation. 

The Roentgen Fund Honorary Lecture offers donors a prestigious opportunity to honor a mentor, recognize a colleague, or remember a loved one in a high-level manner during the ARRS Annual Meeting. At the same time, these generous donors support scholarships and awards to invest in the future of radiology.

I am proud, deeply honored, and flattered to have served as the 123^rd president of the American Roentgen Ray Society (ARRS). As you know, ARRS is the oldest radiology society, and we are widely regarded as the education society.

Health care and radiology are in the midst of unprecedented change, in part, due to the after effects of the COVID pandemic and the resultant Great Resignation, including what will probably be permanent alterations in the workforce. There is unprecedented “consumerism” in medicine with a mandate to improve patient access and to have transparent pricing. There has been a shortage of radiologists fueled, in part, by a desire to be part-time, a trend toward exclusive subspecialization, ever-increasing expectation for service to our hospitals and health care systems, and decreasing reimbursement. There is a concern about what role artificial intelligence and machine learning might play.  

Despite all the changes in our professional environments, ARRS has and will double down on its commitment to provide a professional home and outstanding, trusted educational resources for all our members—ranging from those in-training seeking preparation for the new oral boards examination, to those in practice desiring trusted continuing education, and to those in academic departments educating the next generation and contributing to cutting-edge clinical research. The ARRS strives to connect with radiologists at our Annual Meeting and through the American Journal of Roentgenology (AJR), online symposia, live webinars, as well as other books and publications. 

In my view, the future for radiology and for ARRS is bright and exciting. During my career, there has been explosive growth in advanced imaging technology with concomitant development of new diagnostic approaches and image-guided interventions and therapies. Radiology expertise is more critical than ever before in working with our clinical colleagues to screen, diagnose, treat, and care for our patients.  At the same time, there is an opportunity to respond to the unprecedented pressure to be more efficient, while ensuring appropriateness, safety, and positive outcomes.

Radiology continues to attract the brightest medical students, reflected in the reality that there are more students interested in radiology than currently available training slots. Our residency and fellowship training programs continue to evolve and improve. The job market is robust for radiologists, and there are plenty of excellent opportunities for radiologists in our various communities.

Thank you for allowing me to serve as your ARRS president this last year. I would also like to thank the members of the ARRS Executive Council, particularly Executive Committee members: President-elect Angelisa Paladin, Vice President Deb Baumgarten, and Secretary/Treasurer Christine Glastonbury. Special thanks to Susan Cappitelli, ARRS Executive Director, too.

I look forward to connecting with many of you during our upcoming Annual Meeting in Boston, MA, May 5–9, 2024. 

Point-of-care ultrasound (POCUS) is a focused ultrasound (US) examination performed and interpreted by the clinician at the patient’s bedside to answer a specific clinical question or guide an invasive procedure. Because the clinician can correlate findings with a patient’s signs and symptoms, POCUS can provide valuable diagnostic information to narrow the differential and guide management in real time [1, 2]. Integration of POCUS into clinical practice has been shown to increase diagnostic accuracy and expedite time to diagnosis and treatment, as well as reduce costs and length of stay and improve patient safety and satisfaction [3–8].

POCUS examinations are focused and operator-dependent; therefore, they tend to provide limited information. As such, POCUS does not replace comprehensive radiologist-performed diagnostic studies; CT is overall superior in evaluating patients with an acute abdomen (i.e., sudden onset of severe abdominal pain) [1, 8]. However, because POCUS is portable, noninvasive, radiation-free, and easily repeatable, it is especially valuable in high-acuity settings, where expedient answers and patient stability are a consideration. POCUS may not be the best definitive test, but it is an excellent initial diagnostic tool that can aid in critical decision-making [9]. The scope of POCUS has expanded significantly in recent decades to include a myriad of applications. Among these are targeted evaluations of acute intraabdominal pathology, where rapid recognition and prompt management are key. This includes hemoperitoneum, ectopic pregnancy, abdominal aortic aneurysm (AAA), obstructive uropathy, appendicitis, bowel obstruction, and pneumoperitoneum [9, 10]. This InPractice article provides an overview of the scope and utility of POCUS for the acute abdomen, focusing on commonly used applications in clinical practice.

Free Fluid

Intraperitoneal free fluid is the pathologic accumulation of fluid within the peritoneal cavity. This can result from various disease processes, including traumatic hemorrhage, ruptured ectopic pregnancy, AAA, bowel perforation or obstruction, and ascites. Although many of these pathologies usually warrant additional diagnostic imaging, POCUS is a valuable initial test that can quickly detect free fluid, which can influence workup and management [11].

Free Fluid in Trauma Setting

Evaluating intraperitoneal free fluid in the setting of trauma is among the most well-established uses of POCUS. First described in Europe in the 1970s and adopted in the United States by the 1990s, this examination is now known as “focused assessment with sonography in trauma” (FAST) [12]. The FAST examination includes a quick survey of key areas in the intraperitoneal cavity for free fluid, a sign of hemorrhage, and an indirect indication of organ injury; cardiac and thoracic components are also included. The abdominal component of FAST evaluates the right and left upper quadrants, focusing on the perihepatic and perisplenic spaces, respectively, along with the pelvis [11, 12] (Fig. 1).

The sensitivity and specificity of FAST for detecting intraperitoneal free fluid is 64–98% and 86–100%, respectively [13]. Though not perfect, FAST has greater accuracy compared with physical examination, laboratory tests, and radiography to detect intraabdominal injury. In hemodynamically unstable patients, the diagnostic accuracy increases significantly [14]. Because of its utility, the FAST examination has become the initial screening modality (replacing the previous standard of diagnostic peritoneal lavage) at most trauma centers nationwide and is included in the Advanced Trauma Life Support protocol [15]. A FAST examination is primarily indicated in the setting of blunt trauma but can help triage and prioritize further diagnostic testing and management in cases of penetrating abdominal trauma. A positive FAST—that is, the presence of free fluid—suggests an intraabdominal injury, whereas a negative FAST alone does not obviate additional testing for intraabdominal injury. This is because a FAST examination cannot reliably rule out injuries to solid or hollow organs [13]. 

The amount of free fluid detected at a specific point in time depends on the rate of accumulation, location, and the patient’s position [9]. Free fluid gravitates to the most dependent area, which is the right upper quadrant (RUQ) in a supine patient [16]. Within the RUQ, the hepatorenal recess (also known as Morison pouch) is a common area of interest; however, the caudal tip of the liver is where fluid tends to collect first. In the left upper quadrant, attention should be directed to the perisplenic area, particularly in the subdiaphragmatic space. In the pelvis, fluid tends to collect posterior to the uterus, known as the pouch of Douglas, in females and in the rectovesicular space or lateral to the bladder in males [17] (Fig. 2).

Despite its recognized utility, the FAST examination has several limitations. In addition to inability to exclude organ injury, it can also be limited by other factors, including operator experience, body habitus, and bowel gas. Free fluid can have varying appearances depending on the type and composition of fluid, and it can change over time. For example, blood is initially anechoic or black, but blood becomes more echogenic as it clots, which makes it difficult to identify and distinguish free fluid from surrounding organs, fat, or other structures. US cannot differentiate the type of fluid (i.e., blood, urine, ascites) and is unable to detect retroperitoneal hemorrhage [11, 12].

Free Fluid in Nontrauma Setting

The FAST examination is highly valuable when evaluating free fluid from nontraumatic hemoperitoneum (such as from ruptured ectopic pregnancy), bowel perforation or obstruction, ascites, and undifferentiated hypotension [11]. When evaluating or managing a patient with ascites, POCUS allows for quantification and distribution of the fluid and can provide real-time procedural guidance for paracentesis at the bedside, which improves success and reduces complications [3]. The other topics are covered separately in the subsequent sections.

Ectopic Pregnancy

Ectopic pregnancy is the leading cause of maternal mortality in the first trimester, and prompt recognition is key [18, 19]. US is the primary imaging modality throughout pregnancy, and the main goals of POCUS, especially in the first trimester, are to identify an intrauterine pregnancy (IUP) and evaluate for free fluid. Confirming an IUP essentially excludes ectopic pregnancy, whereas the absence of an IUP should raise concern for an ectopic pregnancy, especially if the patient has concerning signs or symptoms. Though not a goal of POCUS, it is possible to identify an extrauterine gestational sac containing a yolk sac or fetal pole, which is diagnostic of ectopic pregnancy. Additional nonspecific findings that may also be seen include a complex mass, tubal ring, and free fluid, but their absence does not rule out ectopic pregnancy [11].

In the setting of known or suspected ectopic pregnancy, free fluid in the RUQ is highly concerning for rupture, which can be life-threatening. This finding not only predicts the need for operative intervention, but it significantly expedites the time to diagnosis and definitive management [18–20].

Abdominal Aortic Aneurysm

AAA is a relatively common acute abdominal process with high mortality. A ruptured AAA requires rapid diagnosis and prompt surgical intervention. Clinicians often rely on classic signs and symptoms, including severe abdominal or back pain, syncope, hypotension, or a pulsatile abdominal mass, but these have poor sensitivity [21]. CTA is the preferred imaging study for ruptured AAA, and US is a well-established and validated screening modality [22].

POCUS has excellent ability to detect AAA, which is defined by a diameter exceeding 3 cm when measured from outer wall to outer wall (Fig. 3).

A systematic review and meta-analysis found POCUS to have a sensitivity of 99% and specificity of 98%, when performed by emergency medicine physicians [23]. Although POCUS can accurately determine the presence or absence of AAA, the ability to detect signs of rupture is poor, which is largely due to the limited ability to visualize the retroperitoneum. Findings that indicate rupture include deformation of aneurysmal shape, heterogeneity or focal discontinuity of the intraluminal thrombus, focal disruption of the outer wall, hypoechoic areas in the paraaortic region, and hemoperitoneum [24].

POCUS is a great initial imaging option for suspected AAA, especially in the emergency department (ED), but adequate visualization may be limited by body habitus or bowel gas. The latter can be mitigated by graded compression, whereby slow, sustained pressure is applied to the abdomen to displace loops of bowel (and associated intraluminal gas) to allow better visualization of underlying structures. Like the FAST examination, AAA assessment is one of the core POCUS applications and is a required part of residency training for nonradiology specialties [10].

Cholelithiasis and Cholecystitis

Cholelithiasis and cholecystitis are common biliary pathologies characterized by gallstones in the gallbladder and inflammation of the gallbladder, respectively. US is the reference standard for diagnosis. Biliary POCUS is well established for identifying cholelithiasis or cholecystitis [10].

Sonographically, gallstones typically appear as a hyperechoic structure with distinct posterior shadowing. Imaging findings of cholecystitis include thickened gallbladder wall, pericholecystic fluid, and sonographic Murphy sign, in addition to sludge or gallstones in most cases [11] (Fig. 4).

Like other abdominal POCUS examinations, body habitus and bowel gas can be limiting. For the latter, having the patient sit upright or move into a left lateral decubitus position can often help move the bowel loops away from the gallbladder to improve visualization. Additional pitfalls include misidentification of anatomy or mistaking normal physiologic changes with pathologic findings, such as a contracted gallbladder [11, 25].

Despite these limitations, emergency physician–performed POCUS for cholelithiasis and cholecystitis has sensitivity and specificity comparable to that of radiologist-performed US [25, 26]. Biliary POCUS alone has been shown to reliably inform surgical decision-making and can reduce length of stay in the ED [27, 28]; however, routine adoption in clinical practice has been limited. Although POCUS does not replace comprehensive imaging, it is a safe, efficient, and reliable diagnostic option for cholelithiasis and cholecystitis.

Obstructive Uropathy

Obstructive uropathy can result from intrinsic or extrinsic obstruction of the urinary tract system and can be unilateral or bilateral, depending on the etiology. Renal colic commonly results from nephrolithiasis, which can lead to hydronephrosis when obstruction occurs. CT is the preferred imaging study for suspected nephrolithiasis, but POCUS is appropriate for initial imaging examination [11].

The focus of renal POCUS is to detect signs of obstruction (i.e., hydronephrosis and urinary retention) rather than identifying the stone, itself. POCUS is less sensitive, but more specific for nephrolithiasis compared with CT and has test characteristics comparable to those of traditional US. Use of POCUS is associated with shorter length of stay in the ED [29]. POCUS is highly specific for nephrolithiasis with moderate hydronephrosis, but less accurate in cases of mild or no hydronephrosis [30] (Fig. 5).

Advanced signs of obstruction are associated with larger stones, which often require surgical intervention, rather than conservative management [31]. For younger patients in whom uncomplicated renal colic is suspected, POCUS is a favorable initial imaging modality and perhaps the only imaging study needed. In patients with less typical signs and symptoms, POCUS can influence clinical suspicion and help inform the need for further imaging [32].

Appendicitis

Appendicitis is the most common surgical emergency worldwide and can be complicated by perforation, which occurs in approximately 20% of cases [33]. Along with clinical and laboratory findings, multiple imaging studies play a role in diagnosing appendicitis. CT may be the most accurate, but radiologist-performed US is well established and especially favorable in children in whom radiation exposure is a concern [34, 35]. POCUS has emerged as a promising diagnostic tool with relatively high sensitivity and specificity for appendicitis [34].

Characteristic sonographic findings include target sign in the short axis, blind-ended pouch in the long axis, lack of compressibility, diameter greater than 6 mm, wall thickness greater than 3 mm, appendicolith, and hypervascularity. Indirect findings suggestive of appendicitis include periappendiceal free fluid or abscess, hyperechoic mesenteric fat, enlarged mesenteric lymph nodes, increased peritoneal thickness, and signs of small bowel obstruction (SBO) [35] (Fig. 6).

Benefits of POCUS examination include lack of radiation exposure, lower costs, and ability to help prioritize radiology studies or expedite surgical consult. It may be particularly useful in centers where radiologist-performed US is not continually available. Visualizing the appendix is often limited by body habitus, pain, retrocecal location, and operator skill and experience. In addition, because a normal appendix is often difficult to visualize, this may be a more challenging POCUS study to learn [9, 34]. POCUS is a promising adjunct diagnostic tool, but it has not been extensively studied as a stand-alone test for appendicitis [34].

Bowel Obstruction

Bowel obstruction is a common acute abdominal process that needs timely diagnosis and management to avoid complications, such as ischemia, perforation, and necrosis. Obstruction is defined by impaired flow of bowel contents with varying degrees, ranging from partial to complete obstruction [36]. CT is commonly used to diagnose SBO but can be time-consuming, expensive, and involve radiation exposure. Radiography is often used as an initial imaging study, but sensitivity and specificity are poor and outperformed by POCUS [37]. A systematic review and meta-analysis found POCUS to have a high sensitivity and specificity for diagnosing SBO, rivaling that of CT, with the added benefit of saving time and potentially radiation [38]. The high diagnostic accuracy of POCUS is primarily for complete obstructions; POCUS is less reliable for partial obstruction [39]. Like other POCUS applications, evaluating SBO is highly operator-dependent. Although it may be easy to learn and demonstrate competency, US fellowship training is associated with significantly increased diagnostic accuracy [37–40].

Sonographic findings of SBO include dilated bowel with a diameter of greater than 2.5 cm, fluid-filled loops of bowel, decreased peristaltic movement, increased wall thickness, prominent valvulae conniventes, and a collapsed colonic lumen [40, 41] (Fig. 7).

Free fluid in the peritoneal cavity is associated with higher-grade obstruction and predicts need for operative intervention [42]. A transition point is often difficult to visualize, but POCUS can locate and identify the potential cause of obstruction, such as hernia, intussusception, masses, and signs of ischemia [43]. Evaluating SBO is not a core application of POCUS; it is a suitable modality for initial imaging evaluation and early management of SBO.

Pneumoperitoneum

Pneumoperitoneum is free air in the peritoneal cavity [44]. Free air suggests perforation of a hollow viscus organ, which can result from weakening of the bowel wall, ischemia, foreign body, bowel obstruction, or infection and has high morbidity and mortality [45]. CT is the imaging study of choice. Radiography is often used as an initial diagnostic study for pneumoperitoneum, but sensitivity is generally poor, especially when the amount of air is small. An upright lateral view has greater sensitivity compared with posterior-anterior or supine views, but this is not always possible, especially in critically ill patients [45, 46]. POCUS has proven value as an initial diagnostic test that can expedite recognition and timely management of pneumoperitoneum [44, 47]. US cannot identify the site or extent of perforation like CT, but POCUS has greater sensitivity than radiography with comparable specificity and PPV [48].

On US, free air is evaluated by focusing on the least dependent areas in the peritoneal cavity, where the air tends to migrate. In a supine patient, air moves anteriorly toward the interface between the peritoneal cavity and anterior abdominal wall and is often best identified in the RUQ over the liver [9, 49]. The highly reflective surface of air produces increased echogenicity of the peritoneal line, which is referred to as the enhanced peritoneal stripe sign. Often accompanying this is reverberation artifact, consisting of repeating hyperechoic horizontal lines directly below the enhanced peritoneal line. “Dirty” shadowing may be seen, obscuring the underlying organs (Fig. 8A). Because air can move freely within the peritoneal cavity, these findings change with patient position, known as shifting phenomenon [9, 47, 49]. Similarly, the scissors maneuver can help detect free air and visualize its movement. This technique consists of applying pressure with the probe over the liver to displace the free air and associated artifacts, making these findings less prominent. When the compression is released, the free air returns and associated artifacts become visible again [50].

An important potential pitfall is mistaking free air for intraluminal bowel gas. To differentiate between the two, it helps to focus on the hepatic region where bowel gas is minimal and consider position change or compression to help further identify pneumoperitoneum. Free air moves independent of respiration and peristalsis, unlike intraluminal air in the bowel [9, 47].

Gastric contents in the peritoneal cavity may accompany pneumoperitoneum in cases of bowel perforation. On US, this will appear as free fluid with echogenic debris in the dependent areas of the abdomen [9, 47, 49] (Fig. 8).

POCUS is a valuable diagnostic tool that can be applied at the bedside to quickly answer focused clinical questions. With a broad and continually expanding scope, POCUS is used by many specialties and is incorporated in medical education and training. Although POCUS does not replace comprehensive imaging in patients with an acute abdomen, it has value as an initial imaging modality that can rapidly provide key diagnostic information. POCUS can influence clinical suspicion, guide decision-making, and expedite the diagnosis and treatment by enabling providers to correlate clinical and imaging findings with the patient in real time.

References

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3. Peabody CR, Mandavia D. Deep needle procedures: improving safety with ultrasound visualization. J Patient Saf 2017; 13:103–108
4. Roxas R, Gallegos L, Bailitz J. Rapid detection of aortic occlusion with emergency ultrasonography. Ann Emerg Med 2011; 58:21–23
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6. Howard ZD, Noble VE, Marill KA, et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med 2014; 46:46–53
7. Durgun Y, Yurumez Y, Guner NG, Aslan N, Durmus E, Kahraman Y. Abdominal pain management and point-of-care ultrasound in the emergency department: a randomised, prospective, controlled study. J Coll Physicians Surg Pak 2022; 32:1260–1265
8. Laméris W, van Randen A, van Es HW, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338:b2431
9. Abu-Zidan FM, Cevik AA. Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced. World J Emerg Surg 2018; 13:47
10. [No authors listed]. Ultrasound guidelines: emergency, point-of-care and clinical ultrasound guidelines in medicine. Ann Emerg Med 2017; 69:e27–e54
11. Ma O, Mateer JR, Reardon RF, Joing SA, eds. Ma and Mateer’s emergency ultrasound, 3rd ed. McGraw Hill, 2014
12. Bloom BA, Gibbons RC. Focused assessment with sonography for trauma. StatPearls Publishing, 2023
13. Körner M, Krötz MM, Degenhart C, Pfeifer KJ, Reiser MF, Linsenmaier U. Current role of emergency US in patients with major trauma. RadioGraphics 2008; 28:225–242
14. Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012; 307:1517–1527
15. Boulanger BR, Kearney PA, Brenneman FD, Tsuei B, Ochoa J. Utilization of FAST (focused assessment with sonography for trauma) in 1999: results of a survey of North American trauma centers. Am Surg 2000; 66:1049–1055
16. Rozycki GS, Ochsner MG, Feliciano DV, et al. Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study. J Trauma 1998; 45:878–883
17. Lobo V, Hunter-Behrend M, Cullnan E, et al. Caudal edge of the liver in the right upper quadrant (RUQ) view is the most sensitive area for free fluid on the FAST exam. West J Emerg Med 2017; 18:270–280
18. Rodgerson JD, Heegaard WG, Plummer D, Hicks J, Clinton J, Sterner S. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med 2001; 8:331–336
19. Moore C, Todd WM, O’Brien E, Lin H. Free fluid in Morison’s pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med 2007; 14:755–758
20. Stone BS, Muruganandan KM, Tonelli MM, Dugas JN, Verriet IE, Pare JR. Impact of point-of-care ultrasound on treatment time for ectopic pregnancy. Am J Emerg Med 2021; 49:226–232
21. Fernando SM, Tran A, Cheng W, et al. Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis. Acad Emerg Med 2022; 29:486–496
22. Lindholt JS, Vammen S, Juul S, Henneberg EW, Fasting H. The validity of ultrasonographic scanning as screening method for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 1999; 17:472–475
23. Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med 2013; 20:128–138
24. Catalano O, Siani A. Ruptured abdominal aortic aneurysm: categorization of sonographic findings and report of 3 new signs. J Ultrasound Med 2005; 24:1077–1083
25. Ross M, Brown M, McLaughlin K, et al. Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review. Acad Emerg Med 2011; 18:227–235
26. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 2010; 56:114–122
27. Hilsden R, Mitrou N, Hawel J, Leeper R, Thompson D, Myslik F. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. Trauma Surg Acute Care Open 2022; 7:e000944
28. Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the gallbladder. Acad Emerg Med 1999; 6:1020–1023
29. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014; 371:1100–1110
30. Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. The accuracy and prognostic value of point-of-care ultrasound for nephrolithiasis in the emergency department: a systematic review and meta-analysis. Acad Emerg Med 2018; 25:684–698
31. Goertz JK, Lotterman S. Can the degree of hydronephrosis on ultrasound predict kidney stone size? Am J Emerg Med 2010; 28:813–816
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36. Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology 2015; 275:332–342
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38. Gottlieb M, Peska GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: a systematic review and meta-analysis. Am J Emerg Med 2018; 36:234–242
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41. Hefny AF, Corr P, Abu-Zidan FM. The role of ultrasound in the management of intestinal obstruction. J Emerg Trauma Shock 2012; 5:84–86
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The ultimate game-changer in the breast biopsy world, stereotactic-guided breast biopsies allow breast imagers to offer their patients an amazing alternative to surgical biopsy. Not only is there a shorter recovery time compared to invasive surgical biopsies, but stereotactic core biopsy also leaves little to no scarring on the breast. 

On day one—Sunday, May 5, 2024—of the 124th ARRS Annual Meeting in Boston, MA, Drs. Stamatia Destounis, Haydee Ojeda-Fournier, Mary Guirguis, and I will present “Ready, Set, Stereotactic-Guided Breast Biopsies,” a Featured Session promising a treasure trove of insights that will transform your breast imaging practice. My colleagues have curated an exceptional program that dives deep into the intricacies of breast biopsy and troubleshoots challenging breast imaging cases, empowering breast imagers with the skills and expertise to handle even the most demanding procedures. 

From theory to application, workshop participants will acquire a comprehensive understanding of breast biopsy indications, breast lesion characteristics, and modern breast imaging modalities. Whether you are an experienced practitioner or just commencing your breast biopsy voyage, our Featured Session will provide every tool you need to confidently and deftly navigate difficult scenarios, including both deep and superficial breast lesions, as well as patients with small, thin, or augmented breasts.

For emerging or unfamiliar technology, nothing beats a live demonstration of it—a proof of concept and the processes that make it easier to grasp everything. Instead of relying solely on textbook teaching or typical lecture-and-slides didactic session, our “Ready, Set, Stereotactic-Guided Breast Biopsies” presentation will allow radiologists to witness several really cool aspects of stereotactic core breast biopsy . . . up close! 

An effective live demo, though, leverages its innate interactivity, welcoming everyone to become active participants in the continuing educational process. To that end, our esteemed subspecialized faculty have also prepared specific case-based examples to showcase this minimally invasive procedure for breast lesions only visible on imaging.

What further sets “Ready, Set, Stereotactic-Guided Breast Biopsies” apart is ARRS’ commitment to real-world knowledge, bridging the gap between abstract idea and practical implementation. Exploring the fascinating connections among anatomy and pathology, technique and technology, we will remain focused on the everyday nuances that arise in private, academic, and in-training breast imaging. Leaving no clinical stone unturned, you will leave us knowing how to best audit your own practice.

Fun and educational alike, our Featured Session and live demonstration on Sunday, May 5 satisfies two of the three hours of Category 1 CME for radiologists qualified as an interpreting physician under the Mammography Quality Standards Act. 

Despite the advancements in diagnosis and treatment, lung cancer (LC) remains the leading cause of cancer-specific mortality with an estimated 235,760 new cases and 131,880 deaths in 2021 [1]. Although LC affects all races and ethnicities, disparities in LC outcomes and mortalities exist. Barriers related to medical and sociodemographic factors, including language, access to smoking cessation resources, LC stigma, and health literacy, among other social determinants of health, are factors that play a role in the existing disparities in the LC care continuum [2, 3]. Lung cancer screening (LCS) can serve as a pillar to bridge disparities in LC outcomes through primary risk reduction with smoking cessation and secondary risk reduction with LCS [4]. However, despite the proven benefits of LCS in reducing LC mortality, only a fraction of the eligible population has been screened, and the proportion of individuals eligible for LCS among underserved populations is likely to be lower [5]. The ongoing COVID-19 pandemic, which has exacerbated health disparities among racial/ethnic minority communities and other underserved communities, has resulted in diversion of medical resources to address immediate needs [5, 6]. The effects of postponing nonurgent medical care, including LCS, because of the pandemic are unknown. Without targeted outreach, the low participation rates and delays in LCS will widen existing disparities in LC outcomes among underserved communities [6].

The recent update in the U.S. Preventive Services Task Force (USPSTF) LCS eligibility guidelines lowers the required smoking history to 20 pack-years and age to 50 years [7]. This provides an opportunity to improve overall LCS participation rates among diverse patient populations through tailored approaches that consider barriers related to social determinants of health. Therefore, it is vital that we take steps to understand barriers to LCS and develop targeted multilevel outreach interventions to increase LCS participation rates. The purpose of this InPractice piece is to use a modified social-ecologic model of barriers to LCS (Fig. 1) to discuss multilevel interventions and advance equity in LCS uptake among diverse patient populations by increasing awareness, opportunities, and participation in LCS (Table 1). This framework can be adapted to advance equity in LCS among radiology practices in different settings.

Table 1—Summary of Multilevel Barriers to and Facilitators of LCS Awareness, Opportunities, and Participation

Barriers to and Facilitators of Lung Cancer Screening Awareness

Barriers

At the individual level, some of the barriers to awareness include unfamiliarity with LCS as a health preventive service tool (Fig. 2), unawareness of the new USPSTF and Centers for Medicare & Medicaid Services (CMS) recommendations for LCS, unfamiliarity with insurance coverage and costs, uncertainty about available accredited LCS programs, lack of culturally appropriate information, and lack of information at an appropriate health literacy level [8–10]. 

At the provider level, unfamiliarity with the new USPSTF and CMS recommendations and identifying patients who are eligible under the new guidelines for LCS are substantial barriers reported in the literature [9–11]. Other barriers at the provider level include unfamiliarity regarding where to refer patients; unfamiliarity with insurance coverage; lack of knowledge about available resources for management of abnormal LCS findings and follow-up of incidental findings; and skepticism about the benefits of LCS, given that clinical trials recruited predominantly White non-Hispanic patients with a higher socioeconomic status than that of the general U.S. population [10]. 

At the community and health care system level, suboptimal quality of institutional information about LCS (i.e., information not tailored for the surrounding communities) and a lack of institutional social media presence or engagement through social media campaigns to disseminate information about LCS are barriers to LCS [12, 13]. Furthermore, electronic medical records (EMRs) that are not optimized to automatically notify providers of eligible patients have been reported as a barrier [10].

Facilitators

At the individual level, facilitators for LCS are creating patient-centered, culturally tailored educational content to increase interventions to raise awareness and increase health literacy about the new guidelines and fostering non-stigmatizing language and guidelines from national organizations such as the International Association for the Study of Lung Cancer (IASLC) [4, 10, 12, 14]. An effort must be made to inform patients about the importance of early LC detection through LCS, the availability of insurance coverage, and the location of nearby LCS centers using websites such as the “Lung Cancer Screening Locator Tool” [10, 15]. Community health fairs, conventional media, social media, educational brochures, and mailed invitations are examples of how LCS educational information can be disseminated in multiple settings [10]. The educational material can be tailored to focus on hope based on the advancements in LC treatment by including patient testimonials about their experiences with LCS and by tailoring the education to fit the needs and capacities of diverse populations [10, 16]. Online content can provide information and details about LCS programs in multiple languages at the recommended health literacy levels [13]. The Internet and the use of social media can play a key role in the dissemination of information regarding LCS [17]. Prior studies have shown that digital awareness strategies leveraging social media were effective in increasing LCS engagement [17].

At the provider level, unfamiliarity with expanded eligibility criteria and where to refer patients for LCS can be addressed through educational webinars, institutional online resources, and provider-specific educational material that offers continuing medical education credits [18–21]. All these resources will address unfamiliarity with eligibility criteria, skepticism about the benefits of LCS, lack of awareness about LCS insurance coverage, and concerns related to the management of LCS findings [9, 10]. 

At the community and health care system level, an important facilitator to LCS is updating EMR systems to identify patients who are eligible for LCS under the new guidelines. This information can be incorporated into EMR systems with alerts for eligible high-risk patients, autopopulated referral tools, and lists of certified LCS centers that will help identify eligible patients and promote uptake among diverse patient populations [10, 22]. Online content can facilitate LCS by providing information about LCS programs that is tailored for the local communities served by radiology practices and health care institutions [10, 12]. Furthermore, implementing institutional social media campaigns that emphasize the expanded new eligibility criteria will help overcome knowledge gaps and barriers to awareness [23].

Barriers to and Facilitators of Lung Cancer Screening Opportunities

Barriers

At the individual level, some of the barriers include decreased opportunities to provide accurate smoking history in the EMR, cost concerns related to insurance coverage of LCS and subsequent followups (Fig. 3), challenges to understanding LCS results when examinations show abnormal findings, fragmentation of care for management of abnormal LCS results and incidental findings, and difficulties navigating the complexities of health care systems [4, 8, 10]. Cost transparency and cost concerns are areas of active research, because cost influences how patients access and use health services [2]. For example, a recently published study evaluated the out-of-pocket cost of invasive procedures after LCS and showed that the rates of invasive procedures in commercially insured populations exceed those of invasive procedures in clinical trial participants [2].

At the provider level, some of the barriers include difficulty identifying patients who meet eligibility criteria, understanding the influence of comorbidities on the LCS eligibility criteria, and lack of assistance with following up on results [4, 10]. Additional barriers at this level include inconsistent documentation of smoking history, insufficient time to conduct shared decision-making because of other medical responsibilities, difficulty accessing multilingual decision-making aids, and anticipation of patient emotions about participating in LCS [4, 9, 10].

At the community and health care system level, some of the barriers are lack of health insurance coverage for LCS under the new USPSTF guidelines and barriers to telemedicine and broadband Internet access for conducting shared decision-making telehealth encounters. Uncertainty in defining the population-level health data of patients who meet eligibility criteria and would benefit from LCS, the absence of American College of Radiology (ACR)–accredited radiology practices performing LCS in communities, and a lack of community-based strategies to increase participation among underserved communities are additional barriers at this level [4, 5, 8, 10].

Facilitators

At the individual level, facilitators of opportunities for LCS include increasing the opportunities to provide an accurate smoking history through educational campaigns and additional opportunities in other health encounters to capture LCS eligibility information [24]. For identifying LCS-eligible patients, leveraging teachable moment and care coordination strategies during existing routine appointments can be effective. A previous study showed that among women undergoing screening mammography who were given a brief survey to assess LCS eligibility, only a small fraction of LCS-eligible women had undergone LCS [25]. 

Facilitating care coordination and overcoming transportation barriers can provide additional opportunities for patients to undergo LCS [4, 26]. For example, same-day screening appointments at the time of other medical appointments have been shown to be beneficial to patients who have trouble with transportation, taking time off from work, and finding assistance with dependent care, and this strategy could be expanded to be offered to patients eligible for LCS [27]. Concerns about the costs of LCS can be alleviated by providing information about expected costs related to LCS and by offering information about diverse financial support options provided by institutions. People who are uninsured or have concerns about out-of-pocket expenses related to LCS can be referred to community health care workers and patient navigators who can assist patients in identifying grant funding and institutional financial assistance programs to cover LCS among patients who do not have insurance or have a low income [22, 28]. Health care workers can also assist patients in navigating the complexities of the health care system and clarify additional questions related to their LCS results [22].

At the provider level, LCS can be leveraged as an opportunity to advance early LC detection and tobacco cessation. Primary care providers can benefit from training on shared decision-making encounters for the initial enrollment in LCS to gain further knowledge and expertise about tobacco cessation; the safety of tobacco cessation medications; and additional benefits of LCS with low-dose CT, such as coronary artery calcium scoring and evaluation of emphysema, among others [16, 29]. Prior studies have shown that additional findings such as interstitial lung disease, severe coronary artery disease, thyroid cancer, and renal masses can have clinical implications among patients undergoing LCS [29, 30]. Other facilitators are explaining the LCS results to the patient by identifying and addressing most concerning factors to them and incorporating an assessment in the decision-making process with a patient-centered approach [31]. In addition, creating EMR-based dashboards and alert systems that assist primary care practices in identifying patients who are eligible for LCS, particularly under the updated USPSTF guidelines, will provide additional opportunities for patients and providers to engage in conversations about participating in LCS [10]. Other facilitators can be addressing the importance of consistent documentation of smoking history, multilingual decision aids, and educational workshops or seminars to optimally manage incidental findings and address patient concerns related to undergoing LCS [24].

At the community and health care system level, facilitators of opportunities include the development of system-level policies that combine the updated USPSTF guidelines for LCS and consider social risk factors affecting patients and their communities to promote equitable LCS use and advocacy efforts that increase telehealth and patient portal access by increasing broadband Internet access points and digital patient navigators among underserved communities [5, 7, 10, 12, 17]. Including social risk factors in the calculation used for new LC risk models and LCS eligibility criteria can potentially benefit racial and ethnic minority groups and other underserved patient populations [4]. Increasing access to information about local accredited LCS centers and optimizing EMR systems to identify population-level health data of eligible patients under the new guidelines are additional facilitators to aid in removing these barriers [10, 15, 22].

Barriers to and Facilitators of Lung Cancer Screening Participation

Barriers

At the individual level, barriers to participation include conflicting personal and health schedules, such as medical appointment times that conflict with working hours, dependent care schedules, understanding the importance of adherence to annual LCS and recommended follow-up (Fig. 4) for the detection of early LC, anxiety and stigma about LC diagnosis, concerns about radiation exposure, and access to primary care services to get LCS referrals [4, 9, 10, 26].

At the provider level, barriers to participation include a lack of locally accessible LCS centers or LCS centers outside the health care system that do not offer a streamlined referral and follow-up process, lack of public transportation access to get to appointments, and lack of systemwide patient navigators or health care workers who can aid primary care providers in ensuring patients undergo LCS and help track adherence to recommended follow up of results [4, 10, 26].

At the community and health care system level, barriers include EMR-based LCS appointment reminders that are not available in multiple languages or that are available only through patient portals, decreased availability of system-based dashboards that will alert patients and providers about adherence to follow-up of abnormal LCS examinations, lack of accessible smoking cessation services for patients who smoke, and lack of access to multidisciplinary lung nodule clinics to assist patients in management of abnormal LCS findings [4, 10, 32].

Facilitators

At the individual level, facilitators of participation for LCS include providing schedule flexibility by offering off-hours appointments during weekends and evenings or collaborating with community organizations to offer resources and promote screening during social events in the communities [28, 33]. Providing transportation to LCS appointments, such as ride sharing or cab vouchers, or providing access to mobile LCS units can assist patients in overcoming transportation barriers that could lead to missed LCS appointments [10]. To improve participation, providers can collaborate with radiology practices in communicating the importance of LCS and can promote follow-up through reminders sent to patients, which have been shown to increase LCS adherence [34]. The ACR National Lung Cancer Roundtable (NLCRT) launched a campaign to decrease the stigma associated with a LC diagnosis and decrease concerns about radiation exposure [35–37]. Increasing access to LCS clinics that offer an integrated approach to LCS in collaboration with primary care practitioners can assist in overcoming barriers related to a lack of access to primary care practitioners [38, 39]. 

At the provider level, facilitators include increasing the availability of community health care workers and patient navigators who can aid primary care practices to assist patients in participating in LCS [40]. 

Patient navigators can assist primary care providers in conducting shared decision-making, identifying and confirming LCS eligibility of patients, and assisting patients in clarifying additional steps or concerns needed to engage in LCS [40]. Collaboration between radiology and primary care practices can lead to offering integrated LCS programs that have streamlined referral pathways for LCS independent of practice location [38, 39]. In addition, LCS radiology programs that collaborate with primary care providers and community organizations to offer LCS, smoking cessation services, and screening for other cancers can be opportunities to increase participation in LCS and meet other population health preventive service goals [41, 42].

At the community and health care system level, facilitators of opportunities include EMR-based LCS appointment reminders available in multiple languages and through additional services other than patient portals, updating population-level health dashboard alerts of patients who are eligible or overdue for LCS under the new USPSTF guidelines, and creating system-based alerts to notify providers about newly eligible patients [10, 34]. Studies that have evaluated LCS adherence rates, patient characteristics associated with adherence, and diagnostic testing rates after screening revealed that underrepresented racial/ethnic minority populations and individuals who currently smoke are less likely to remain in the program [32]. Patients who undergo LCS and are currently smoking can benefit from the integration of smoking cessation counseling services into part of their LCS encounters, and participation in LCS increases adherence to a smoking cessation program [43]. Interventions that combine promoting participation in LCS and connecting patients who are current smokers with an evidence-based intervention composed of a web-based program and text messaging, are examples of a coordinated approach that increases participation in both LCS and smoking cessation [43, 44]. Finally, for assisting patients who have abnormal LCS results, improving telehealth access, increasing the capacity of smoking cessation services, and implementing a tailored approach with multidisciplinary lung nodule clinics for the management of abnormal LCS results and EMR dashboards that automatically track adherence to follow-up and outcomes can provide a system-based care coordination that will aid these patients in accessing LC care [38, 45–47].

To advance equitable participation in LCS and achieve the population health goal of improving LC outcomes for all patients through early detection, it is paramount that multilevel interventions are tailored to fit the needs and capacities of diverse patient populations served by all types of community practices. To achieve this goal, transdisciplinary system-based programs and interventions are key to address systemic barriers, improve access and uptake of LCS, and improve LC outcomes primarily among underserved patient populations. As radiologists and promoters of the health and well-being of our patients, partnering with patients, community organizations, and other medical specialties to assist patients in overcoming multilevel barriers to LCS will allow us to design sustainable programs to promote awareness of, opportunities for, and participation in LCS for all patients.

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14. International Association for the Study of Lung Cancer (IASLC) website. IASLC language guide. www.iaslc.org/IASLCLanguageGuide. Published May 2021. Accessed November 12, 2023
15. American College of Radiology (ACR) website. Lung cancer screening locator tool: screening location finder. www.acr.org/Clinical-Resources/Lung-Cancer-Screening-Resources/LCS-Locator-Tool. Published 2021. Accessed November 12, 2023
16. Flores EJ, Neil JM, Tiersma KM, et al. Feasibility and acceptability of a collaborative lung cancer screening educational intervention tailored for individuals with serious mental illness. J Am Coll Radiol 2021; 18:1624–1634
17. Jessup DL, Glover Iv M, Daye D, et al. Implementation of digital awareness strategies to engage patients and providers in a lung cancer screening program: retrospective study. J Med Internet Res 2018; 20:e52
18. American College of Radiology (ACR) website. Lung cancer screening resources. www.acr.org/Clinical-Resources/Lung-Cancer-Screening-Resources. Accessed October 7, 2021. Accessed November 12, 2023
19. American College of Radiology (ACR) website. Lung CT Screening Reporting & Data System (Lung-RADS). www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads. Published 2021. Accessed November 12, 2023
20. LuCa National Training Network website. Enhancing provider education on lung cancer care. lucatraining.org. Published 2021. Accessed November 12, 2023
21. American College of Radiology (ACR) website. National lung cancer roundtable lung cancer screening webinar series. pages.acr.org/2021-NLCRT-Webinar-Series.html. Published 2021. Accessed November 12, 2023
22. Percac-Lima S, Ashburner JM, Rigotti NA, et al. Patient navigation for lung cancer screening among current smokers in community health centers a randomized controlled trial. Cancer Med 2018; 7:894–902 
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25. Lopez DB, Flores EJ, Miles RC, et al. Assessing eligibility for lung cancer screening among women undergoing screening mammography: cross-sectional survey results from the National Health Interview Survey. J Am Coll Radiol 2019; 16:1433–1439
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27. Healio website. ‘I’ve never been treated so well’: same-day cancer screening program helps reduce barriers. www.healio.com/news/hematology-oncology/20210907/ive-never-been-treated-so-well-sameday-cancer-screening-program-helps-reduce-barriers. Published September 7, 2021. Accessed November 12, 2023
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What does the general public hear about lung cancer screening (LCS) from newspapers here in the United States of America? And why does what the public hears about LCS in the papers matter? Mass media is an important source of medical information for the public at large. Print sources, radio, television, online, and social media platforms all influence public knowledge of medical topics, but especially so for older adult populations, print media remains a truly trusted resource [1].

Public perception of LCS is particularly critical, since eligible individuals may not be aware of LCS opportunities, as well as the benefits and risks of screening with low-dose CT (LDCT). In-office discussion is often limited by time constraints; in a JAMA study from 2018, practitioners spent, on average, less than 1 minute discussing LCS [2]. According to findings from the U.S. National Lung Screening Trial, LCS with LDCT was associated with a 20% reduction in lung cancer-specific mortality [3], yet despite so many additional trials providing further support, LCS uptake continues to represent too small a fraction of the eligible population. Could the composition of coverage concerning LCS help to shape public understanding and influence the opinions of those eligible for LDCT screening? 

For AJR, my colleagues and I analyzed 12 years’ worth of LCS coverage in U.S. newspapers to assess the volume, tenor, and scope of that coverage [4]. The good news? Most of the coverage, itself, was good. And in could-be-better news, although many articles mentioned at least one benefit of LDCT LCS, additional important benefits were uncommonly included. The worst news, though? Critical logistics were seldom mentioned, and radiologists were infrequently interviewed.

From 2010 to 2022, a total of 859 articles mentioning LCS were included across a range of local, regional, and national newspaper sources. Weekly circulation sizes ranged from a low of 713 readers for one local paper to 1.2 million for the New York Times and 1.5 million for the Wall Street Journal. Annual article volume ranged from a high of 130 in 2014 (15% of the total) to a low of 33 (4% of the total) in 2020. Unfortunately for data, 2022 proved to be an incomplete year (Fig. 1).

The nadir of LCS coverage in 2020 coincided with the onset of the novel coronavirus disease (COVID-19) pandemic. Understandably, COVID-19 dominated the news that year, comprising about 25% of frontpage news articles for 2020 [5].

Of all articles, 25% were published during the month of November, Lung Cancer Awareness Month. It is gratifying to see LCS information so well disseminated during this month of greater public awareness, but such clustering reminds us: more sustained coverage throughout the year might be beneficial.

For a majority of articles, 76%, sentiment towards LCS was positive; moreover, negative sentiment comprised just 3% of the total. However, a higher proportion of negative sentiment (8%) came from articles on the highest quartile of weekly circulation (i.e., the most widely read newspapers).

Full articles appeared most commonly (65%), but short news briefs—often a small paragraph within a collection of multiple news items—accounted for a large proportion of the total article number (31%). Typically, these news briefs were limited in scope (e.g., an announcement for a screening program). 

Most articles (64%) mentioned at least one benefit of LCS: early detection and mortality reduction (49%). (Meanwhile, other benefits, such as the ease of LDCT or low radiation dosage, were rarely stated.) And we found it was a minority of articles (23%) that mentioned at least one potential risk.

Logistical aspects of LCS were infrequently stated, including updated recommendations for an annual CT examination until eligibility criteria are no longer satisfied (27%) and participation in a smoking cessation program (28%).  

Although many eligible individuals had questions regarding the potential cost or insurance coverage of LDCT LCS, we found it was a minority of articles (33%) that broached these subjects.

Importantly, despite playing a leading role in LCS programs, radiologists were mentioned or interviewed in a minority of articles (9%). Low media representation may be a missed opportunity to illustrate the importance of radiologists—and the field of imaging—to early cancer detection and management.

References

1. Forman-Katz N, Matsa KE. News Platform Fact Sheet. Pew Research Center website. www.pewresearch.org/journalism/fact-sheet/news-platform-fact-sheet. Published September 20, 2022. Accessed October 19, 2023
2. Brenner AT, Malo TL, Margolis M et al. Evaluating shared decision making for lung cancer screening. JAMA Intern Med 2018; 178:1311–1316
3. National Lung Screening Trial. U.S. Department of Health and Human Services’ National Institute of Health, National Cancer Institute website. www.cancer.gov/types/lung/research/nlst. Accessed October 19, 2023
4. Zippi ZD, Cortopassi IO, Johnson EM et al. U.S. newspaper coverage of lung cancer screening from 2010 to 2022. AJR 2023; 221
5. Krawczyk K, Chelkowski T, Laydon DJ. Quantifying online news media coverage of the COVID-19 pandemic: text mining study and resource. J Med Internet Res 2021; 23:e28253