Concise, Clinically Pertinent Mammography Requests and Reports as an Aid to Increasing the Utilization of Screening and Diagnostic Mammography William H. Hindle, MD Associate Professor of Clinical Obstetrics and Gynecology Director, Breast Diagnostic Center W o m e n ' s Hospital LAC-USC Medical Center Los Angeles, California
rhe quality of the physician-to-physician communication is critical to the utilization and usefulness of screening and diagnostic mammography for the detection of breast cancer in women. Current standards of practice require that the documented communication between the referring physician and the m a m m o g r a p h e r be pertinent, lucid, and definite. Both are responsible for precise verbal and written communication. The physician who refers a patient for m a m m o g r a p h y , both screening and diagnostic, is asking for a medical consultation. It should be requested with appropriate information and reported in a clinically useful manner. When there is a question of malignancy by either physician, the formal written request and report should be supplemented by a direct physician-tophysician phone call. Both physicians should understand the other's needs and limitations. The referring physician needs to know from the mammographer:
T
1) What precise, clinically useful information is the mammographer able to give me? 2) How certain is the mammographer of his or her conclusions? 3) What does the mammographer recommend? The m a m m o g r a p h e r needs to know from the referring physician: 1) What exactly does he or she want to know? 2) What is the patient's pertinent clinical history? 3) What are the physical findings of the patient's breast and axillary examination? In the final written report, the referring physician needs to know: 1) Is it normal? 2) If not, what exactly is abnormal? 3) What specifically should be done now? 86
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© 1991 by The Jacobs Institute of Women's Health 1049-3867/91/$3.50 WHI Vol. 1, No. 2 Winter 1991
Mammographic evaluation (work-up) can include: 1) 2) 3) 4)
Special positional views Cone down compression views Magnification views Ultrasound a) Why indicated? b) Is there a nonradiologic procedure that will accomplish the same objective, eg, fine-needle aspiration or physical examination? (Some mammographers, with the prior general consent of the referring physician, proceed immediately with their recommended ultrasound evaluation.)
The m a m m o g r a p h e r needs to know: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10)
Is the request for screening or diagnostic mammography? Patient's age and date of her last menstrual period Is she pregnant (or could she be)? Family history of breast cancer a) First degree relative? b) What age onset? Has she had breast surgery? If so, what and when? Has she had breast radiation therapy? If so, for what and when? Any physical findings (bilateral breast and axillae)? Is there a mass? If so, on which side and in which quadrant of the breast? Are any axillary nodes palpable? Is there any serosanguineous nipple discharge?
Some m a m m o g r a p h e r s prefer not to do m a m m o g r a p h y on pregnant or lactating w o m e n and on w o m e n younger than 30 years of age because their dense breasts m a y cause the m a m m o g r a m s to be of limited informative value. The patient should be instructed to bring in her prior m a m m o g r a m s (and reports) for comparison to her current mammogram. A clinically cogent concise m a m m o g r a p h y report should conclude with a specific impression and recommendation. Examples of fundamental impressions are: 1) No abnormal findings or "normal" 2) Specific findings and their exact location 3) Estimate of malignant potential: mammographically benign, indeterminate,* or malignant. The basic recommendations could be: 1) Annual mammogram 2) Follow American Cancer Society guidelines for mammography (which should be printed at bottom of the report form) 3) Return for further evaluation (work-up) 4) Repeat mammogram in 6 months 5) Ultrasound 6) Fine-needle aspiration 7) Open biopsy 8) Needle localization biopsy Historically in some local situations, the referring primary care physicians have preferred not "to have their hands tied" in the clinical management of their patients by a specific recommendation for action by the mammographer. However, the American College of Radiology is formulating a suggested uniform format for m a m m o g r a p h y reports that will include such a specific recommendation. M a m m o g r a p h y conclusions should avoid the words "positive," "negative," "fibrocysfic disease," and such phrases as "cannot be ruled out," "malignancy cannot be excluded," and " m a m m o g r a p h y is not a substitute for biopsy." These words and phrases.are not precise or accurate and are cliniWHIVol. 1, No. 2 Winter1991
*Some mammographers, preferring not to use the term "indeterminate," are willing to commit themselves to an impression of benign or suspicious and a recommendation of biopsy or followup.
HINDLE:MAMMOGRAPHYREQUESTSANDREPORTS 87
cally misleading to the referring physician and the patient. It is not helpful to the referring physician to have the mammographer document and share his or her anxiety in the written report. "Dysplasia" is a specific histologic term describing architectural tissue change and, in gynecology, implies definite premalignant potential. Its use in a mammography report can be confusing, misleading, and alarming to the referring physician. Dysplasia and similar words may have local agreement as to meaning but are not universally understood as to precise definition and clinical implication. An asymptomatic woman sent for screening mammography can become a "problem case" for the referring physician who receives a lengthy, vague, and confusing mammographic report that the clinician does not understand and, after reading it, does not know what, if any, action should be taken. Disclaimers and precatory language, both of which do not provide legal protection to the mammographer, should not be included in the "impression" or "recommendation" of a mammography report. From the point of view of the referring physician, if it is to be included at all, pertinent educational data, eg, the American Cancer Society mammography guidelines, should be printed at the bottom of the report/page. Follow-up and follow-through are essential for both the referring physician and the mammographer. Several legal jurisdictions have held the referring physician responsible for making certain that the patient did have her mammography as requested and, if not, to document why not, in addition to again advising the patient to have mammography. A "tickler file" should be maintained by both physicians. The patient should be informed of the mammogram results by the referring physician. Reports of mammographically suspicious and malignant lesions should be promptly (in person or by phone) explained to the patient by the referring physician. All questions should be answered in detail with care and understanding. Many physicians will give a copy of the written mammography report to the patient. With suspicious and malignant mammography reports, both the referring physician and the mammographer should make certain the patient is personally notified and seeks appropriate care. Some mammographers will make a follow-up phone call to the referring physician about specific recommendations in 2 to 3 months to be certain appropriate action has been taken and if not, to document why not. Examples of appropriate mammography reports are shown in Appendixes 1 and 2. The use of such a clear and concise clinically meaningful format should increase the utilization and usefulness of mammography for the detection of breast cancer.
ACKNOWLEDGMENT The author wishes to acknowledge Dr. Irwin M. Freundlich, Professor and Deputy Chairman, Department of Radiology, MD Anderson Cancer Center, Houston, Texas, for his review of this paper and his helpful suggestions.
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Appendix 1.
EXAMPLE OF SCREENING MAMMOGRAPHY REPORT
June 4, 1990 Dr. William H. Hindle 234 S. Figueroa #1641 Los Angeles, CA 90012 RE: SCREENING MAMMOGRAM OF Dear Dr. Hindle, The breasts show no radiographic abnormality. Comparison with previous films dated 05/11/89 shows no change. Recommendation: 1. Physical examination annually 2. Routine mammogram in one year Please schedule follow up mammogram for June 1991. Sincerely,
MD The American College of Obstetricians and Gynecologists guidelines for screening mammography are: 1) a baseline mammogram after age 35, 2) a mammogram every 1-2 years as recommended by her physician from age 40 until 50, and 3) annual mammograms after age 50.* * The American College of Obstetricians and Gynecologists, Committee Opinion on Routine Cancer Screening: Number 68. Washington, DC: ACOG, 1989.
Appendix 2.
EXAMPLES OF SCREENING MAMMOGRAM DIAGNOSES
1. Suspicious of malignancy 2. No evidence of malignancy 3. Lesion present, almost certainly benign, but reexamination in 6 months recommended. 4. Lesion present that may be cystic or solid. Ultrasonography is recommended and if solid it should be considered suspicious of malignancy. 5. No radiographic evidence of malignancy but it is possible that a palpable neoplasm may be hidden in the extensive benign disease present.
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rhe quality of the physician-to-physician communication is critical to the utilization and usefulness of screening and diagnostic mammography for the detection of breast cancer in women. Current standards of practice require that the documented communication between the referring physician and the m a m m o g r a p h e r be pertinent, lucid, and definite. Both are responsible for precise verbal and written communication. The physician who refers a patient for m a m m o g r a p h y , both screening and diagnostic, is asking for a medical consultation. It should be requested with appropriate information and reported in a clinically useful manner. When there is a question of malignancy by either physician, the formal written request and report should be supplemented by a direct physician-tophysician phone call. Both physicians should understand the other's needs and limitations. The referring physician needs to know from the mammographer:
T
1) What precise, clinically useful information is the mammographer able to give me? 2) How certain is the mammographer of his or her conclusions? 3) What does the mammographer recommend? The m a m m o g r a p h e r needs to know from the referring physician: 1) What exactly does he or she want to know? 2) What is the patient's pertinent clinical history? 3) What are the physical findings of the patient's breast and axillary examination? In the final written report, the referring physician needs to know: 1) Is it normal? 2) If not, what exactly is abnormal? 3) What specifically should be done now? 86
HINDLE: MAMMOGRAPHYREQUESTS AND REPORTS
© 1991 by The Jacobs Institute of Women's Health 1049-3867/91/$3.50 WHI Vol. 1, No. 2 Winter 1991
Mammographic evaluation (work-up) can include: 1) 2) 3) 4)
Special positional views Cone down compression views Magnification views Ultrasound a) Why indicated? b) Is there a nonradiologic procedure that will accomplish the same objective, eg, fine-needle aspiration or physical examination? (Some mammographers, with the prior general consent of the referring physician, proceed immediately with their recommended ultrasound evaluation.)
The m a m m o g r a p h e r needs to know: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10)
Is the request for screening or diagnostic mammography? Patient's age and date of her last menstrual period Is she pregnant (or could she be)? Family history of breast cancer a) First degree relative? b) What age onset? Has she had breast surgery? If so, what and when? Has she had breast radiation therapy? If so, for what and when? Any physical findings (bilateral breast and axillae)? Is there a mass? If so, on which side and in which quadrant of the breast? Are any axillary nodes palpable? Is there any serosanguineous nipple discharge?
Some m a m m o g r a p h e r s prefer not to do m a m m o g r a p h y on pregnant or lactating w o m e n and on w o m e n younger than 30 years of age because their dense breasts m a y cause the m a m m o g r a m s to be of limited informative value. The patient should be instructed to bring in her prior m a m m o g r a m s (and reports) for comparison to her current mammogram. A clinically cogent concise m a m m o g r a p h y report should conclude with a specific impression and recommendation. Examples of fundamental impressions are: 1) No abnormal findings or "normal" 2) Specific findings and their exact location 3) Estimate of malignant potential: mammographically benign, indeterminate,* or malignant. The basic recommendations could be: 1) Annual mammogram 2) Follow American Cancer Society guidelines for mammography (which should be printed at bottom of the report form) 3) Return for further evaluation (work-up) 4) Repeat mammogram in 6 months 5) Ultrasound 6) Fine-needle aspiration 7) Open biopsy 8) Needle localization biopsy Historically in some local situations, the referring primary care physicians have preferred not "to have their hands tied" in the clinical management of their patients by a specific recommendation for action by the mammographer. However, the American College of Radiology is formulating a suggested uniform format for m a m m o g r a p h y reports that will include such a specific recommendation. M a m m o g r a p h y conclusions should avoid the words "positive," "negative," "fibrocysfic disease," and such phrases as "cannot be ruled out," "malignancy cannot be excluded," and " m a m m o g r a p h y is not a substitute for biopsy." These words and phrases.are not precise or accurate and are cliniWHIVol. 1, No. 2 Winter1991
*Some mammographers, preferring not to use the term "indeterminate," are willing to commit themselves to an impression of benign or suspicious and a recommendation of biopsy or followup.
HINDLE:MAMMOGRAPHYREQUESTSANDREPORTS 87
cally misleading to the referring physician and the patient. It is not helpful to the referring physician to have the mammographer document and share his or her anxiety in the written report. "Dysplasia" is a specific histologic term describing architectural tissue change and, in gynecology, implies definite premalignant potential. Its use in a mammography report can be confusing, misleading, and alarming to the referring physician. Dysplasia and similar words may have local agreement as to meaning but are not universally understood as to precise definition and clinical implication. An asymptomatic woman sent for screening mammography can become a "problem case" for the referring physician who receives a lengthy, vague, and confusing mammographic report that the clinician does not understand and, after reading it, does not know what, if any, action should be taken. Disclaimers and precatory language, both of which do not provide legal protection to the mammographer, should not be included in the "impression" or "recommendation" of a mammography report. From the point of view of the referring physician, if it is to be included at all, pertinent educational data, eg, the American Cancer Society mammography guidelines, should be printed at the bottom of the report/page. Follow-up and follow-through are essential for both the referring physician and the mammographer. Several legal jurisdictions have held the referring physician responsible for making certain that the patient did have her mammography as requested and, if not, to document why not, in addition to again advising the patient to have mammography. A "tickler file" should be maintained by both physicians. The patient should be informed of the mammogram results by the referring physician. Reports of mammographically suspicious and malignant lesions should be promptly (in person or by phone) explained to the patient by the referring physician. All questions should be answered in detail with care and understanding. Many physicians will give a copy of the written mammography report to the patient. With suspicious and malignant mammography reports, both the referring physician and the mammographer should make certain the patient is personally notified and seeks appropriate care. Some mammographers will make a follow-up phone call to the referring physician about specific recommendations in 2 to 3 months to be certain appropriate action has been taken and if not, to document why not. Examples of appropriate mammography reports are shown in Appendixes 1 and 2. The use of such a clear and concise clinically meaningful format should increase the utilization and usefulness of mammography for the detection of breast cancer.
ACKNOWLEDGMENT The author wishes to acknowledge Dr. Irwin M. Freundlich, Professor and Deputy Chairman, Department of Radiology, MD Anderson Cancer Center, Houston, Texas, for his review of this paper and his helpful suggestions.
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Appendix 1.
EXAMPLE OF SCREENING MAMMOGRAPHY REPORT
June 4, 1990 Dr. William H. Hindle 234 S. Figueroa #1641 Los Angeles, CA 90012 RE: SCREENING MAMMOGRAM OF Dear Dr. Hindle, The breasts show no radiographic abnormality. Comparison with previous films dated 05/11/89 shows no change. Recommendation: 1. Physical examination annually 2. Routine mammogram in one year Please schedule follow up mammogram for June 1991. Sincerely,
MD The American College of Obstetricians and Gynecologists guidelines for screening mammography are: 1) a baseline mammogram after age 35, 2) a mammogram every 1-2 years as recommended by her physician from age 40 until 50, and 3) annual mammograms after age 50.* * The American College of Obstetricians and Gynecologists, Committee Opinion on Routine Cancer Screening: Number 68. Washington, DC: ACOG, 1989.
Appendix 2.
EXAMPLES OF SCREENING MAMMOGRAM DIAGNOSES
1. Suspicious of malignancy 2. No evidence of malignancy 3. Lesion present, almost certainly benign, but reexamination in 6 months recommended. 4. Lesion present that may be cystic or solid. Ultrasonography is recommended and if solid it should be considered suspicious of malignancy. 5. No radiographic evidence of malignancy but it is possible that a palpable neoplasm may be hidden in the extensive benign disease present.
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