Role of Breast Imaging Radiologists as Advocates for Screening Mammography

Abstract

The objective of this article is to outline opportunities for breast imaging radiologists to advocate for screening mammography. Despite breast cancer being the second most common cancer in women and screening mammography’s ability to reduce mortality from this disease, there remains suboptimal utilization in the community. The different guidelines for screening presented by respected organizations has created confusion for patients and referring clinicians and the eventual underutilization of screening mammography. As experts in the value of early detection, breast radiologists are well suited to take on the role of screening advocates. Using specific action steps and examples, we create a template for a radiologist to utilize in the promotion of screening among the breast imaging team, clinicians, administrators, and the community at large. By deliberately filling the role of screening mammography advocate, one can satisfy the mandate for radiologists to bring increased value to the health care team while contributing to community health and patient satisfaction.

Introduction

Screening mammography is known to reduce breast cancer mortality, but it unfortunately remains underutilized by women who qualify for this life-saving test (only 66% of women over 40 years of age report a mammogram within 2 years) (1–4). There are conflicting guidelines from professional bodies on the particulars of screening mammography with regards to initiation, interval, and cessation of screening for women at an average risk of breast cancer (Table 1) (5–11).

The variation in guidelines has led to confusion among patients and providers. For example, a study of women in their 40s revealed a distrust of the recommendations that suggested delaying mammography until age 50, with 86% believing that would be unsafe (12). On the other hand, 50% of providers in one study stated that they intend to change their advice to patients to reflect one organization’s recommendation to delay screening until age 50 (7, 13). Studies on the effects of the U.S. Preventative Task Force regimen on breast cancer screening have shown anywhere from a negligible to a 4.3% drop in mammography use since their release (14–16). Whether solely attributable to the controversy or not, data confirms that screening mammography participation, which had been steadily increasing from 37% in 1987 to a peak of 70% in 2000, has since been steadily declining, and the most recent data indicates participation in screening mammography to be at around 66% in 2015 (4, 17).

Despite the controversy, all guidelines acknowledge that even in the aged 40–49 group there is a 15% mortality reduction, with the recommendation for delaying the screening age being due to concerns for potential harms (such as false positives) (18). Therefore, all organizations agree on access to mammography starting at age 40, with individual decision making on whether to initiate screening. However, one-third of eligible women have not had a recent mammogram (4, 17).

It is important that the effectiveness of screening in mortality reduction be emphasized, and an advocate is needed who can push for optimal patient care by providing education on evidence-based recommendations that benefit society. The breast radiologist is the ideal individual to take on this role, as they are an expert in breast imaging—its interpretation, limitations, supporting data, and actual patient case studies. Furthermore, as the physician leader of the breast imaging team, they are able to influence the missions of the group to include advocacy, which gives purpose to the staff and increases job satisfaction. As a member of the interdisciplinary care team, the breast imaging radiologist interfaces with other health care specialists and thus has a natural access point for advocacy. Finally, as breast radiologists interact with patients face to face, they have firsthand knowledge of common concerns, which they are able to compassionately address in both individual and group settings, thereby increasing patient satisfaction.

This article describes how the breast imaging radiologist can demonstrate value as an advocate by promoting screening in three broad arenas: within the breast imaging team, with nonradiologist providers, and directly to the community. Physician advocacy helps put the focus on education, quality of care, and patient experience, which, in this way, adds value to the health care team that goes beyond fee-for-service–based health care models (19, 20).

How to advocate for screening among the breast imaging team

To start, the screening mammography advocate should begin with members of the breast imaging team (radiologists, technologists, sonographers, schedulers, managers, and administrators). This is the most important place to start because team members can derive purpose from connecting around a shared mission as cochampions in breast cancer education. When members of the team are educated on the topic, all interactions with the public remain consistent.

Education of Team Members

Team members should be educated on the evidence behind the screening guidelines and the differences between the most common guidelines. This can be accomplished by sharing articles on the science of screening, data from medical conferences, and interesting cases. The team should come to consensus about the endorsed screening regimen and commit to communicating that recommendation to the public in ongoing interactions.

Empowering the Team Members to Educate Patients

The members of the breast imaging team have many opportunities for face-to-face interaction with patients. Patient visits represent an opportunity for direct teaching. During breast team meetings, the radiologist may solicit feedback on specific patient concerns, such as radiation dose or supplemental dense breast screening, and develop consensus policies. These consensus statements can be drafted into informational brochures for distribution to patients and referring physicians. Should patients endorse these concerns in their interaction with any team member, they can be addressed with consistency. In addition to brochures, consider creating multimedia educational content, such as videos or interactive displays in waiting rooms. For health care systems with online scheduling or patient applications, educational material can be made available on those platforms for patient perusal. When the patient is seen in the clinic, visits should end with a team member emphasizing the recommendations for that individual patient’s follow-up visit and answering concerns they may have about screening.

Create Culture

The advocate can help their practice remain mindful of screening mammography by infusing it into the culture. When possible, as breast cancer cases are diagnosed, the team can keep track of these “wins” of screening. This may take the form of e-mail updates keeping count of cancer detection, ceremonies honoring breast cancer survivors, or highlights of screening-detected malignancies during breast cancer awareness month. These empower the members of the breast imaging team as champions of breast cancer detection.

Maximize Impact

Breast imaging radiologists should seek ways to improve the performance of breast cancer screening by incorporating state-of-the-art technology that improves the sensitivity and specificity of cancer detection. When new technology proven to increase cancer detection or decrease false positives becomes available, an advocate should champion its incorporation into their practice. For example, the addition of digital breast tomosynthesis (DBT) is known to maximize the impact of screening; therefore, radiologists needing to campaign for the purchase of DBT equipment can frame requests through the lens of advocating for improved patient outcomes (21, 22). Similarly, physician advocates should seek to improve patient experience by promoting ideas that affect patient satisfaction, such as patient-controlled compression or the incorporation of radiolucent cushions (23, 24). With positive experiences, patients may be more likely to return and become screening advocates themselves.

How to advocate for screening to nonradiologist providers

Online Resources

Recently, the American College of Radiology (ACR) produced a comprehensive resource kit for breast cancer screening. The toolkit, “Talking to Patients about Breast Cancer Screening,” equips providers with data, a risk/benefit assessment, and practical patient-focused information on breast cancer screening, and it includes continuing medical education credit. Using a multipronged approach of educational videos, premade presentations, and handouts on the particulars of screening, the breast imaging radiologist can publicize this extensive resource as they advocate for screening among patients, referring clinicians, and administrators (25).

Tumor Boards

Most institutions have established multidisciplinary meetings of surgeons, medical oncologists, radiation oncologists, pathologists, and ancillary health care team members; this is an opportunity for radiologists to add value beyond image interpretation (21). The importance of appropriate screening guidelines can be highlighted by emphasizing the lower stage and better prognosis of screening-detected cancers. Also, as patients with complicated medical histories or diagnoses are discussed, necessary screening should be recommended, especially for those whose history indicates that they are at high risk for breast cancer. The breast imaging radiologist can share recently published “Science of Screening” articles from this journal to address screening concerns.

Educational Meetings

A breast imaging radiologist can use hospital grand rounds or local medical society meetings to share information on screening as a way to provide necessary continuing education for referring clinicians. By choosing to participate in such a visible role, the breast radiologist establishes themselves as an expert on breast disease and remains involved in the ongoing conversations about patient care, ultimately contributing to the value-based model that is increasingly gaining focus in medicine. As health care is evolving to a model that extends beyond managing high volumes of patients to one that encourages providers to add value and, by emphasizing patient experience and population health, educating providers, advocating for screening can contribute to this value-added model (19, 26).

Partnerships

With repeated conversations on screening mammography’s importance, the radiologist will develop credibility, respect, and trust among their colleagues. A natural segue is the development of a nonradiologist physician cochampion of screening. Screening-focused colleagues in related fields (family practice, oncology, surgery, gynecology) may offer speaking engagements for the breast radiologist to discuss screening mammography at specialty-specific section meetings, hospital committees, or business meetings with administrators.

Institution-wide Campaign

Screening mammography advocates may consider partnering with the administration of their health care system to create employee screening days. All eligible hospital employees could be contacted and encouraged to participate in screening. If necessary, the breast clinic hours can be adjusted to accommodate employee work schedules (a courtesy that demonstrates the institution’s commitment to employee well-being). An employee screening campaign, while beneficial on the individual scale, could also serve as a marketing tool, as participating health care workers may more readily encourage patients to engage in screening.

How to advocate in the community

Team-based Approach

When radiologists have participated in the direct education of the public on screening examinations, there have been high levels of audience satisfaction and increased knowledge of the value of radiologists (27). In addition, there are advantages to empowering other health care team members to discuss screening, as variety in the approach and presentation may connect with different members of the community. For example, oncologists may better discuss the success rates of the treatment of lower stage screening-detected cancer, while navigators may better discuss access to screening and scheduling. A team-based approach places the radiologist in a coordinator role, which may appear more magnanimous and less self-serving.

Social Media

About 70% of Americans use social media, and when radiologists communicate with the public via online platforms, they are able to build their personal brand and that of their practice (28–30). Patients are known to post questions and search for answers about breast health on the internet, and there is a need for credible expert information in the quantity of voices online. A radiologist can create professional accounts on different platforms to share understandable educational content and research-based recommendations, contributing to public service and demonstrating additional value beyond image interpretation (29, 30). Social media marketing firms may be hired to manage content and deploy a variety of tools (blog posts, videos, and posters), which can create bite-sized educational nuggets suitable for different platforms such as YouTube, Instagram, or Facebook (30). Online conversations on Twitter (called “tweet chats”) have been used with success to increase the understanding of breast cancer, establishing social media as an emerging field for radiologist advocates (30, 31).

Media

Radiologists can purposefully connect with local, national, or entertainment media who continue to produce conflicting reports on screening mammography recommendations (32). Both print and television news outlets are often open to having health experts provide information, especially during breast cancer awareness month. A breast radiologist can present their expert opinion and story idea in a short e-mail pitch, providing an attention-grabbing angle or “hook” while keeping the outlets’ audience in mind (33, 34). If the pitch is accepted, it is mutually beneficial for the radiologist to suggest questions to the production team and to focus the discussion on pertinent information. The physician should practice beforehand to increase their effectiveness by using simple terms and they should share stories along with facts to increase the audience’s retention (34). Many institutions have media teams that can help with preparing for on-camera interviews. When aired, the radiologist can share these articles or clips on social media to increase their reach, create a personal brand, and represent work samples for future pitches. With ongoing name recognition, weekly or monthly written columns or appearances can be negotiated.

Marketing

Promotional events such as “Mammo Mondays” or “Wellness Wednesdays” can provide access to the radiologist for question and answer sessions as well as opportunities for busy patients to have after-hours access to a mammography suite for screening. Hospitals and academic centers often partner with community organizations and fairs; the involvement of passionate radiologists would be welcome. Many religious organizations, business groups, retirement communities, schools, and businesses would appreciate short discussions from expert radiologists at their meetings. A short standard presentation can be created for consistency and convenience so that different health care team members can participate in these speaking engagements (especially during times of increased demand).

Conclusions

The roles of radiologists are evolving during the current transition from fee-for-service reimbursement to a patientcentric, value-added model (21). The role as advocate can represent an untapped frontier for breast imaging radiologists. Since value is partially determined by patients and referring clinicians (19, 35), the savvy radiologist should tap into areas of weakness in the current health care model to increase education and optimize resources to increase patient satisfaction.

Exploring a role in advocacy is in keeping with ACR Imaging 3.0—a necessary move for radiologists to take leadership roles in health care and extend their role beyond the interpretation of large volumes of imaging studies (34). In the emerging value-based model, breast imaging—with its direct patient contact, roles in preventive care, and well-documented outcome metrics—is poised to triumph (26). The breast imaging radiologist as an advocate for breast screening mammography aligns with the emerging valuecentric model by promoting appropriate imaging, increasing patient safety, and enhancing patient outcomes.

Funding

None declared.

Conflict of interest statement

None declared.

References