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Radiologists agree on the importance of breast cancer screening and are taking steps to improve access and empower women to make informed decisions. Click to see steps you can take in your community and practice.

Each year, Arizona resident Michelle Ochenkoski dreads scheduling her annual mammogram. 鈥淚t fills me with fear and anticipation, because every year they see something questionable on my mammogram,鈥� Ochenkoski says. 鈥淚t creates a lot of stress and anxiety.鈥�

Ochenkoski is among the 50% of all women who have dense breast tissue, which can mask tumors on a mammogram and can also increase a woman鈥檚 risk of developing breast cancer. Recognizing these factors, Arizona legislators approved a in 2014 that requires healthcare providers to notify patients, like Ochenkoski, whose mammography results indicate that they have dense breast tissue.

The only problem was that Ochenkoski, like many women, didn鈥檛 understand what the notification meant, so she just tucked it away in her medical file with everything else. But after Ochenkoski鈥檚 mammogram this year, her primary care physician (PCP) asked if she鈥檇 like to visit the new dense breast consultation clinic at the Mayo Clinic in Arizona to speak to a radiologist about the implications of dense breast tissue and explore additional screening options. Ochenkoski eagerly agreed.

鈥淚t was such an eye-opener to really understand how dense breast tissue appeared on my mammogram, and what else the radiologist could see with additional imaging,鈥� she says. 鈥淭he consultation made such a big impact on me that I decided to get additional imaging so I could finally have an answer to my questions about breast health.鈥�

Since Mayo opened its dense breast consultation clinic in February of 2019, more than 140 patients have scheduled appointments to speak directly with a radiologist about their breast density. Leveraging the radiologists鈥� expertise, the program has helped women better understand the correlation between dense breast tissue and increased cancer risk, empowering them to make more informed breast imaging decisions.

Identifying the Gap

After Arizona and several other states mandated that healthcare providers send notifications to patients who have dense breasts, the president signed a similar directive into federal law in February of 2019. The notifications encourage patients with dense breast tissue to discuss additional screening options with their physicians 鈥� typically PCPs, OB/GYNs, and internists 鈥� who don鈥檛 always have the imaging expertise needed to explain the tests.

鈥淎 lot of confused women come to us asking, 鈥榃hat does this mean? Do I need to do additional imaging?鈥欌�� says Jewel Kling, MD, MPH, NCMP, associate professor of medicine and associate chair for research in women鈥檚 health internal medicine at the Mayo Clinic in Arizona. 鈥淚t creates challenges in a primary care setting, because we have limited time to spend with patients, and even a five-minute conversation about breast density becomes a battle of priorities.鈥�

As a result, referring physicians like Kling frequently called Victor J. Pizzitola, MD, MPH, division chair of breast imaging at the Mayo Clinic in Arizona to ask him how to respond to patients鈥� questions about supplemental screening. He didn鈥檛 have an immediate solution for streamlining the process 鈥� but a few years later, when fourth-year resident, Kristin A. Robinson, MD, asked how she could get more involved in patient care during her breast imaging fellowship, it suddenly clicked. As Pizzitola and Robinson brainstormed ideas, they realized that a dense breast consultation clinic could be the perfect opportunity for radiologists to add value.

鈥淲e realized there was a gap because the notification told patients to talk with their doctors, but their PCPs and OB/GYNs may not have the updated knowledge on supplemental screening exams 鈥� or even the time to have a breast density conversation,鈥� Robinson says. 鈥淲e wanted to address it in a way that was helpful to both the referring provider and the patient by establishing a consultation clinic to fill that gap. Breast imagers were already having these types of conversations with patients, so this created a more formal environment to share our expertise.鈥�

Making a Case for Consultation

Early in the planning process, Pizzitola identified the top five mammography referrers at the Mayo Clinic in Arizona and asked them what they thought of the idea. Their immediate reaction was relief. 鈥淥pening that dialogue with our referring providers was critical because it helped us understand how ill-equipped they were to discuss breast density with patients,鈥� Pizzitola says. 鈥淐reating the consultation clinic took the onus off referring providers and allowed the radiologists the opportunity to share their knowledge with patients directly.鈥�

When Pizzitola introduced the idea to other radiology leaders at the Mayo Clinic in Arizona around June of 2018, they agreed that it would advance the practice and improve patient care. But as he began meeting with hospital administrators, he hit some logistical roadblocks. 鈥淭he immediate answer we got from the administrators in finance and billing was, 鈥楴o. Radiologists can鈥檛 see patients, because they can鈥檛 chart or bill for this,鈥欌�� Pizzitola says.

To convince administrators of the idea鈥檚 potential, Pizzitola diagramed the clinic鈥檚 workflow, from ordering to billing. He reached out to a breast imaging colleague at another Mayo Clinic location who had experience with billable evaluation and management consultations. This colleague explained how radiologists could perform, chart, and bill for consultations, and how referring physicians could order them through the electronic medical record (EMR). Pizzitola and Robinson used this information to create a business plan with a financial impact analysis.

鈥淚n order to make this viable and long-lasting after my fellowship, we had to show our institution that if we鈥檙e taking a radiologist鈥檚 valuable time away from the reading room, at least we can be reimbursed for the additional service we鈥檙e providing,鈥� Robinson says. 鈥淎lthough it is revenue-producing, our primary focus is on improving care by providing a direct consultation service to our patients.鈥�

Pizzitola and Robinson proposed a pilot phase for the project and designed an Internal Review Board (IRB) survey to collect feedback from patients to measure the clinic鈥檚 effectiveness throughout this phase. As the logistics came together, the proposal for the consultation clinic slowly gained administrators鈥� support.

Finding Space and Time

From there, Robinson and Pizzitola worked with Mayo鈥檚 IT department to build an electronic interface in the EMR that would allow clinicians to order the consultations. They also spoke directly with referring physicians to develop the clinic鈥檚 workflow, including when and where to consult with patients. Together, they decided that a referrer could order a consultation any time after a woman with dense breast tissue has a normal screening mammogram and that the consultation would occur as a separate visit.

While it made logistical sense to hold the consultations in Mayo鈥檚 breast clinic, which also houses oncology, breast surgery, and women鈥檚 health providers, it wasn鈥檛 feasible to dedicate an exam suite or conference room exclusively to dense breast consultations. Instead, the clinic had to share space with the other specialties in the center. 鈥淲e had to get other clinicians in the breast clinic on board with the fact that we鈥檇 be using suites just like they do,鈥� Robinson says. 鈥淚t wasn鈥檛 a huge hurdle, but because imaging consultations were such a new concept, we had to sort out the scheduling and patient flow with other providers to make it as efficient as possible for everyone.鈥�

Since the breast imaging department didn鈥檛 have the bandwidth to staff the clinic every day, Robinson and Pizzitola began scheduling appointments for a few hours at a time, before dedicating a full day or two per week. This required support from the rest of the radiology staff, who had to cover Pizzitola and Robinson鈥檚 time away from reading mammograms. 鈥淓arly on, I handled most of the visits, but if I couldn鈥檛 get off clinical service, Dr. Pizzitola volunteered some of his administrative time,鈥� Robinson says. 鈥淭here were a lot of technical kinks to figure out, such as learning how to sign consultation notes and learning how to bill in our EMR, so the pilot allowed us to streamline the workflow before expanding the program.鈥�

Educating Patients

With the guidance and approval of women鈥檚 health providers, Robinson developed a slideshow presentation to share with patients during the consultations. 鈥淎s breast radiologists, we have quite a bit of experience discussing findings as they relate to imaging and recommendations for biopsy. That said, we have little experience with formal clinical consultations,鈥� Pizzitola says. 鈥淲e collaborated with referring providers to translate our imaging expertise surrounding breast density and available adjunct examinations into an understandable level that could be easily dispensed to patients.鈥�

The presentation explains the four categories of breast density and illustrates how dense tissue and cancer appear in various types of imaging. These visual aids guide the discussion between radiologists and patients about supplemental screening options 鈥� such as whole-breast ultrasound, contrast-enhanced MRI, molecular breast imaging (MBI), and contrast-enhanced mammography 鈥� while addressing common questions, such as radiation dosage and costs that may not be covered by insurance.

The clinic helps patients compare supplemental screening options and make decisions about their next steps. 鈥淚t was life-changing for me to see the examples of dense breast tissue in a normal mammogram, and then to see a tumor revealed in an MBI,鈥� says Ochenkoski, who had a post-consultation MBI, which came back normal. 鈥淚 saw how additional imaging can literally save women鈥檚 lives, because a cancerous tumor showing up on an MBI com-pared to a regular mammogram could mean the difference between Stage 2 and Stage 4 disease.鈥�

At the end of the consultation, if the patient decides to pursue a secondary exam, the radiologist can immediately schedule it while charting the visit 鈥� copying the referring physicians in the EMR so they receive notifications about the order and the results. Alternatively, if the patient requests more time to consider the next steps, the radiologist simply notes which options they discussed to keep the referring physician apprised. 鈥淚t鈥檚 important that the referring physicians stay in the loop with our recommendations because they鈥檙e the ones tracking each woman鈥檚 health,鈥� Robinson says. 鈥淧lus, it鈥檚 reassuring for the patient to know that we鈥檙e all connected so we can take care of them as a team.鈥�

Expanding the Reach

The first patients and referring physicians who used the dense breast consultation clinic gave it positive reviews in surveys and emails. 鈥淚t filled a gap that we鈥檝e seen since states started mandating these breast density notifications,鈥� Kling says. 鈥淚t鈥檚 a great service that we can refer patients to, because they have concerns and questions that general physicians, can鈥檛 always answer. The program allows radiologists to provide those answers directly to patients, who can use that information to decide their next steps.鈥�

Within six weeks after launching the program with five referring physicians, Pizzitola opened it up to the rest of the Mayo Clinic in Arizona. He sent an email to the internal referring provider base, detailing what the new clinic offered and how it could benefit patients and physicians. 鈥淚 included screenshots showing them where to find the dense breast notification in mammography reports and which buttons to click in the EMR to order a consultation,鈥� he says.

Once the clinic opened to general practitioners beyond women鈥檚 health, the appointment schedule filled quickly. As Robinson鈥檚 fellowship drew to a close, the clinic needed additional resources to meet the increasing demand. Pizzitola asked the department鈥檚 other breast imaging subspecialists to get involved, and they began shadowing Robinson to observe the flow of the conversations and the logistics of charting the consultations in the EMR.

After Robinson moved to Mayo Clinic鈥檚 Florida location for a staff breast imaging position, Pizzitola also engaged the new breast imaging fellow who took her place. Now, the fellow and the three dedicated breast imagers rotate clinic hours to offer appointments six or seven days a month. They schedule consultations in one-hour time slots, but most conversations last between 30鈥�45 minutes. On average, the clinic sees six to eight patients per day 鈥� totaling about 40鈥�50 each month. 鈥淚t has become incredibly popular,鈥� says Pizzitola, noting that in November of 2019 the clinic was already scheduling through February of 2020. 鈥淏ut we鈥檙e limited by our radiologists鈥� bandwidth because reading film is still the priority.鈥�

To help, the department is hiring an additional breast radiologist who will participate in the clinic. After the pilot study concludes, Pizzitola plans to shorten the length of consultation visits by streamlining the presentation and refining the target referral demographics based on the patient鈥檚 personal history and other risk factors.

Producing Results

The pilot phase and IRB portion of the program won鈥檛 conclude until 200 patients have visited the clinic and sufficient data has been collected. Pizzitola plans to publish the survey results and present the data at The Society of Breast Imaging meeting next spring. As of mid-September of 2019, the clinic had seen 140 patients. Of those, 104 patients completed IRB surveys before and after their visits, revealing significant early results.

鈥淲e鈥檝e had really positive feedback, both objectively, looking at the information they learned, and subjectively, asking about the usefulness of these visits,鈥� Robinson says. 鈥淏efore the consultation, about 60% of patients knew that breast density affects breast cancer risk and detection, and afterward, 92% got those questions correct.鈥�

About 89% of patients said they were very satisfied with the consultation experience, and 92% agreed that they left with the knowledge to make an informed decision about their supplemental screening options. In total, consulting radiologists recommended some type of supplemental screening to 101 patients, and 71 of those exams have been performed so far. These secondary exams have not yet detected any additional cancers.

鈥淭he goal was never to get patients to do additional imaging. It鈥檚 about doing the right exams on the right subset of patients who really need additional imaging,鈥� Pizzitola says. 鈥淭he way we quantify return on investment is knowing that we鈥檙e improving patient care by filling the gap of knowledge around breast density. This empowers women to take charge of their own care by understanding what options are available and making informed decisions.鈥�

The Dense Breast Consultation Clinic also gives radiologists a more direct role in interacting with patients. 鈥淭he perception of radiologists as dark room readers is outdated,鈥� Robinson says. 鈥淭hanks to Imaging 3.0, we are recognizing that if there is a gap in patient care, radiologists can add value beyond reading exams and doing procedures.鈥�

By taking the time to educate patients, radiologists in the dense breast consultation clinic are promoting the importance of imaging. 鈥淚 finally have an answer instead of fearing the worst,鈥� Ochenkoski says. 鈥淚鈥檇 never met a radiologist before, so it鈥檚 important to get them out in front of patients so we can see who鈥檚 making decisions for our care. I now consider the radiologist part of my care team, and I think that鈥檚 a missing link in women鈥檚 care.鈥�