Can breast ultrasound reduce patient's level of anxiety and pain?

Patients' perceptions of targeted breast ultrasound and digital breast tomosynthesis in the diagnostic setting: A mixed methods study

BACKGROUND

Although DBT is the standard initial imaging modality for women with focal breast symptoms, the importance of ultrasound has grown rapidly in the past decades. Therefore, the Breast UltraSound Trial (BUST) focused on assessing the diagnostic value of ultrasound and digital breast tomosynthesis (DBT) for the evaluation of breast symptoms by reversing the order of breast imaging; first performing ultrasound followed by DBT. This side-study of the BUST evaluates patients' perceptions of ultrasound and DBT in a reversed setting.

METHODS

After imaging, 1181/1276 BUST participants completed a survey consisting of open and closed questions regarding both exams (mean age 47.2, ±11.74). Additionally, a different subset of BUST participants (n = 29) participated in six focus group interviews 18-24 months after imaging to analyze their imaging experiences in depth.

RESULTS

A total of 55.3% of women reported reluctance to undergoing DBT, primarily due of pain, while the vast majority also find bilateral DBT reassuring (87.3%). Thematic analysis identified themes related to 1) imaging reluctance (pain/burden, result, and breast harm) and 2) ultrasound and DBT perceptions. Regarding the latter, the theme comfort underscores DBT as burdensome and painful, while ultrasound is largely perceived as non-burdensome. Ultrasound is also particularly valued for its interactive nature, as highlighted in the theme interaction. Perceived effectiveness reflects women's interest in bilateral breast evaluation with DBT and the visibility of lesions, while they express more uncertainty about the reliability of ultrasound. Emotional impact portrays DBT as reassuring for many women, whereas opinions on the reassurance provided by ultrasound are more diverse. Additional themes include costs, protocols and privacy.

CONCLUSIONS

Ultrasound is highly tolerated, and particularly valued is the interaction with the radiologist. Nearly half of women express reluctance towards DBT; nevertheless, a large portion report feeling more confident after undergoing bilateral DBT, reassuring them of the absence of abnormalities. Understanding patients' perceptions of breast imaging examinations is of great value when optimizing diagnostic pathways.

An Image-Rich Educational Review of Breast Pain

Breast pain is extremely common, occurring in 70% to 80% of women. Most cases of breast pain are from physiologic or benign causes, and patients should be reassured and offered treatment strategies to alleviate symptoms, often without diagnostic imaging. A complete clinical history and physical examination is key for distinguishing intrinsic breast pain from extramammary pain. Breast pain without other suspicious symptoms and with a negative history and physical examination result is rarely associated with malignancy, although it is a common reason for women to undergo diagnostic imaging. When breast imaging is indicated, guidelines according to the American College of Radiology Appropriateness Criteria should be followed as to whether mammography, US, or both are recommended. This review article summarizes the initial clinical evaluation of breast pain and evidence-based guidelines for imaging. Additionally, the article reviews cyclical and noncyclical breast pain and provides an image-rich discussion of the imaging presentation and management of benign and malignant breast pain etiologies.

Efficient management of new patient referrals to a breast service: the safe introduction of an advanced nurse practitioner-led telephone breast pain service

INTRODUCTION

There has been an almost 100% increase in referrals to breast cancer diagnostic clinics in the past decade. Breaching of the two-week cancer referral target is now commonplace, potentially delaying diagnoses of breast malignancy in many women. Almost one in five of these referrals are women with mastalgia, not a symptom linked to breast cancer. The objective of the study was the safe introduction of an advanced nurse practitioner-led telephone service for women with mastalgia to improve the service for women and create capacity for those with "red flag" breast symptoms.

METHODS

Referrals to clinic were triaged, women with mastalgia only were directed to a telephone-based assessment clinic and symptoms evaluated using a multidisciplinary created proforma.

RESULTS

Within 23 months, 1,427 women were assessed in the breast pain telephone assessment clinic: 863 (61%) were aged over 40 and 564 (39%) aged under 40. A total of 1,238 underwent telephone assessment. Reassurance and discharge only was needed for 365 (26%). The aetiology of pain was identified as musculoskeletal in 1,104/1,238 (89%) of patients, with only 39/1,238 (3.2%) identified as having true breast pain. Additional symptoms were mentioned by 264 women (18%) during the consultation; all immediately redirected back to a diagnostic clinic. Mammography was undertaken in 609 women (43%). Seven women (0.6%) were diagnosed with a breast malignancy. Patient survey indicated that 93% of patients were satisfied with the care received and 97% said they would recommend the service to a family member or friend.

CONCLUSIONS

Although face-to-face assessments for breast pain remain the standard practice in many breast units, data indicating the safety of a telephone assessment clinic, along with high levels of patient satisfaction, question whether services can be delivered differently.

Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain

With the shift of the healthcare system toward patient-centered, value-based care, the role of the breast radiologist is essential and increasingly multifaceted. Beyond sole image interpreters, breast radiologists serve as subject matter experts within multidisciplinary care teams, acting as advocates and initiators into the healthcare system and providing patient-centered care through effective communication and patient education. These vital roles are well demonstrated through the imaging evaluation and management of the most common breast symptom that affects the majority of the patient population-mastalgia. By leveraging the opportunities provided during the evaluation of the symptomatic breast to optimize patient communication and education, as well as integration of care delivery, breast radiologists add significant value to patient care and ultimately improve patient outcomes.

The Effect of Targeted Ultrasound as Primary Imaging Modality on Quality of Life in Women with Focal Breast Complaints: A Comparative Cohort Study

Background: The high diagnostic performance of modern breast ultrasound (US) opens the possibility to shift toward targeted US as initial imaging test in women with breast complaints. This comparative cohort study investigates the effects of starting with US followed by digital breast tomosynthesis (DBT), as practiced in the breast ultrasound study (BUST), on women's health-related quality of life (QoL). Methods: Fifty BUST participants and 50 "controls" who underwent DBT and US in regular order filled out the EQ-5D-3L three times during their visit: BUST participants before US (T1), after US (T2), and after DBT (T3) and non-BUST participants before DBT (T1), after DBT (T2), and after US (T3). Changes in QoL from baseline to T2 and T3 were assessed using generalized least squares, also taking into account the effects of biopsy, age, and complaint type. Results: Participants' mean age was 50.6 years (BUST: SD = 12.1, controls: SD = 11.5). At T2 the overall QoL was higher [t(102.9) = 2.4, p = 0.017] and anxiety levels were lower [t(98.7) = -2.4, p = 0.020] in BUST participants compared with controls. However, from T2 to T3 these effects equalize, resulting in similar performances in QoL and anxiety at T3, respectively [t(97.6) = -2.3, p = 0.023] and [t(97.2) = 3.1, p = 0.002]. Compared with BUST participants, controls show a clear decrease in pain after US [t(106.5) = -2.8, p = 0.006]. Women undergoing biopsy had lower QoL [t(167.1) = -2.4, p = 0.017] and pain [t(154.1) = -2.1, p = 0.038], and more anxiety [t(187.4) = 4.3, p = 0.000]. Conclusions: The results suggest that changing the radiological order by starting with US has a short-term positive effect on overall QoL, anxiety, and DBT pain experience in symptomatic women. Owing to its negative impact, biopsies should be performed cautiously. In conclusion, the moment of reassurance for women advances by reversing the radiological order according to the BUST, showing the high importance of human interaction in diagnostic care in addition to the clinical performance of imaging modalities.

No association between breast pain and breast cancer: a prospective cohort study of 10 830 symptomatic women presenting to a breast cancer diagnostic clinic

BACKGROUND

Women with breast pain constitute >20% of breast clinic attendees.

AIM

To investigate breast cancer incidence in women presenting with breast pain and establish the health economics of referring women with breast pain to secondary care.

DESIGN AND SETTING

A prospective cohort study of all consecutive women referred to a breast diagnostic clinic over 12 months.

METHOD

Women were categorised by presentation into four distinct clinical groups and cancer incidence investigated.

RESULTS

Of 10 830 women, 1972 (18%) were referred with breast pain, 6708 (62%) with lumps, 480 (4%) with nipple symptoms, 1670 (15%) with 'other' symptoms. Mammography, performed in 1112 women with breast pain, identified cancer in eight (0.7%). Of the 1972 women with breast pain, breast cancer incidence was 0.4% compared with ∼5% in each of the three other clinical groups. Using 'breast lump' as reference, the odds ratio (OR) of women referred with breast pain having breast cancer was 0.05 (95% confidence interval = 0.02 to 0.09, P<0.001). Compared with reassurance in primary care, referral was more costly (net cost £262) without additional health benefits (net quality-adjusted life-year [QALY] loss -0.012). The greatest impact on the incremental cost-effectiveness ratio (ICER) was when QALY loss because of referral-associated anxiety was excluded. Primary care reassurance no longer dominated, but the ICER remained greater (£45 528/QALY) than typical UK National Health Service cost-effectiveness thresholds.

CONCLUSION

This study shows that referring women with breast pain to a breast diagnostic clinic is an inefficient use of limited resources. Alternative management pathways could improve capacity and reduce financial burden.

Imaging, Paternalism and the Worried Patient: Rethinking Our Approach

The Covid pandemic has taught many lessons, including the importance of mental health. The value of the radiologist in holistic patient care may be underestimated and underresearched. Barriers to the acceptance of imaging as an important component in reassurance may be rooted in old ideas minimizing the importance of mental health.

How can additional ultrasonography screening improve the detection of occult breast cancer in women with dense breasts?

Purpose

Although mammography is a gold standard for breast cancer screening, the number of cancers that cannot be detected with mammography is substantial, especially in dense-breast (DB) women. Breast sonography can be a useful and powerful screening tool in these cases. The aim of this study is to assess the application of whole-breast sonography in the evaluation of breast lesions in women with DB tissue and estimate its accuracy in comparison with mammography.

Material and methods

A total of 207 asymptomatic DB women participated in this study. The breast tissue density was assessed using ACR BI-RADS. Patients underwent high-resolution ultrasonography of the breast in addition to physical examination and mammography. Different risk factors were also assessed.

Results

152 of 207 (73.4%) cases who had mammography performed had DB, and 55 (26.6%) cases had very dense breasts (very DBs). None of the cases had a positive history of malignancy, while 19% of them had a positive history of breast cancer in first- or second-degree relatives.

Conclusions

All findings were higher in cases with DB compared to very DBs except for fibroadenoma, which was detected more in cases with very DBs. Our study showed that the prevalence of different breast lesions had a significant relationship with the density of the breast. In our study, 48.3% of the cases were diagnosed with a lesion in their sonography result, although 81.0% of them were benign lesions, and the other 19.0% needed follow-up or biopsy evaluation. A substantial number of mammographically occult breast lesions, either benign or malignant, could be detected by ultrasound in DB tissue.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

ACR Appropriateness Criteria® Breast Pain

Breast pain is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.