In 1992, the Mammography Quality Standards Act mandated that mammography facilities send each patient a summary of the mammographic report written in lay terms within 30 days of the exam. If assessments are suspicious or highly suggestive of malignancy, the facility is required to make reasonable attempts to communicate these results as soon as possible (http://www.fda.gov/cdrh/mammography/frmamcom2.html
). For patients who name a primary care provider, the facility must similarly convey the same results sent to patients to their primary care providers following the same time period requirements (http://www.fda.gov/cdrh/mammography/frmamcom2.html
). Despite these requirements, little has been published about the efficacy of these written reports and how often radiologists communicate results verbally to patients.
Our nationally representative sample of community-based radiologist indicates that very little verbal communication occurs about the results of screening mammography even when the results were abnormal. Only about half to three quarters of radiologists discuss the results of diagnostic exams with patients, with most frequent communication occurring when a diagnostic mammogram is abnormal. Communicating a clear explanation of imaging results and the follow-up management plan to both women and their primary care providers is a critical element of the imaging process. In particular, for abnormal results, good communication of both the results and the need for further tests improves receipt of appropriate follow-up care (14
). Production and interpretation of high quality images and a subsequent written report of findings are insufficient, if the patient does not understand or appreciate the ramifications of the findings and subsequent recommendations.
Many women have a heightened anxiety about the results from breast imaging (19
). This is particularly true if they have breast symptoms such as a mass or thickening or if they have been recalled for additional breast imaging based on the interpretation of a mammographic screening examination. The discussion of results from breast imaging may presumably be deferred to the primary care provider, but very little is known about this communication and there may be an initial delay of several days or longer between the completion of the examination and the transmission of results to the patient and primary care provider. Not all patients have access to a primary care provider and can self-refer for screening mammography. Thus, relying on the primary care provider to explain the results for all patients may either postpone the communication even longer or result in no communication between a trained clinician and patients following mammography.
Although this study does not specifically address the levels of patient satisfaction with communication of results by the radiologist, most patients prefer timely and face-to-face explanation of the results from a breast-imaging provider (21
). In addition, women who receive their abnormal mammogram results either in person or over the phone are more likely to understand that their results are abnormal compared to women who receive their results in writing (21
). We found radiologists verbally communicated results from screening examinations very infrequently (<6%). In most radiologic practices, this is standard practice, as screening examinations are usually batch read, sometimes as many as 100 a day, and in-person communication of the results would take a significant amount of time. Most busy community practices do not have the personnel and/or technical support to provide real time interpretation of screening mammography with immediate communication to the women. In most patient populations, ~90% of screening mammograms will be normal and will not require additional imaging (24
) and the results are most commonly communicated by mail in concordance with MQSA (http://www.fda.gov/cdrh/mammography/frmamcom2.html
). In this study, we were unable to determine whether batch readings were done, though we believe it is it is very common for screening mammography. On-line versus batch interpretation of mammograms offer very different communication experiences with patients; unfortunately, we were unable to examine the affect of these different interpretations methods on communication with patients in our study
We found verbal communication between radiologists and women was considerably more frequent for abnormal diagnostic exams compared to normal diagnostic exams. Unfortunately, these data suggest that in some radiologic practices more than 1 out of 4 patients with an abnormal diagnostic mammogram, who may require a breast biopsy or additional imaging, such as breast MRI or ultrasound, leave the radiology department without knowledge of results or follow-up recommendations.
Female radiologists reported being more likely to communicate results of normal and abnormal diagnostic examinations to women compared to their male counterparts. This may reflect differences in practice patterns or heightened sensitivities for distributing results to patients among female radiologists. We also found that radiologists with more years of experience reported being more frequent communicators of normal results of diagnostic mammograms. Presumably these data suggest that radiologists who have spent more time in the field of breast imaging have learned the importance of communicating results to their patients compared to those with less overall experience. Lastly, we found that radiologists who spend 80-100% of their time in breast imaging are less frequent communicators of abnormal diagnostic mammograms than radiologists who spend 40-79% of their time in mammography. This is an interesting finding that we are unsure how to interpret. Perhaps radiologists who spend a significant amount of time in breast imaging have competing demands with interventional procedures, which makes it difficult to find time to talk with patients other than those receiving the interventional procedures.
We found that most radiologists use general rather than numeric statements to convey information about breast cancer risk, but that radiologists who do use numeric statements are more confident in their use of statistics than those who do not use numeric statements. Conveying risk information to patients is complicated (25
), and at least one recent study found that pictorial, graphical and general statements all had limitations in conveying risk information to patients in a way that they can accurately recall (25
), but that accurate recall was more likely to be associated with conveying numeric risk values using gambling odds (e.g., ‘1 chance in X’). We know of no studies that specifically assessed how to convey risk of breast cancer at the time of an abnormal mammogram, although one study found that having discussions with a healthcare provider about family history of breast cancer increased perceived risk of developing breast cancer and was associated with improved adherence to screening, but did not promote knowledge of personal risk factors. Clearly, much more information is needed about how best to inform women about their risk of breast cancer especially around the time they receive abnormal mammography results.
An important strength of our study is the significant response rate by community-based radiologists to a mailed survey about their approaches in conveying information to patients at the time of mammography. The population of radiologists eligible to take part in our study included those who are active members of a federally funded consortium of radiologists who are not likely associated with tertiary care centers and thus are representative of the majority of radiologists interpreting mammography around the country. A limitation is that we did not conduct this assessment at the time of the mammogram, but relied on physician self-report, which may be affected by recall bias.
In summary, nearly all patients will reap benefits from conversations about results and recommendations of their screening and diagnostic mammograms, especially when the results are abnormal. Radiologists who are directly and frequently involved in the imaging and management of breast diseases are well positioned to provide this information directly to patients, rather than health care providers who episodically deal with breast related issues. Experienced radiologists can answer questions and ensure the patient understands the recommendations spanning from yearly screening mammography to the necessity for breast biopsy and they can more accurately describe next steps. If at all possible, this information can be most efficiently delivered while the patient is still in the radiology department and can often incorporate the actual radiologic images as part of the discussion. This approach may not be practical for screening mammography but should be part of routine practice for diagnostic mammograms as we know these patients have a higher frequency of breast disease than the screening population and a higher percentage of these patients will need either additional imaging such as MRI or a breast biopsy. Some of the anxiety associated with these mammograms can be allayed with a timely and informed discussion of results with the patient. To ensure both knowledge and comfort with communicating results to patients, we need to develop training programs for providers including radiologists, physician’s assistants, nurse navigators and others involved with breast disease. Lastly, more research is needed to identify how best to convey patient risk at the time of an abnormal mammogram.