Featured Article
Primary Care’s Role in Breast Health, and How Breast Centers May Support Them
Christine B. Weldon,1,2 Teena Francois-Blue,3 Ariel J. Thomas, 3 Kathy Tossas-Milligan,3 Julia R. Trosman,1,2 Betty Roggenkamp,1 Anne Marie Murphy3
1Center for Business Models in Healthcare,2 Northwestern University,3 Metropolitan Breast Cancer Task Force
Multiple studies have concluded that primary care referrals and PCP/patient interactions are critical components for successful completion of mammography screening.1-3 Chicago was recently found to have the lowest mammography screening rates in the country for women enrolled in Medicare (Dartmouth Atlas 2010). There were even lower screening rates for women enrolled in Medicaid and those who are uninsured. There is a significant racial disparity in breast cancer mortality between White and Black women.4-6 The Metropolitan Chicago Breast Cancer Task Force initiated a project in 2013, funded by the Chicago Community Trust and the Avon Foundation for Women, to identify facilitators of high quality breast cancer screening, follow-up, and treatment referral for women that can be implemented in health centers providing primary care services to uninsured and underinsured patients.
Changes in the United States Preventive Services Task Force (USPSTF) recommendations for mammography (formerly annual screenings beginning at 40, to biennial screens beginning at 50) have negatively affected how physicians are directing care for high risk women.7 Many do not realize that USPSTF necessitates the consideration of a patient’s individual risk and explicitly excluded Black women from its new recommendations. Black women tend to get breast cancer earlier than White women.8,9 Leading researchers at the National Cancer Institute have determined there currently is no clinically useful way to assess a patient’s risk that would identify a different starting point for mammograms [other than 40] except for genetic risk.10 However, certain risk factors may increase the need for regular mammography or other screening modalities. These are points of concern because a high proportion of uninsured and underinsured women are minorities, who are often at higher risk and require referral into specialty care (e.g. black women are more likely to have dense breasts requiring MRI use for screenings and have a higher risk of being diagnosed with aggressive breast cancers at an age less than 40). 10 The USPSTF is undergoing research to refine their guidelines and may make substantive changes based on additional data that have been released.11 Twenty-five percent of breast cancers are diagnosed in patients under the age of 50. This 25% does not include cancers that were growing but not diagnosed until after age 50.11
Unlike some other screens or preventive care interventions (e.g. flu shot), many breast imaging sites require referrals for screening mammograms, even though this is not legally required. A patient must first go to their primary care doctor and then leave the primary care setting to get the mammogram. Thus, there can be many barriers to accessing mammography. The Task Force project interviewed primary care sites that serve lower income patients to attempt to understand both facilitators and barriers to utilization of mammography and primary care. The literature suggests that “patient factors alone do not account for the quality gap, and patient-doctor communication is a potential target for intervention.”1 This gap is central to the project’s objective of promoting dialogue about breast healthcare and interventions in a readily accessible way for low-income and underserved women. Improved patient-provider communication in primary care settings not only promotes adherence to mammography recommendations, it also promotes timeliness to crucial follow-up after receipt of abnormal screenings.
An extensive scan of academic literature and national medical guidelines to identify key practices that enable optimal breast health was conducted. With the information secured from the literature and the prior work carrying out care process analysis across 26 breast centers in Chicago, an interview guide was created to engage in a standardized primary care assessment. A research protocol was developed that enabled us to interview practitioners at several sites to determine their adherence to guidelines, to identify best practices, and to identify barriers to optimal care.
Ten sites for engagement were developed, each of which served a predominantly minority and Medicaid population in Chicago, with a reasonable volume of women over the age of 40. Face-to-face interviews utilizing the detailed interview script were conducted. In addition to collecting information on current practices at sites, the interviewees participated in in-depth discussions of breast health practices in screening, diagnosing, and treating breast cancer. This allowed for an initial discussion of process improvement ideas.
Analysis identified that the following themes facilitated quality primary care practices and improved breast cancer screening, diagnosis, and treatment outcomes, n=15.
While primary care physicians have a significant influence on patients, they are very busy handling multiple health concerns for a large number of patients. Breast Centers may develop or enhance their relationship with primary care physicians by supporting breast health activities. The following table summarizes what patients need to support their breast health and what primary care and breast centers may do to assist patients and each other.
| What patient’s need | Primary Care’s Role | Breast Center’s Role | How Breast Center may assist PCP |
| Reminder to get annual screening | Remind patient via phone and/or mail until they complete annual screening.Utilize appropriate screening methods for high risk patients. | Remind patient via phone and/or mail of annual screening, starting at 40. | Communicate with primary care offices to discuss patients who have not completed annual screening. |
| Completion of breast screening and diagnostic process | Track and follow up on patient completion of mammogram.Provide open order through diagnostic completion.Work with breast center so patient does not have to collect paperwork. | Get paperwork for patient from referring physician’s office.If indicated, complete diagnostic follow-up imaging on same day as screening. | Keep PCP informed of results.Help PCP follow up by scheduling no-shows and follow up appointments.Setup patient service with PCPs: same day wellness visits at PCP and mammogram at breast center |
| Assessment of family and personal cancer risk | Consistently conduct medical history and genetic risk history at each wellness encounter.Refer indicated patients to genetic assessment. | Review patient history and refer indicated patients to genetic assessment. | Inform PCP of genetic assessment referrals.Provide PCP with information on high risk breast cancer screening guidelines and local genetic assessment resources / clinics. |
| Coordinated care between PCP and cancer care team | Utilize a standard protocol to support patient’s overall health and co-morbidities during active treatment and through survivorship. | Provide patient and PCP with clear steps to take when cancer diagnosis occurs. | Provide PCP with a breast cancer care initiation checklist.Follow-up immediately to make sure PCP has received diagnosis and that patient has diagnosis as well. |
Working together, there is a great opportunity to streamline breast health for patients while keeping them engaged in their care. Primary care physicians and their staff are vital to successful breast health programs. Breast Centers should work with their primary care partners to streamline processes and ensure patients do not fall through the cracks.
We would like to thank the Chicago Community Trust and Avon Foundation for Women for supporting this project. We would also like to thank Dr. Melissa Simon for her guidance and mentoring through this work.
For more information, please contact Christine Weldon at weldon@centerforbusinessmodels.com
References
- Schueler KM, Chu PW, Smith-Bindman R: Factors associated with mammography utilization: a systematic quantitative review of the literature. J Womens Health (Larchmt) 17:1477-98, 2008
- DuBard CA, Schmid D, Yow A, et al: Recommendation for and receipt of cancer screenings among medicaid recipients 50 years and older. Archives of Internal Medicine 168:2014-21, 2008
- Vinikoor LC, Lavinder E, Marsh GM, et al: Predictors of screening mammography among a North and South Carolina Medicare population. Am J Med Qual 26:364-71, 2011
- Hirschman J, Whitman S, Ansell D: The black:white disparity in breast cancer mortality: The example of Chicago. Cancer Causes & Control : CCC 18:323-33, 2007
- Whitman S, Orsi J, Hurlbert M: The racial disparity in breast cancer mortality in the 25 largest cities in the United States. Cancer Epidemiol 36:e147-51, 2012
- Rauscher GH, Murphy AM, Orsi JM, et al: Beyond the mammography quality standards act: Measuring the quality of breast cancer screening programs. AJR Am J Roentgenol 202:145-51, 2014
- Sharpe RE, Jr., Levin DC, Parker L, et al: The effect of the controversial US Preventive Services Task Force recommendations on the use of screening mammography. J Am Coll Radiol 10:21-4, 2013
- Mandelblatt JS, Cronin KA, Bailey S, et al: Effects of mammography screening under different screening schedules: Model estimates of potential benefits and harms. Ann Intern Med 151:738-47, 2009
- Harris JR, Lippman ME, Morrow M, et al: Diseases of the Breast (ed Fifth edition.)
- Wacholder S, Hartge P, Prentice R, et al: Performance of common genetic variants in breast-cancer risk models. N Engl J Med 362:986-93, 2010
- Kopans DB: The recent US preventive services task force guidelines are not supported by the scientific evidence and should be rescinded. J Am Coll Radiol 7:260-4, 2010
Synopsis: NCoBC 2015 Conference Ticklers
Administrative Do’s and Don’ts
Saturday March 14th during the Admin Track
Management and leadership can be tough, especially as budgets are cut and personnel is limited. Administrators need to keep employees engaged and motivated with a focus on quality patient care. This talk will review some of the common mishaps made by administrators, as well as techniques to build a cohesive team with a focus on providing high quality care and an excellent patient experience.
Amy Chatten
Executive Director
Mammography Educators
San Diego, CA
So I have Dense Breasts? Now what? Whole Breast Automated Screening and TOMO, New BiRads
Saturday March 14 during the Imaging Track
Breast density is a hot topic. Patients and physicians can be confused on just what adjunctive test will be the best for their patients. This session will provide the technologist with information on how to communicate to the patient the density of their breast and to help facilitate adjunctive screening test. Information will be provided to help develop a fl ow sheet to assist your physicians on how to initiate the conversation regarding breast density and which test is appropriate for their patients. The BiRads have changed and the classifi cations regarding breast density have been updated to improve reporting. Are you aware of the new changes????
Belinda Zaparinuk RT(M),BS,CBEC
Manager
Eisenhower Schnitzer/Novack Breast Centers
Rancho Mirage, CA
Supporting the Patient through the Diagnosis of Breast Cancer:
I Will Walk Beside You
Sunday March 15th RN Track in the Afternoon
There are few things in life more devastating than hearing the words of “you have breast cancer.” In the ever complex world of breast cancer diagnosis and treatment, the patient is often left with an overwhelming burden of decision making which will certainly affect the rest of their lives. It is the navigator who can be the bridge to the complexities of medical practice find resources and stand in the shadow of the patient for support.
I bring this navigation role to our attention in that shared decision-making can create a healthier environment for our patients. When working in teams with clinicians from different disciplines, we all succeed in keeping the patient in the forefront and share the responsibilities for their well-being. As an NP and nurse navigator, I am often both patient advocate and clinician, keeping lines of communication open to discuss issues with the physician of record both in and out of the hospital. Time to sit and chat with a patient and their family about a recent diagnosis of breast cancer goes a long way to establish a trusting and fulfilling relationship. It turns out that our newest and brightest technology cannot completely replace our time and caring when it comes to serving our patient populations. A very wise patient once said to me “…you don’t have to be brave, you just have to show up.” But I reminded her that this does not mean she needs to show up alone. I walk with every woman, at any time until such a time as they can fly away back to the lives they once had before they heard the words “…you have breast cancer.”
Cathy Friedlander Cole, NP, MPH, CHES, CN-BP
Oncology Nurse Navigator
Department of Oncology
Los Robles Regional Medical Center
Thousand Oaks, CA
Neoadjuvant Chemotherapy: Impact on Imaging/Pathology
Sunday March 15th NCBC/ASBD Track
Neoadjuvant chemotherapy (NACT) was used for locally advanced breast cancers in order to modify the surgical management of these patients. Today, patients with small tumors are also off ered NACT. The advantage is of course the in vivo study of the tumor being subjected to treatment. The decision about the type of treatment is not based on survival because we know that disease free survival and overall survival is exactly the same whether adjuvant or neoadjuvant therapy is used.
Medical oncologists are selective in the cases they treat with neoadjuvant chemotherapy because history has shown that some tumors are much more sensitive to chemotherapy; as such, estrogen receptor negative tumors demonstrate the best response and Her2neu positive tumors are exquisitely sensitive to treatment with Trastuzumab. The key in the work-up of patients receiving neoadjuvant chemotherapy is the cooperation between the radiologist, the surgeon and the pathologist. The radiologist will establish the original diagnosis and mark the site with a radioopaque clip. This will allow the surgeon to have the area localized at the time of surgery and also will allow the pathologist to determine the area of most interest for examination to determine the type of response.
Clinical evaluation of response is poor, radiologic evaluation of response is good, but the most eff ective evaluation of the percentage of response is done by pathologic examination. The pathologist must examine 100% of the tumor bed area before being able to establish a diagnosis of complete response. A complete pathologic response (pCR) has been de emed as the complete disappearance of viable tumor both from the breast and the lymph nodes. The presence of residual duct carcinoma in situ is considered acceptable for a diagnosis of pCR.
Kristie Bobolis, MD
Medical Director Breast Health Center
Attending Staff Physician Dept. of Medicine Hematology-Oncology
Sutter Roseville Medical Center
Roseville, CA
Julio A. Ibarra, MD
Medical Director of Pathology & Breast Center
Orange Coast Memorial Medical Center
Fountain Valley, CA
Atypias: What Are They and What To Do With Them
Sunday March 15th NCBC/ASBD Track
Atypical lesions in the breast have and continue to be a problem not only for diagnosis but also for management of these patients. Some of the conditions that are included in this category include the atypical hyperplasias such as ADH (Atypical Ductal Hyperplasia) and LN (Lobular Neoplasia); then there are the lesions that have been associated with an upgrade such as papillary lesions, radial scars, sclerosing adenosis, which by themselves are not necessarily atypical. The literature is covered with reports on upgrades associated with these lesions; the interesting aspect is the fact that there are certain factors that appear to increase the risk for an upgrade such as the lack of radiologic-pathologic correlation, the presence of a positive family history, the size of the needle and the number of core biopsies obtained. From this, it is clear to understand 
why there is a tremendous amount of variability in the rates of upgrades. Furthermore, there are no prospective trials analyzing these lesions; all the literature has are retrospective reviews with their own built in biases. Although not a trial, there is a prospective analysis of lobular lesions (Murray et al) where they found a very low upgrade rate in cases with radiology- pathology concordance (2 out of 72 cases).
To make things more confusing, the names of these lesions are not necessarily universally accepted. For example lobular neoplasia is a term coined by Haagensen in 1978 to include atypical lobular hyperplasia and lobular carcinoma in situ, however there are groups that refuse to lump these two diagnoses because the literature has well established risks for each one, with atypical lobular hyperplasia being lower than lobular carcinoma in situ (4-5 times vs 8-11 times); on the other hand there was the LIN terminology proposed by Bratthauer and Tavassoli in 2002 in which they split the lobular lesions into 3 and not two categories. And to end the discussion, one must include the most recent addition to the lobular neoplasia, the pleomorphic lesions which share morphologic and radiologic similarities with duct carcinoma in situ but molecularly appear to be a distinct entity for which we have very little follow up information in the literature.
In discussing the atypical ductal lesions we must not forget to discuss columnar cell change and hyperplasia with and without atypia, at epithelial atypias, all of which are considered “precursor lesions” for ADH because they share many of the molecular changes. And of course we can’t go into this lecture without knowing that the interobserver concordance of these lesions has been shown to be dismal, particularly when speci fic criteria are not given to the reviewers.
Julio A. Ibarra, MD
Medical Director of Pathology & Breast Center
Orange Coast Memorial Medical Center
Fountain Valley, CA
Dennis R. Holmes, MD, FACS
Chief Breast Surgeon & Director
Los Angeles Center for Women’s Health
Los Angeles, CA
Tips and Traps for Mammo Coding 2015
Monday March 16th
After many years of no coding changes for breast imaging, 2015 brings new codes, guidelines and billing requirements. The new tomosynthesis and breast ultrasound codes will be discussed in detail as well as the associated coding and compliance concerns to ensure attendees are submitting for their services in an accurate and compliant manner. This informative and dynamic session will include a Q&A portion to ensure that attendees receive the information relevant to their organizations.
Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC H
President
Coding Strategies, Inc.
Powder Springs, GA
Ask the Navigation Expert (Question #1)
Dear Marlee,
I work in a breast center as a NCBC Certified Imaging Navigator (CN-BI). We are currently working to develop a more comprehensive navigation system, but we are not quite there yet. My question is: how do you handle when a patient calls and asserts that she knows her core biopsy test results are in, but her doctor is out of town and she wants results now?
Great question! There are legal and ethical parameters that must be followed anytime medical information is to be given out. Many states and facilities allow for Imaging Navigators to give results of a test, often breaking it down into allowing for benign results only. So always check with your individual facility and state regulations for your individual scope of practice. Also, remember to document the call, your response and action, and any follow up to the call. Here are some responses from the NCBC Navigation Certification Core Committee on designation specific responses for further consideration:
Cathy Cole, CN-BP (Provider): Over the years I have developed a trusting relationship with the surgeons and give the results to patients myself. If that is not currently a part of your job description, you might try calling the ordering provider’s office or a colleague on-call to try and alleviate the patient’s anxiety.
Janell Clark, APN-BC, MSN, MBA, CN-BP (Provider): The physician or radiologist may designate someone to give results which will include specific instructions on what information may be given, such as results, definitions, recommendations or referrals. In my position as a Nurse Practitioner I often give results but respect the relationship the patient has with her ordering provider first.
Andrew Newman, CN-BI (Imaging): Referring provider preferences vary widely. They often prefer the radiologist or imaging staff give the patient results because that can expedite the process of results, referrals, and getting the patient an appointment within a reasonable amount of time. Patients have right to their medical records and it is becoming more commonplace for results to show on an individual’s medical website before personal contact can be made. A good navigation program develops a relationship with providers based on understanding to earn trust and ultimately the best possible care for our mutual patients.
Julie Shisler, LPN, Manager CN-BC (Clinical): Medical Assistants or Licensed Practical Nurses may or may not be approved to give results of a pathology report dependant on facility or state regulations and scopes of practice. While you feel great compassion for this patient it may not be in the best interest to cave into emotions and give results if you are not tasked for this job. At our facility, for imaging biopsies, our radiologists routinely give results and have developed that relationship with the ordering providers. If you are trained to give results, be sure you stay within the limitations of what to tell a patient and use caution not to cross the line into giving medical advice except what has been given to you specifically to that patient.
Melissa Hopkins, RN, BA, CN-BN (Nurse) Chair: It’s great to hear that you are in process of how to handle these types of situations. Kudos to your team! Relationships with patients and their providers are important when deciding who and how results are given. Factors to consider include:
- Patient preference to caller and method of contact
- Ordering provider preference and availability
- Patient’s emotional status and availability
- The content of the report (ie: positive, atypical, discordant, benign) and the follow up recommendations
- Attentiveness to the report (ie: preliminary, more than one report pending)
As an RN working in mammography, I always find out before the procedure how the patient wants to be notified and if they have a preference on who contacts them, or an appointment time is set up prior to the procedure for results. I am authorized to call on all benign results, many atypical results, and only occasional positive results as I believe that most patient prefer to hear from their doctor or radiologist first, and then follow up with the navigator for any follow up support.
Dr. John Bell, MD, Program Medical Advisor: It is the patient’s right to know. There should be a policy and procedure to deal with this situation in advance for quality of care. If that is absent the covering provider should be notified to give the patient results.
Ask the Navigation Expert (Question #2)
Dear Marlee:
I work in a surgical center as an NCBC Certified Advocate Navigator (CN-BA). In our surgical center we have a lot of breast cancer patients transitioning to chemotherapy or radiation and have trouble keeping up the day-to-day tasks in life, such as housekeeping. Do you have any suggestions on what we can routinely suggest to help them?
As you review for this apparent barrier to care, be sure to look for other barriers such as employment, childcare, and transportation issues. Try looking to your community and network with other navigators who may have already developed a list of helpful resources, especially your Social Work navigator peers. Here are some great suggestions from our experts for your consideration.
Janell Clark, APN-BC, MSN, MBA, CN-BP (Provider): It is very common for patients that have transitioned from surgery to other modalities of treatment and may need help with ADLs (activities of daily living). We can suggest a routine or regimen that is recommended by the Occupational/Physical/Recreational therapist that may aid in housekeeping as an exercise or part of treatment.
Julie Shisler, LPN, Manager CN-BC (Clinical): This is something that can often be set up ahead of time. Help the patient make a list of things they will need to help with meals, cleaning, driving children, etc so when people offer to help there is a ready task list. It may take some encouragement to get a woman to accept help but it works out well for many. If they do not have family or friend support, there are organizations such as ‘Cleaning for a Reason’ that provide free housekeeping services through local companies.
Melissa Hopkins, RN, BA, CN-BN (Nurse) Chair: In discovering this common barrier the first call to action should be to assess for her current list of assets: friends, family, community organizations and help her to prepare a list of tasks. There are also national organizations that can be accessed through CancerCare.org such as ‘Cleaning for a Reason’. One thing I always suggest is the use of an online website such as CaringBridges.org that allows for updates at the patient’s discretion and also a list of items that selected readers can find of items the patient needs. Patients often do not need 8 pre-frozen meatloaves at the beginning of the week, but without guidance that is often all the support knows to do. Make the list as comprehensive as possible including dates and services needed and readers can pick and choose what they are available for without the patient or family needing to ask directly at all.
Cathy Cole, NP, CN-BP (Provider): I have many resources that I keep updated to assist with these tasks and I provide them to the patients as needed. Depending on the need, I can arrange on behalf of the patient or give websites or phone numbers if the patient or family wishes to contact directly. I also suggest that they engage friends, family or church groups that can pitch in and create a calendar to rotate tasks for the patient and family. Everyone wants to help, this gives them direction and a chance.
Dr. John Bell, MD, Surgeon, Program Medical Advisor:
- Social Work Referral
- American Cancer Society
- Cleaning for a Reason
Ask the Navigation Expert (Question #3)
Dear Marlee,
I am an NCBC Certified Nurse Navigator (CN-BN). I have a patient who is about to start an aggressive chemotherapy and she wants to wear a cold hat and gloves to prevent hair and nail loss. I’ve seen some of the other patients do that, but I cannot find any research standards for or against it. What do you know about this and are there alternatives to this that I could offer them?
It is always important to check with your facility guidelines on whether or not this is an acceptable comfort measure. If not, this is a great start to researching information for presenting and advocating for your patients if you find is a helpful resource. Here are some comments from other professionals and you can see the wide range of thoughts on the subject:
Julie Shisler, LPN, Manager CN-BC (Clinical): The cold hat has not proven to consistently prevent hair loss though some have seen positive results. She might be able to rent the caps, you will need several because you have to change them every 30 minutes. Patients will be very cold and complain of a headache. Some insurance companies may cover the service, similar to a wig so check into that. The American Cancer Society may have resources that can assist.
Cathy Cole, NP, CN-BP (Provider): We do provide cold cap therapy for those that chose this method with a doctor’s order, and we keep the freezer in the infusion center. It is not an FDA approved therapy and despite some compelling anecdotal information, there is not much research out there. I have several medical oncology colleagues who fear a scalp metastasis, so will not order caps, but will allow for gloves or booties in ice water during treatment. In the 10 cases I have worked with, no one lost their hair, but long term effects are not known.
Dr. John Bell, MD, Surgeon, Program Medical Advisor: There are no evidence-based standards to avoid the consequences of chemotherapies that cause hair or nail loss. There is also no apparent harm to try.