Practice reporting has had a tumultuous history. Specifically in the U.S., mammography reporting has suffered from a lack of uniformity and standardization, which changed with the implementation of the American College of Radiology’s (ACR) Breast Imaging and Reporting and Data System (BI-RADS). While limitations still remain for breast imaging, emerging technologies and software applications are finessing the mammography reporting technique, and paving the way for further homogeny and an overall improved patient experience.
A rocky start
Free-text reporting has been the standard method used by radiologists, despite increasing use of speech recognition and structured reporting, says Bruce I. Reiner, MD, of Baltimore Veterans Affairs Medical Center in Baltimore. “At the end of the day, radiology as a whole has undergone tremendous transformation and innovation, and reporting really hasn’t,” says Reiner.
One exception is mammography which has successfully developed standardization to the ACR BI-RADs reporting methods.
BI-RADs arose in the early 1990s out of the need for simplicity and uniformity. “The clinical community was up in arms, saying that you’re giving us all this descriptive information in these free-text reports, but we don’t know what to do with it and we don’t know what the take-home message is,” Reiner recalls. Because of the “heterogeneous nature” of the reporting, the clinical community sought to better understand the clinical significance, as well as follow-up recommendations.
The heterogeneous nature of the reporting stemmed from the fact that there was a tremendous amount of variability with regard to the radiologist, explains Reiner. “Depending on the time of the day and the day of the week, as well as the stress level of the physician, the contents and the organization of the report could be all different,” he says. Essentially, BI-RADS created a more uniform reporting method that has been “very well received by the clinical community.”
But BI-RADS also presents other challenges, namely, tthat it is scored according to the single most significant finding, oftentimes “camouflaging” the other findings that are also significant, explains Reiner.
To remedy this, a more itemized report needs to be created for the clinical community, to spell out all significant findings of the study. According to Reiner, these reports should give clinical significance, anatomic location, modifiers regarding size, morphology, follow-up recommendations and if possible, a diagnosis or differential diagnosis.
“But in order to do that,” he warns, “which the clinical community would really welcome, there would really need to be a certain amount of constraints on reporting,” he says, referring to the free text report as a historic “security blanket” within the community. The implementation of itemized reporting could potentially lead to data mining, the most important feature of the mammography report, as well as the future of evidence-based medicine, Reiner offers. “You cannot mine radiology reports unless you have standardized data, so it becomes circular,” he says, explaining that unless there is a standardized lexicon and structure within the reports, evidence-based medicine cannot be achieved. “This is where we need to go,” he notes.
BI-RADS smoothes out the bumps
Wendie Berg, MD, PhD, FACR, of American Radiology Services, Johns Hopkins Medical Institutions, in Lutherville, Md., agrees with Reiner, saying that not only is mammography reporting the most standardized area of radiology, but possibly of all areas of medicine as well.
“It is extremely standardized,” she offers. The report always follows the same model: breast density is first quantified into one of four categories, followed by a description of the findings for which there is a standard terminology, or lexicon, followed by standardized wording for final assessments and recommendations.
“Two people looking at the same lesions generally, with a high degree of consistency, will describe [the finding] the same way. This has been in place since the first BI-RADS lexicon was produced in the early 1990s,” she says.
But despite its organization and consistency, “It’s still an art, and it’s still difficult,” Berg says. Focus can be a challenge for the radiologist who is not a dedicated mammography reader, and may be in the middle of reading studies from other areas of radiology.
“The [reader] may be an excellent radiologist, it’s just very difficult