Response to COVID-19 in Breast Imaging

Abstract

Coronavirus disease 2019 (COVID-19) is a novel respiratory virus first identified in Wuhan, China, in late 2019. Symptoms vary from asymptomatic (particularly at younger ages) to severe acute respiratory distress syndrome. Death is estimated to occur in 1%–2% of those who contract the disease; most of these occur in patients ages 60 years and older. While COVID-19 is not known to have any effect on the breast or the risk of breast cancer, responsible leadership requires protection of our patients, staff, and radiologists in reducing potential exposure and disease as well as the effective use of breast imaging staff and radiologists. Here we ask select leaders in breast imaging to respond either specifically or in general to the following questions: What is necessary breast imaging? What will be done if care will be delayed for one month? Two to three months? Longer? How are you protecting staff? How are you implementing social distancing? What do breast radiologists do when the schedule is mostly cleared out? What do staff do when the schedule is mostly cleared out? Please note that these are rapidly changing times, and practices may have changed since acceptance of this manuscript. Linda Moy and Hildegard K. Toth New York University Langone Health, New York, NY Dr Linda Moy is Professor of Radiology at New York University (NYU) Langone Health. She serves as a Special Consultant to the Editor of the Journal of Breast Imaging (JBI) and is a member of the Board of Directors for the Society of Breast Imaging (SBI). Dr Hildegard Toth is an Associate Professor of Radiology and Section Chief for Breast Imaging at NYU. New York University Langone Health is a large academic health care center in New York City. The catchment area includes the tri-state region of New York, New Jersey, and Connecticut. Our practice is a mix of a National Cancer Institute–designated Cancer Center, several outpatient imaging centers, as well as tertiary care hospitals. Our breast imaging team includes 47 radiologists with expertise in breast imaging. In 2019, NYU Langone Health performed more than 150 000 mammographic examinations. New York University Langone Health has a patient-centric practice that balances providing breast imaging services to our patients with the potential risk of contracting COVID-19 by our patients, technologists, support staff, and radiologists. We have continued to perform diagnostic examinations, but our volume of these has decreased because we have stopped performing screening mammography and screening ultrasound (US). In our practice, some asymptomatic patients with above average risk, eg, those with a personal history of breast cancer, may be scheduled as a diagnostic exam. Some of these women do not wish to postpone their exam and are relieved to know that their mammogram was normal. Also, we continue to perform all percutaneous US, tomosynthesis, and MRI-guided breast biopsies as well as nonwire localizations. Furthermore, our radiologists are prioritizing the reviews of outside films to expedite biopsies and presurgical evaluations of cancers. There is a shift to nonwire localization when possible so that patients can be rapidly rescheduled as operating room availability opens up. Occasionally, we have been able to offer a diagnostic workup with same-day biopsy for outpatients. New York University Langone Health has postponed all screening mammograms and screening breast US examinations. We are also performing screening breast MRIs on high-risk patients who do not want their examinations delayed. Add-on breast MRIs are performed but only if approved by the radiologist, eg, staging for the extent of disease. Following a Department of Surgery mandate, all breast surgeries, including elective surgeries (benign disease, discordant lesions, high-risk lesions) and for cancers are temporarily on hold. The exceptions are for emergencies, such as hematoma or a devitalized flap. We offer oral therapy for patients with a delay in their breast cancer surgeries. Our surgeons, medical oncologists, and radiation oncologists are developing protocols for cancers that are not amenable to delay or to oral therapy. A helpful guide for the management of our breast cancer patients is the American Society of Breast Surgeons’ executive summary regarding the COVID-19 pandemic (1). To protect our staff, NYU Langone Health implemented “source control” as the standard of practice. At this time, no visitors are allowed to accompany the patients. As of Thursday, April 2, 2020, all patients arriving at the NYU Perlmutter Cancer Center are given a mask. They are then screened by a nurse in the lobby of the NYU Langone Health facilities (Table 1). If an answer in the affirmative to any of the above questions is obtained, the patient is instructed to wear a face mask and is placed in an isolation room. A referring clinician or the radiologist, wearing full personal protective equipment (PPE), assesses the patient and triages as follows: fine, the patient may proceed to the breast imaging department; go home and get a virtual consult; or go to the Emergency Department (ED). If the patients are allowed to proceed to the breast imaging department, they are again screened by our front desk. If they are symptomatic, they are rescheduled and sent to virtual urgent care or the ED. Screening Questionnaire for Potential Exposure to COVID-19 Our mammography and US units are ALWAYS being wiped down between patients, even before the COVID-19 pandemic. We use germicidal wipes (Sani-cloth, PDI, Woodcliff Lake, NJ) with the recommended contact time on each part of the unit that touches the patient. In addition, our cleaning staff is extremely diligent and cleans all doorknobs, light switches, surfaces, keyboards, iPads for patient consent, handles on cabinets, etc., multiple times a day. Our staff feels adequately protected with these measures. Breast imaging appointments are being spread out throughout the day. Mammograms are now every 30 minutes rather than every 15 minutes. Also, we removed chairs from our waiting rooms, and all patients are instructed to sit six feet away from each other. Our technologists are not allowed to congregate in the technical area. Instead, they are sent to various mammography rooms, US rooms, and reading rooms, if available. All staff and radiologists must wear a face mask. The breast radiologists are working on many academic pursuits that are consistent with the academic mission of our medical school. These tasks include research projects, writing manuscripts, preparing talks, and grant submissions. To support a departmental initiative to increase peer learning, we will perform a thorough analysis of positive predictive value 1, 2, and 3 of all imaging modalities to improve patient care. Another priority of our radiology leadership is to develop teaching files, including radiology-pathology teaching files for our medical students. Also, our radiology leadership is fostering the understanding of artificial intelligence (AI) among the breast radiologists. Therefore, they are encouraging breast radiologists to review educational material on AI. Breast radiologists may participate in ongoing AI reader studies and may assist with image annotation and segmentation. Finally, all radiologists may volunteer to be redeployed and to assist elsewhere in the hospital. Staff are being deployed elsewhere within the cancer center and within the radiology department. They are tasked with materials management, rescheduling patients both for radiology department and cancer center clinicians, assisting with filing and paperwork, specimen transport, and updating the protocol and procedure manuals. Mary S. Newell, MD Emory University Health System, Atlanta, GA Dr Newell is Professor of Radiology and Imaging Sciences and Assoicate Director of Breast Imaging at Emory University. She is President of the Georgia Radiological Society and a member of the Board of Directors for the Society of Breast Imaging. What they say about living in “interesting times” proves true. As my associate Michael Cohen pointed out to me, we as breast imaging radiologists have worked daily our entire careers to address the immediate needs of our individual patients, to assuage their fears, and to expedite their care. How disconcerting it is for us now to be faced with a new take on the risk versus benefit equation! Our Emory Breast Imaging division encompasses 5 breast centers served by 13 faculty (2 of whom share appointments with other divisions) and 5 fellows. Our hospitals run the spectrum from tertiary care center to hybrid private practice/academic model to large public hospital. Despite these disparate settings, our radiology leadership has been able to marshal a cogent, highly effective, unified voice in leading the response to this crisis. In breast imaging, we have done the following: Initially, all patients were cancelled for a two-week span. This is being continued in a rolling manner, week over week. No screening patients are being done. We ran lists to identify all Breast Imaging Reporting and Data System (BI-RADS) 4 and 5 patients, all outstanding BI-RADS 0 (recall only), and all patients who were on the schedule but cancelled. We triaged these for urgency and created spreadsheets that allow us to track each group. We are adding patients who call in with new symptoms and triaging them as well. By doing this, we will know who to schedule first when full-service resumes. We are seeing all patients triaged as urgent. These are patients who have or may well have breast cancer and would undergo therapy in the near term (eg, known cancer needing localization, extent of disease determination, highly suspicious screening imaging findings or clinical symptoms, or probable abscess). We have subtriaged our “time-sensitive patients” to see who might benefit from evaluation in the near term. We are limiting our patient-facing days to two per week and bundling cases on those days so that we can limit physician and technologist exposure. We have enacted minimal staffing. When attending faculty aren’t onsite, they are doing academic work. Fellows are assigned to sites when their presence might expedite care but are otherwise being encouraged to study at home and work on projects. A few technologists are coming in even on nonpatient-facing days to call patients, do paperwork and quality assurance, etc. Our technologists and radiologists are using surgical masks, eye protection, and gloves during all patient contact. We explain that this is not because we are sick but simply for everyone’s safety. Patients have welcomed this. We have moved our waiting room furniture and are scheduling patients at single half-hour intervals to promote social distancing. We are continuing to send reminder letters so as not to disrupt this safety chain, but we have included an insert explaining that, for now, our appointments are markedly limited due to COVID-19 but that we will have extended hours when routine service resumes. We thought that it was important to continue to send the letters for full transparency and in case patients wanted to seek care at another center. We did suspend sending the certified letters we send to patients who have not returned for care despite a reminder (and to their referring physician) as a form of terminal communication, as these, in this setting, serve no actionable purpose for the patient—she can’t get an appointment! We will print and send them as appropriate once operations have resumed. The new and disconcerting risk versus benefit conundrum for all of us comes when assessing those patients below the urgent category: attempting to balance the risk of exposure against the benefit of (minimally) earlier diagnosis (assuming a delay of month or two). Do we bring in a patient and risk possible community exposure to her, our technologists, breast center staff, and ourselves for a finding that is unlikely to be breast cancer? At Emory, we are trying to be clear-eyed in assessing, on a patient-by-patient basis, whether we feel the need for evaluation outweighs the risk of community exposure and possible infection. Unfortunately, as we are all finding, this is difficult and necessarily subjective. One thing I know is: We breast imaging radiologists will approach this task with diligence and vigilance, in a way that serves the most in the best manner possible. Donna Plecha, MD Case Western Reserve University School of Medicine, Cleveland, OH Dr Plecha is the Theodore J. Castele Professor and Chair of Radiology at the Case Western Reserve University School of Medicine. University Hospitals of Cleveland Health system is an academic, research-oriented health care system associated with the Case Western Reserve University School of Medicine, with 18 affiliated hospitals and multiple outpatient facilities. Working in alignment with our institution’s COVID-19 Incident Command Center, executive leadership, as well as the breast multidisciplinary leadership team, we have defined our essential and nonessential breast procedures and imaging exams. Governor Mike DeWine issued a stay-at-home order for the state of Ohio, which went into effect on March 23, 2020. What is necessary breast imaging?Our Incident Command Center and executive leadership agreed to suspend all screening exams, including mammography, MRI, and US. We are calling patients two weeks ahead of their appointment in a rolling fashion. We have not rescheduled them at this time and have informed patients that we will be calling them in the future to reschedule them. Our team has discussed prioritizing our high-risk patients when we begin screening in the future. We have started planning capacity optimization for when we do start screening again, such as expanding hours on weekends to accommodate the volumes of backlog where and when appropriate. What will be done if care will be delayed for one month? Two to three months? Longer?We are currently offering diagnostic imaging and biopsies. After the stay-at-home order was put in place by the governor, diagnostic studies have diminished due to patient preference to reschedule. We are tracking patients that have canceled and no-shows so that we can reschedule them in the future. We will reach out to category 3 patients to reschedule their diagnostic follow-up exam. How are you protecting staff?Our patients and staff have their temperature taken and answer screening questions before entering our buildings. All of our technologists are encouraged to wear surgical masks. Our staff does feel adequately protected. To conserve PPE, the staff are encouraged to use one mask during the entire shift, unless the mask is no How are you implementing social have implemented of at six feet among staff and patients. In our multidisciplinary breast centers, are to with the of patients, which has the of patients and staff We are also limiting staff hours because of the in patient The staff is on between patients in all waiting To conserve PPE, the staff are encouraged to use one mask during the entire shift, unless the mask is no What do breast radiologists do when the schedule is mostly cleared of March and of April is for many we have several breast imaging radiologists on with few at this A few radiologists have to take time that was not during this We have limited the of sites that need a by diagnostic patients to days at We are educational to and on research and other The has every physician out a to individual in case the of needs to be implemented in the future. This has to be What do staff do when the schedule is mostly cleared hours will continue to be in to has sent out for staff regarding time and Some of our technologists are able to US, or in the radiology department. MD The University of MD Cancer Center, Dr is Professor of Radiology and Chair of the Department of Breast Imaging at the University of MD Cancer She is of the When the COVID-19 pandemic first the it was difficult to know the appropriate because MD is a cancer center with a of patients. We are to providing cancer care for patients who from the and it was to the immediate when the of and social the The of the of and no and in In with our in the with the rapidly of the we started with all screening and routine breast imaging in mammography, US, and in patients at Our to not screening and routine breast imaging was by Governor of on March 2020, and the Emergency by the Board to the In and medical procedures that are not are from being April 2020. The are to and spread and to conserve and material in of needs from the pandemic. After the breast imaging and procedures that are to include the following: BI-RADS 3 follow-up of at mammography, US, or follow-up imaging US, percutaneous follow-up imaging US, recommended as of multidisciplinary patients that do not have for imaging as first of care to of breast such as or review of imaging performed at an outside or a workup of imaging evaluation done at an in of a BI-RADS or by the and biopsy of BI-RADS mammography, US, or is important to a operating in the of rescheduling exams, including necessary if patients to has been the of April 2020, we are rescheduling patient appointments that rather than or of the patient-facing of breast imaging, from is not for many of our clinical To practice as as radiologists and are into so that one of radiologists would work in the for a of then home to perform work for a of with the other all the clinical and potential exposure. This of at any one time is possible given the in volume associated with the rescheduling of nonessential exams. As as this is with the schedule as well. Radiology are during this time (and not in the between and technologist are place the than in as as and any one would use the reading each clinical day. work of and academic may also use this time to continuing medical and communication, and with our clinical are as our is large in and to rescheduling breast imaging exams, we discussed our with our in breast medical radiation and cancer our clinical discussed with us in their practice (eg, for or therapy for Our standard practice is multidisciplinary and and it so MD University of Center, NY Dr is the Dr and Dr Professor and Chair of Imaging Sciences at the University of She is the of the and is a member of the Board of Directors of the The University of Center is of and the as well as community hospitals to from New York state has the of COVID-19 but these are in New York When I in my as Chair on 1, 2020, I no that I would be leading our department a pandemic. March we all imaging examinations that were scheduled March division worked with their to develop a of examinations that This was done in with other who were and surgeries in order to increase capacity as well as potential exposure to the virus for both patients and breast imaging, this included all screening examinations and diagnostic studies such as follow-up and workup of breast of lesions, including those as BI-RADS were also This approach is now in a by the American of Radiology and the American Society of Breast and the We that some examinations that to not be urgent would patient management, such as As we moved to the of that two-week we to which studies two weeks but not a month or were by then only seeing urgent patients in we their for imaging that the for the study was also urgent. This and service All staff can wear a surgical mask each and all mammography technologists have this practice. Our technologists are in patient contact for at minutes for a We will of all staff and faculty for both and outpatient the of that work from home the need for in this We have worked to have as many radiologists either reading at home or in an As it to six weeks to new we are and will the reading as we new New York state has the for for We are not home for mammography due to as the volume of breast imaging (and and we are breast radiologists who general to other of need (eg, and have diagnostic home for them. We have to all reading and put down to six feet of working in and study time at Our are at using a unified to review cases in time with the and other staff from breast and other imaging with volumes are being to of such as where that is As we have a large we are working to at other sites as well. about the as a time for new leaders to and develop of I for a leadership and several but is no for a department during a pandemic. We have daily department leadership and and department leadership virtual that this will between our and our community and We can all be for this

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