There are an estimated 11.1 million cancer survivors in the United States, and cancer is increasingly being seen as a manageable chronic disease. Unfortunately, cancer survivors may experience both physical and psychosocial long-term and late effects of cancer and its treatments that can have a profound effect on both health status and quality of life. Specialized cancer survivorship clinics have been started in many cancer centers in response to the needs of the growing number of survivors, but the overall costs and effectiveness associated with providing survivorship-focused care have yet to be evaluated. This paper explores the body of knowledge that contributed to the development of survivorship clinics and examines the potential benefits of these clinics along with a real-world description of a dedicated adult survivorship clinic.
In this age of consumer-driven health care and competitive markets, cancer centers must be innovative in their program development and offer personalized services to informed consumers. Many national medical societies and health care organizations have developed cancer service excellence criteria that include supportive care services as being an integral and preferred element of cancer care to support conventional biomedical treatments. Proper planning and thought must be given to a process that will design a navigation program that aligns specific customer requirements and enhances the patient, caregiver, and physician experience. A well-planned process will produce successful program components that eliminate or greatly reduce the need for costly redesigns or reorganization after implementation. The objectives of such a design would be to improve participant's health outcome and quality of life, manage side effects, prevent secondary infections and avoid secondary cancers, improve access to care, lower cost, and promote program growth.
This article aims to describe how ethically and efficiently research has been conducted in our practice. What started out as a very informal set of internal checks and balances at our practice has evolved into a very busy research department. We now have numerous internal and external studies. Research opportunities include computer-aided detection, full field breast ultrasound, elasticity imaging, cone beam computed tomography of the breast, and breast tomosynthesis. There are many ways a mammography center can conduct research; we have found that commitment is a major factor. Each project needs adequate time and supervision. The dedication must be there to see the projects through to completion.
A pathology second opinion of breast biopsy material has many proponents, but is still infrequent in actual practice. Discrepancies between an initial and a review diagnosis vary in frequency between the type of review, cursory or comprehensive, and the specific type of lesion being examined. Among patients with microscopic proliferative lesions, the discrepancy rates can exceed 20%. Discrepancies with an initial diagnosis of atypical ductal hyperplasia and their potential impact on treatment costs are explored. The author's recent experience from a consult second opinion practice is reviewed and the types and frequency of discrepancies are discussed.
The coordination of treatment for the newly diagnosed breast cancer patient can be challenging, especially in a private health care system. The process begins with an effective imaging program, built on trust and seamless coordination among breast radiologists, referring clinicians, and treating physicians. Once the imaging component is in place and a multidisciplinary breast conference has been established, the next logical step is to bring the patient together with a group of medical experts in a clinic setting to discuss her case. This Multidisciplinary Breast Clinic model facilitates direct communication between the multidisciplinary breast conference participants and the patient. In addition to increasing patient satisfaction, the clinic—if appropriately presented to the community—also has the potential of directing additional patients into the system for treatment. All medical specialties involved in the treatment of breast cancer, including many ancillary and support providers, come together to consult with the patient in a “one-stop shopping” appointment. The purpose of the clinic is not just to provide a treatment plan but also to educate and offer support. It also assures the patient that her providers are communicating with one another regarding her treatment. This type of service, in addition to being the right thing to do, sets a health care system apart in the competitive cancer care market.
Breast magnetic resonance imaging (MRI) stands out among other MRI applications in its intense need for high resolution, high contrast, and rapid scan time. These technical constraints push MRI technology to the extreme—choices made for a particular protocol may result in advantages and limitations. Decisions and their outcomes are discussed for reconstruction methods, pulse sequences, radiofrequency systems, shimming systems, and dynamic approaches. Technical choices will depend on the manufacturer and principal purpose for the scanner. The appropriate choices will vary if the system is designed for whole body applications or if it is a dedicated breast system. Quality MRI technology will facilitate optimal demonstration of subtle lesions and allow consistent imaging of all patients.
Since breast magnetic resonance imaging (MRI) can identify lesions not seen on other imaging methods, MRI-directed biopsy and localization is a necessary part of a breast MRI practice. A wide variety of MRI-compatible localization wires, localization markers, biopsy needles, and vacuum-assisted biopsy devices are available. The attributes of each device are described. Stereotactic guidance systems are now produced that will accommodate almost any current MRI system. Dedicated breast MRI systems with full integration of interventional capability are now available. The superior definition of lesion extent by MRI may allow the minimally invasive treatment of breast cancer in the future.
In our outpatient Breast Center, we have spent years establishing a workflow pattern that is efficient for our facility. In the following pages, we will describe the unique and effective workflow designed to meet our patients' needs. We have developed a Radiology Information System (RIS), which includes patient scheduling, film requests, patient tracking, pathology results, and patient health history. We average 250 screening patients a day, with an additional 50-100 diagnostic patients. We are now 100% digital, using a picture archiving and communication system (PACS) and a homegrown RIS. Daily we strive to maintain the highest professional standards while providing the patient with excellent service. With an efficient behind-the-scenes workflow, the patient experiences seamless professional interaction in an environment that serves her needs and addresses her concerns.
The adoption of mammographic service screening has led to decreased mortality from breast cancer due primarily to the detection of smaller, earlier stage cancers. Advances in breast imaging technology have contributed significantly to the presurgical evaluation of women, including use of the image-guided biopsy and interdisciplinary pre-treatment planning. The presurgical imaging and final pathologic reporting of tumor characteristics are often discordant. Modern imaging techniques, including functional MRI and 3-D ultrasound provide a spatial depiction of breast cancer extent not reportable using conventional pathologic techniques dating from an era when a minority of breast cancers were screen-detected. By incorporating imaging data into a large-format pathologic evaluation of surgically resected breast tissue, it is possible to improve correlation of tumor size and extent, multifocality, and the evaluation of surgical margins. The importance of pathologic tumor characteristics in guiding therapy mandates optimization of imaging–pathologic correlation in this era of screen-detected breast cancer.
This article is an overview of 2008 coding, billing and reimbursement as it relates to breast MRI.
The Clinical Breast Care Project (CBCP) was established by direction of the U.S. Congress in January 2000. Human biospecimen collection (breast organ site) is a seminal pillar of the CBCP. To date, more than 33,000 total specimens have been collected and stored under a cooperative congressionally sponsored agreement with the Windber Research Institute in Windber, Pennsylvania. The National Cancer Institute sponsored a workshop in June 2008 entitled Economic Considerations for Implementing the NCI Best Practices for Biospecimen Resources. The authors were asked to present details from the CBCP experience on the cost of setting up and operating a high-level biorepository. These costs were meticulously gathered with input from our clinical, tissue banking, and medical bioinformatics teams. Set-up and operational costs were then computed for each facet of the operation to calculate the total expense of establishing this biorepository. Development and operating costs for other institutions will vary, but the chronology and costs presented here can serve as a guideline for other organizations, clinicians, and scientists interested in establishing a biorepository for translational research.
The initial diagnosis and treatment planning of the breast cancer patient's journey represents a critical time when the comprehensive breast center can enhance the communication, collaboration and coordination among the pathologist, radiologist and surgeon. A collegial environment is critical for this to occur. This article describes the co-dependant role among the three specialties - and from the surgeon's perspective, what skills and services are required of radiology and pathology to assure appropriate treatment planning. Among the many issues discussed are the imaging work-up, the clinical breast exam, specimen radiography, specimen processing, triple test correlation, communication of radiology and pathology findings, and patient communication.
To maintain our portion of the market share and to recruit new patients, our practice has used different marketing methods and tactics to promote our practice and advertise our standard of care. We have spent time and energy investigating the types of customers practices are competing for, including patients, referring physicians, employees, and payers. You cannot know enough about your business or competition. We use many different methods when designing our marketing plan, including tactics to develop physician referrals, tactics to develop new patients and maintain current patient volume, and education of the patients, public, and physicians. We will go into more detail in the following pages. We believe that marketing is not doing any one thing well; it is doing many things well all at once. We continually solicit feedback through surveys and going out into the community, from our patients and referring physicians.
The current diagnostic applications of breast MRI, which include staging of the newly diagnosed breast cancer patient, monitoring of neoadjuvant chemotherapy, and identifying mammographically occult tumors, are reviewed. Contrast-enhanced breast MRI is also useful in the evaluation of ambiguous clinical and imaging findings.
As clinical research in the last several years has continued to reveal the importance of magnetic resonance imaging (MRI) use in breast imaging, we forged ahead to implement breast MRI in our private practice workflow. The initial start-up costs were prohibitive, so our facility decided to start our MRI experience with a mobile unit. This enhanced our experience and comfort level and initiated our ongoing negotiations for MRI growth with our referring doctors, our patients, and our local insurers. It has been a learning curve for everyone involved with the implementation process. In the end, we established an outpatient MRI practice and built a stationary MRI suite that has suited our work environment. This happened slowly, always with serious consideration to finances, local environment, and workflow issues.
Mary Bird Perkins Cancer Center's unique CARE Network in Baton Rouge, Louisiana, is used as a best-practice model to illustrate what can be achieved when breast cancer care facilities set aside politics and collaborate to put women's breast health needs first. How the CARE Network, working in partnership with other health care agencies, was established to meet a regional need and how it has maximized various funding sources to provide free mobile mammography and comprehensive breast cancer services to an uninsured and underinsured population is described. The essential services required to reach and treat this population to help lower the rate of breast cancer deaths in a state which has one of the highest cancer mortality rates in the country are delineated.
This paper presents the conditions underlying the current economic crisis and the increasing efforts to reform the U.S. health care system. The Western industrialized nations, other than the United States, provide universal access to health care. And these nations monitor, incentivize, and, in some instances, control use of care and manage the administrative costs attendant with care in a much more effective manner than the U.S. health care system. Although there is no certainty with respect to the final structure that health care reform will take in the United States, organizational efficiency, information, and evidence-based utilization are three areas in which breast centers should prepare for the future.
