D.27 VANTHCS BREAST CANCER SCREENING PROCESS.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA NORTH TEXAS HEALTH CARE SYSTEM

January 24, 2014 549/114

VANTHCS MEMORANDUM NO.114-01

BREAST CANCER SCREENING PROCESS

1. PURPOSE:

The purpose of this memorandum is to outline policies and procedures at VA North Texas Health Care System (VANTHCS) for providing breast cancer screening for Veterans to include mammography, diagnostic and invasive breast studies, education, reporting, and follow-up of breast imaging services.

2. POLICY:

It is the policy of VANTHCS to provide breast cancer screening services to eligible Veterans to include in house and outsourced mammography and diagnostic breast imaging studies. Male patients are at minimal risk for breast cancer and will be examined and/or have diagnostic testing performed when the clinician determines it necessary.

3. PROCEDURES:

a. Breast Cancer Screening:

(1) The Primary Care Provider (PCP) is responsible for ordering mammography cancer screening studies for eligible female patients who meet criteria for the exam (including CHAMPVA beneficiaries). The American College of Radiology (ACR) Practice Guidelines (accessed through their Web site www.acr.org and VHA Handbook 1105.3) and the U.S Preventive Services Task Force (USPSTF) Screening for Breast Cancer Recommendations and Rationale accessed through their Web site www.ahrq.gov/clinic/uspstfix.htm will be used to guide the process of breast cancer screening/mammography.

(2) Clinical breast examination by a health care provider is available to all eligible women Veterans enrolled in primary care outpatient services.

b. Screening Mammography:

(1) Mammography screening can detect tumors before they reach the size where they can be palpated, and at the point in the disease process when chances for effective treatment and survival are greatest. PCPs are encouraged to discuss mammography with their patients and order the

D.27 RFP: 36C25722R0015

procedure whenever it is clinically indicated, following established guidelines.

(2) ACR guidelines recommend screening asymptomatic women annually beginning at age 40. USPSTF guidelines recommend that all average risk women aged 50 to 74 have mammography screening performed every two years for breast cancer screening. An earlier age is preferable when there is a family history of breast cancer and/or other risk factors present for breast cancer. After age 74, the decision as to when to stop routine mammography screening should be made on an individual basis by each female patient in conjunction with her PCP.

(3) Ordering practitioners are responsible for placing the initial order with appropriate contact information for themselves and their preceptor, if applicable. Ordering practitioners will take responsibility for results of any orders they have placed. When the ordering practitioner is not available to receive and review abnormal results in a timely manner, the practitioner will assign a surrogate to receive and follow up on abnormal test result notifications in concordance with the Mammogram Results Reporting Policy, November 8, 2011.

c. Diagnostic Mammogram. A diagnostic mammogram utilizes additional views or magnification and will be obtained anytime the radiologist suggests suspicious screening findings or a patient report and/or physical examination reveals a breast mass. Other diagnostic studies (e.g., breast ultrasound, breast magnetic resonance imaging (MRI)) may be indicated following the mammogram to determine the location, size, and density of any suspicious findings, and scheduling of these studies is coordinated with the ordering physician/PCP, radiology staff, and the patient.

d. Requests for Mammography and Other Diagnostic Breast Studies:

(1) In-House Mammography. Mammography is performed in Radiology Service, Clinical Addition, 3rd floor at the Dallas facility.

Requests for mammography studies are submitted through CPRS and appointments scheduled by appropriate staff. Examinations may be ordered for diagnostic purposes as well as routine screening. Pertinent physical findings based on breast examination by the health care provider or any clinical symptoms the patient may have should be noted in the CPRS order when requesting diagnostic mammography studies to assist with localization of suspected abnormalities.

(a) Mammography exams are scheduled daily during normal administrative hours, Monday through Friday, at the Dallas facility.

Walk-in appointments are also open during these times, but may not always be available. The Radiology Service mammography technologist or supervisory technologist may be contacted to resolve any scheduling questions. Pregnant patients should not have routine mammography performed.

(b) The Scheduling Clerk will notify the patient of the date and time of appointments for breast screening studies. A scheduling letter and telephone call from Radiology Service scheduling staff will provide the patient with any preliminary instructions in preparation for the test(s) (e.g., not wearing deodorant/antiperspirants, talcum powder, or cream on the breasts or underarms because they can interfere with the test results;

wearing comfortable, two-piece clothing outfit that can easily be removed from the waist up). The Scheduling Clerk will also ask the patient to bring any outside prior mammograms at the time of their exam.

(c) Scheduling Clerks will reschedule mammography patients upon no-shows or appointment cancellations. Patients will be initially contacted by telephone and an appointment letter will be mailed to the patient. When patients cannot be contacted by telephone (discontinued telephone number, wrong number listed, etc.) an appointment letter that includes the Women’s Radiology Suite contact information will be mailed to the patient. A second attempt to reschedule patient no-shows or cancellations may include telephone call, secure messaging and/or certified letter. If a new order is required, the Scheduling Clerk will place a note in CPRS documenting the reason for discontinuing the mammogram order and will add the PCP/Women’s Clinic Cancer Coordinator as a cosigner.

(d) Using the established guidelines, Radiology Service staff will review all pertinent clinical and diagnostic findings to determine if any follow-up breast diagnostic studies may be indicated. Patients will be specifically questioned by the mammography technologist to determine if they have any breast implants, or any scars or moles that might affect the test. The Technologist will ask the patient if they have any breast symptoms such as lumps, nipple changes, nipple discharge or pain. If the patient does have focal symptoms, further diagnostic imaging will be coordinated and scheduled with the patient.

(e) Each patient will complete a breast history form prior to their mammogram which will be reviewed by both the Technologist and the Radiologist. This will include patient’s family history, prior breast procedures, breast symptoms and any history of breast cancer. If these patients have a strong family history of breast cancer, a screening breast MRI may be recommended by the Radiologist.

(f) All male patients are considered diagnostic cases. As such, each will be scheduled for both a mammogram and ultrasound at the same time to work-up any symptoms and to address the need for the exam.

(g) The Radiologist enters mammogram results in CPRS.

Radiology Service staff will mail a letter containing mammography results to all patients who have had mammograms performed in the Mammography Suite. Radiology Service provides the ordering provider with "View Alerts" for abnormal findings. Pre-operative localization procedures to be performed in the Operating Room will also be scheduled by electronic consult to Radiology to enhance coordination of the care. If possible, the surgeon will include the date the patient is scheduled for biopsy in the Operating Room.

(h) If a suspicious lesion is found on the mammography and/or ultrasound, the patient will be scheduled for the respective biopsy, (e.g., ultrasound guided and stereotactic biopsy). After the Radiologist performs the biopsy, the specimen will be submitted to Pathology and to Laboratory Medicine Service. The Pathologist will communicate these results directly to the Radiologist performing the procedure. The Radiologist is then responsible to communicate to the original ordering provider and/or patient and breast surgery clinic of any positive findings. The ordering PCP will enter a consult with the Breast Surgery Clinic when needed.

(2) Studies Performed by Community Mammography Providers are available to Veterans living 50 miles or greater from Dallas VAMC via Non-VA Care Coordination (NVCC) services. All mammography performed under VA auspices, regardless of location, must undergo an annual mammography standards inspection to assess whether or not the mammography program is meeting VHA requirements. Therefore, Radiology Service, NVCC and Women’s Health Program coordinates all mammography non-VA care services in conjunction with the Women’s Cancer Coordinator for non-VA mammography services where VA patients are routinely referred.

(a) The process to be followed for off-site breast radiography shall include (but not be limited to) aspects of the process, such as how care will be coordinated; timely patient communication of study results; and monitoring of patient satisfaction and quality outcomes data (including Mammography Quality Standards Act certification).

When patients are referred by VA directly, the NVCC consult and order will be entered in CPRS by PCPs, and approved by the delegated authority. Non-VA care mammography results of the studies are communicated to NVCC and Radiology Service at the Dallas facility, which will follow the recommended process used for in-house mammography to relay results to providers. Community mammography providers are responsible for communicating the results of the studies they performed to the patients referred to them by VANTHCS.

(b) Continuity of care should be considered when ordering community mammography services. When studies are done by non-VA specialists at VA’s direction, mammograms or other radiological image results (diagnostic mammogram/ultrasound) via written report will be provided to NVCC/Radiology Service. When patients have mammograms and other imaging studies of the breast performed by non-VA radiology sources and then have follow-up exams done at VA, the patient will be asked by Radiology Service to request the films be sent to VA for adequate comparison and analysis.

e. All mammogram reports will be entered into CPRS by NVCC/Radiology Service staff for review by the ordering provider. All abnormal or suspicious findings shall be coded according to ACR BI-RADS category by the Radiologist, and the ordering provider will be notified via the CPRS View Alert system. The ordering provider will assume responsibility for coordinating follow-up care and ongoing evaluation and management of the patient’s care (i.e., consult to Surgery-Breast Clinic, ultrasounds, etc.).

(1) Normal results (BI-RADS Category “1 – negative” or “2 – benign findings”) will be entered into CPRS for review by the treatment team.

Radiology staff will notify patients of results of negative/benign studies (refer to paragraph 3f below).

(2) When positive or suspicious findings are noted (BI-RADS category “3 – probably benign findings” or “0 – need additional imaging evaluation and/or prior mammograms for comparison”), the Radiologist will be assisted by the Mammography Technologist to schedule additional studies. This commonly occurs in one of every ten patients. Additional diagnostic studies that are indicated will be scheduled by Radiology Service staff within five work days (although patient appointment preference may sometimes delay the studies beyond five days). The Radiologist will document communication of the results and the follow-up actions taken to the ordering physician/PCP in his/her report. When the final mammography report is modified as a result of comparison studies or an addendum, an additional summary reflecting the final BI-RADS category must be communicated, and a lay communication provided directly to the patient. The patient may be scheduled for further diagnostic studies and/or be referred to the Surgical - Breast Clinic for further evaluation and follow-up by the physician/PCP who ordered the mammogram.

(3) Mammogram findings suspicious for malignancy (BI-RADS Categories “4 – suspicious abnormality” and “5 – highly suggestive of malignancy”) will be communicated directly by the interpreting Radiologist to the ordering PCP and the surgeon who provides care in the Breast Clinic and/or the covering provider within five working days. If verbal communication to the PCP is not possible, the PCP’s surrogate or Service Chief will be notified within the five-day limit. Additionally, a View Alert about the radiological report will be sent via CPRS to the requesting provider of the mammography exam. The Radiologist will document this communication in his/her report. Prompt verbal notification of the provider does not obviate the need to provide written communication with the patient, either by the Radiology Service or referring PCP (not necessarily both). The patient will be referred by the ordering PCP via CPRS consultative evaluation to the Surgical - Breast Clinic, or referred to whatever appropriate community provider is preferred by the patient (e.g., CHAMPVA patients).

(4) The Mammography Technologist/Coordinator will conduct a monthly data pull for all mammograms with a BI-RADS category 4 and 5.

The patient data are analyzed to monitor the quality of patient care in regard to the breast cancer screening process, including follow-up care provided.

f. Guidelines for Notification of Patients of Normal and Abnormal Mammography Results Performed at VANTHCS:

(1) For “benign” findings, Radiology Service will send a notification letter to the patient. Mammography results will be communicated to the patient in terms easily understood by a layperson within 30 days of the procedure. The communication is documented in the medical record.

(2) When a mammography report is “suspicious” or highly suggestive of malignancy, the summary results and recommended course of action are communicated by the Radiology Service staff to the ordering PCP via verbal communication and View Alert. The PCP/ordering Physician assumes responsibility for notification of the patient and communication of the plan of care (e.g., follow-up diagnostic examinations and/or surgical consultation) within five working days, by telephone and/or letter.

Radiology sends the patient written communication to encourage the patient to call their PCP for the findings, as a backup mechanism, to ensure that the patients are notified of abnormal results.

(3) VHA ordering providers are required to notify patients of mammogram results, and communicate plans for follow up and additional testing, as necessary within 14 days of receiving mammogram results, per Mammogram Results Reporting Policy, November 8, 2011. The communication is documented in the medical record.

g. Quality control and certification requirements for all aspects of breast screening diagnostic services will rest with the surgeon in the Breast Clinic and Radiology Service through technical and professional peer review, according to ACR guidelines and VHA Handbook 1105.3 requirements.

4. RESPONSIBILITIES:

a. The Woman Veterans Program in collaboration with Radiology Service is responsible for the contents of this policy.

b. Chief of Staff oversees, reviews, and ensures that all aspects of this policy are implemented by all Clinical Service Chiefs.

c. All Clinical Service Chiefs, with responsibilities as outlined above, will oversee, review, and ensure that all aspects of this policy are implemented.

d. Staff physicians/primary care providers are responsible for the medical evaluation and treatment of female and male Veterans under their care.

5. REFERENCES:

a. VHA Handbook 1105.3, Mammography Program Procedures and Standards, April 28, 2011; Management of Mammography Referrals and Reports-A best practice workflow, December, 2012, and Memorandum dated November 8, 2011, Mammogram Results Reporting Policy.

b. VHA Handbook 1330.1, VHA Services for Women Veterans, May 10, 2010.

c. ACR Practice Guideline for the Performance of Screening and Diagnostic Mammography, 2008. Available at:

http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Screening_Mamm ography.pdf (accessed 7/22/2013).

d. U. S. Preventive Services Task Force Screening for Breast Cancer Recommendations; and Rationale, updated December, 2009. Available at:

http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm (accessed 7/22/2013).

e. Mammography Quality Standards Act (MQSA), revised April 11, 2011.

6. RESCISSION: VANTHCS Memorandum No. 114-01, dated January 27, 2010.

Jeffery L. Milligan Director

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