D.29 NMVAHCS MCP 114-11 Mammography Program.docx

MAMMOGRAPHY PROGRAM

1. Policy: To establish guidelines and procedures for the ordering and follow-up of mammograms on both asymptomatic and symptomatic patients. It is preferred that prior to ordering a mammogram, the patient’s provider performs a breast exam to determine whether a patient should have a screening versus a diagnostic mammogram.

2. Responsibility:

a. Imaging Service is responsible for:

(1) The performance of mammogram procedures.

(2) Evaluating films on symptomatic patients prior to the patient leaving the department.

(3) Scheduling ultrasounds and work-up mammograms.

(4) Mailing written mammogram results directly to the patient.

(5) Alerting ordering practitioners when their patient is a “no-show”.

b. Referring practitioners are responsible for:

(1) Ordering mammograms via CPRS and describing in the clinical history any abnormal clinical findings including which breast and location of abnormality. (with clock position & distance from the nipple)

(2) Ordering breast ultrasounds, in lieu of mammography, on symptomatic patients less than 35 years of age.

(3) Providing instructions to the patient to call the Imaging Service Mammogram Scheduling Office at 505-265-1711 ext. 5711 or 5125.

(4) Instructing the patient to bring any previous mammogram films done at other facilities for their VA mammogram appointment.

3. Procedure:

a. Screening Mammography is performed to detect unsuspected breast cancer in women with a normal breast exam. Annual exams are recommended for age ≥40.

(1) Referring provider will generate a request ordering a screening Digital Breast Tomosynthesis.

(2) Each clinic is to provide the patient with instructions to call Mammography scheduling to set up an appointment time. Mammography orders will be verified by the scheduler.

(3) Each clinic is to inform patients about the importance of prior mammograms which are for needed for comparison. Patients are to bring most recent previous mammograms not done at the New Mexico VA Health Care System (NMVAHCS) with them to their mammogram appointment.

b. Diagnostic Mammography (bilateral, unilateral, or work-up) is intended to evaluate patients with an abnormal clinical examination or suspicious findings found on the

Memorandum 114-11 Subj: Mammography Program January 19, 2018 2.

screening mammogram. An abnormal clinical finding includes a palpable mass, bloody or clear nipple discharge, focal pain or an area of skin thickening.

(1) Symptomatic patients older than 35 years of age: Referring provider will generate a request ordering a Digital Breast Tomosynthesis, bilateral. Under “clinical history” provider will describe the abnormal clinical findings including which breast and location of abnormality with clock position & distance from the nipple. All patients with a palpable lump will also need to have a breast ultrasound ordered on the same day with the mammogram so that the exams can be scheduled concurrently.

(2) Symptomatic patients less than 35 years of age: Patient should be referred to ultrasound rather than mammography as the initial imaging step. The Radiologist should evaluate the patient and the ultrasound to determine if a mammogram is needed. The referring provider will generate a request ordering a breast ultrasound.

Under “clinical history” provider will indicate which breast and describe location of abnormality. (clock location and distance from the nipple.)

(3) Although mammography and ultrasound are important diagnostic tools, they are not considered emergent procedures. Therefore, they will be performed only on stable patients. No breast ultrasounds will be performed portably.

c. Work-ups: Patients who are called back by the Radiologist for additional imaging studies because of an abnormal mammogram. Requests will be generated by Mammography. The patient’s provider will receive notification of patient “no shows” for workup exams.

d. Scheduling: It is the clinics responsibility to supply the patient with information on how to schedule their mammography appointment. Patients may come to the MRI/Mammography Section and schedule directly with the scheduler or call 265-1711, extension 5125 or 5711.

e. Results: The Mammography Department will directly notify patients of their results in lay terms in accordance with the Mammography Quality Standards Act (MQSA) requirements.

Patients will receive a written letter within (30) days of their exam. In the case of exams where the assessment is “Incomplete, Need additional imaging evaluation,” the patient is called as soon as possible to schedule further work-ups. The patient also receives written notification. “Suspicious” or “Highly suggestive of malignancy” results are verbally communicated to the patient and the healthcare provider as soon as possible. In most cases the patient is informed at the time of their work-up examination and the referring physician is phoned that day. In addition, the patient is notified in writing. The provider will receive results through VISTA using a standard set of interpretations based on the American College of Radiology (ACR) recommendations. It is the responsibility of the provider to refer patients for the appropriate follow-up.

Memorandum 114-11 Subj: Mammography Program January 19, 2018 3.

4. References: Public Law 105-248; (ACR); Community Standards.

5. Rescission: Medical Center Memorandum 114-11, Mammography Program dated August 21, 2014.

6. Expiration Date: January 19, 2021

Signed MCM in D/FMO File Andrew M. Welch, MHA, FACHE Director

Distribution: “M”