Advanced Practice in Breast

ImagingBy

Anne Lang

Consultant Radiographer in Breast Imaging

NHS Lanarkshire

Introduction

Background in breast imaging and drivers

to allow the role development

Education required to undertake the

advanced practice role

Impact on the service

Challenges

The future of Advanced Practice in breast

imaging

Background in speciality

16 years experience as a mammographer

14 years experience as a mammographic

film reader

Double reading programme (2006)

Success of programme and service

demand - 2nd radiographer undertaking

image interpretation

Drivers

Shortage of breast radiologists

Increased demands on the service (7000, breast patients per annum)

National drive to meet demands of the 4 tier structure

Ambition

Expert in clinical field

Education required for role

PgC - Mammography

PgM - Image interpretation

PgM - Interventional Breast Techniques

PgC – Defined Area of Ultrasound Practice -Breast

Optional - PgM – Advanced Research Methods

Optional - Masters dissertation

Impact of the role- Clinical

Increased capacity – 202 new ‘one-stop’ breast patients per week – 25% seen by Consultant Radiographer

Quality- MDT preparation time, QA programme

Expert in clinical field

Sharing examples of good practice – audits, reporting format

Leadership

Leading by example

Organisational change/strategic decision making

SRTP

Scottish Access Collaborative –Breast Surgery Speciality Group

WOS Managed Clinical Network for Breast

SCOR Consultant Radiographer group via ‘glass cubes’

Learning & Development

CPD – Masters, Study days

Mentoring: Advanced Practitioners

Teaching/Lecturing:

Students

Radiographers

Radiology registrars

Specialty doctors

BCN’s

Research

‘Within NHS Scotland what is the current

radiology service offered / variation in

practice in assessing the axilla with

ultrasound and how would any changes to

practice in light of new guidance from the

Royal College of Radiologists be accepted?’

(Pilot study).

Challenges faced

Study time

Service demand/capacity

Confidence

Communication

Relationships

Complexity of the role – decision making

Case Study 1

75 year old female presented to one-stop

breast clinic with a palpable breast lump

in the RLOQ Graded E5 plus palpable

lymph node.

Cranio-caudal views

Medio lateral oblique views

Ultrasound

Ultrasound axilla

Ultrasound guided biopsies and

marker insertion

Post clip mammogram

Magnification view

Stereotactic biopsy

Specimen Xray

Results of core biopsies and

outcome following MDT

Right breast - invasive ductal cancer B5b

Right axilla –malignant node

Left breast – DCIS B5a

MDT outcome - bilateral Mastectomy

Case 2

52 year old female presented to the one-

stop breast clinic with history of a lump in

the lower aspect of her left breast. Could

not be felt at time of clinic E1.

Mammography

Ultrasound of symptomatic area at

5 o,clock

Ultrasound of upper aspect

Marker Insertion

Post clip mammogram

Results and MDT outcome

Both lesions in upper aspect were

invasive ductal cancer B5b

MRI was performed confirming only two

lesions

MDT outcome either localisations WLE

or mastectomy depending on patient

preference

Case 3

35 year old female presented at the one–

stop breast clinic with an E3 lump medial

right breast

Ultrasound

Axilla ultrasound

Ultrasound guided biopsy

Results of core biopsies

Right breast biopsy – Grade 3 invasive

breast cancer B5b

Right axilla biopsy – malignant node

Mammography

Ultrasound guided marker insertion

Post clip mammogram

MDT outcome

Neo-adjuvant chemotherapy

Monitoring of tumour at intervals with

ultrasound

Followed by magnetic seed localisation

and WLE

Case 4

52 year old woman presented at the one-

stop breast clinic with an E4 lump in the

LLOQ. No previous mammogram

Mammogram

Ultrasound

Complications

On dual therapy anticoagulants – for a

pressing cardiac condition

Management of the patient

Ultrasound guided biopsy

Biopsy result and MDT outcome

Grade 3 invasive ductal cancer B5b

For neo adjuvant chemotherapy

Ultrasound guided marker insertion

Post clip mammogram

MDT outcome

Monitoring of neo adjuvant effect

Magnetic seed localisation

WLE

Complexity of cases

Ensure careful reporting and review of

images

Follow protocols - solid lesions in

patients 25 and over to be biopsied

Ultrasound is not a screening tool

Consider the whole medical history of

the patient

Future of Advanced Practice in NHS

Lanarkshire

Advanced Practitioner roles – accelerated training

Mentors available

Remit

Limitations

Skill mix

Summary

Advanced practice in breast imaging is

successful and has been shown to have a

beneficial impact on the breast service in

NHS Lanarkshire

Job Satisfaction

‘……we know who you are and we are

inspired by what you do’ (Band 5

Radiographer)

‘……thank you, I have been told by the

breast surgeon my cancer is very small and

could easily have been missed’ (Patient)