SUBSPECIALTY TRAINING: BREAST IMAGING
The aim of subspecialised training in breast imaging is to prepare a radiologist
for a career in which a significant portion of his/her time will be devoted
to breast imaging and/or breast cancer screening with mammography. Such individuals
will be expected to provide and promote breast imaging and interventional
methods, as well as new imaging breast cancer screening procedures
The aims of establishing a curriculum for sub speciality training in breast radiology is to ensure
• An in-depth understanding of breast disease with particular knowledge of the nature of breast cancer in all its guises;
• A clear understanding of the role of imaging in the early diagnosis of breast cancer;
Development of the necessary clinical and management skills to enable radiologists to become an integral part of a multidisciplinary breast team in symptomatic and or population screening settings
Expertise and facilities
Training must be undertaken in a team with access to full clinical service in
radiology, general surgery/gynaecology and pathology. If possible, oncology,
radiotherapy, plastic surgery, social and preventive medicine should also be
offered.
Training should be supervised by a radiologist with extensive experience
in breast imaging and breast cancer screening methods (e.g. reporting 5000
mammograms per year). The training department(s) should fullfill EU guidelines,
must have mammography, ultrasonography and interventional equipment including
stereotaxic and ultrasonically guided biopsy systems. Trainees should also
have access to breast MRI, nuclear medicine and acquire knowledge of breast
cancer screening. Trainees must also have access to radiological library
containing senology and radiology textbooks and journals and must have
access to a film library.
Overview
Trainees will have obtained a basic knowledge of breast diagnosis in their
initial training. The training outlined below will extend this in to the practical
role.
For those clinical radiologists who wish to devote essentially all their time as specialists/consultants in breast imaging they should undertake 12 months or its equivalent of subspecialty training. Those who wish to practice breast imaging, as one of a mixture of activities would normally expect to undertake 6 months.
.
Trainees will acquire an extensive knowledge of the pathology and epidemiology of breast diseases both female and male and both primary, local recurrence and distant disease. They should have at least a basic knowledge of the treatment of breast disease by surgery, radiotherapy and chemotherapy and be aware of the diagnostic needs of their surgical, radiotherapy and oncology colleagues. It would therefore be helpful for trainees to spend time in breast clinics, operating theatres and radiotherapy and oncology departments. Trainees also must develop skills in the use and interpretation of imaging modalities used in the diagnosis and treatment of distant spread of disease e.g. plain radiographs, ultrasound, CT, MR and nuclear medicine. They will receive training in communication with patients and colleagues and 'breaking bad news'.
They must obtain extensive experience in all diagnostic procedures listed in the syllabus and will be expected to be familiar with the current breast imaging literature, both from standard textbooks and original articles.
As audit is an integral part of the process of breast imaging, particularly screening, the trainee will have ready access to data to analyse the proficiency of his or her activities. Additionally the trainee will be expected to complete a focused audit and develop an understanding of the process of interval cancer review.
They should participate in research and should be encouraged to pursue a project up to and including publication. An understanding of the principles and techniques used in research, including the value of clinical trials and basic biostatistics should be acquired.
They must attend regular multi-disciplinary conferences.
Theoretical training
Trainees should attend 40 hours of theoretical training in the form of
locally delivered tutorials, specialist breast imaging courses as well
as national and international breast imaging and breast screening conferences
such as those of EUSOBI and ECR .
SYLLABUS
A. Clinical
training
Ability to undertake physical examination of the breast and associated structures.
Knowledge of the clinical findings associated with normal, benign and malignant tissue.
Knowledge of the risks of breast disease associated with family history, hormone replacement therapy, etc
Knowledge of breast surgery, treatment and reconstruction and how these might influence imaging appearances.
B. Radiation protection:
Knowledge and understanding of the current legislation governing the use of ionising radiation and of the responsibilities as defined in national and European legislation.
Knowledge and understanding of the need to minimise the radiation dose received by the patient/client.
Knowledge and understanding of the risk/benefit analysis associated with breast screening using ionising radiation as compared with other techniques e.g. ultrasound, MR.
C. Physics
For all imaging modalities
Knowledge and understanding of the physics of image production and how alteration of machine parameters affect the image.
Knowledge and understanding of Image recording and display systems and how alterations in machine parameters effect the image
Knowledge and understanding of Quality Assurance Programmes and the impact that image quality has on clinical performance
Knowledge of artefacts, limitations of resolution and contrast
D. Anatomy and Pathology
Knowledge and understanding of normal embryology, physiology and anatomy of the breast and associated structures in particular changes due to age, lactation, hormonal status, surgery, radiotherapy, etc.
Knowledge and understanding of normal physiology, pathology and pathophysiology of breasts and associated structures including synchronous and metachronous disease.
Knowledge and understanding of benign and malignant diseases of the breast and associated structures and how these processes manifest both clinically and on imaging.
Knowledge of the spread of breast carcinoma and the pathology in other organs
E. Imaging
techniques
Trainees should understand the principles of all imaging methods including
Relative indications and contraindications.
Complications.
Recognition of artefacts
Normal appearances, normal variations, benign and malignant processes both primary, local recurrence and distant spread
Limitations of individual techniques, examinations, sequences/views and the complimentary nature of other techniques and the role of each technique in the investigation of breast disease.
Knowledge and understanding of how imaging findings influence decisions by others e.g. surgeons, pathologists, oncologists, etc
- Mammography including additional and special views
- Ultrasound
- MRI
- Nuclear medicine
F. Interventional
techniques
Trainees should understand the principles of all interventional methods including
Relative indications and contraindications.
Complications.
Advantages and disadvantages
Limitations of individual examinations and complimentary nature of other techniques and the role of each technique in the investigation of breast disease
Knowledge and understanding of how biopsy and interventional techniques influence decisions and treatment planning by others e.g. surgeons, pathologists, oncologists, etc
The applicable procedures are:
- Cyst aspiration
- Fine needle aspiration cytology (free hand and/or image guided)
- Mechanical and vacuum assisted Core biopsy (free hand and/or image guided)
- Image-guided localisation
- Abscess management
- MR guided focused ultrasound and any other new techniques.
G. Communication
Knowledge and understanding of the importance of effective communication with both the patient and the members of the multidisciplinary team.
Knowledge and understanding of the principles of breaking bad news and the psychosocial consequences of doing this badly.
H. Team working
Knowledge of roles and responsibilities of other members of the breast imaging team e.g. clerical officers, radiographers, nurses, support staff, secretaries, etc .
Knowledge of roles and responsibilities of other members of the Multi-Disciplinary Team .
Knowledge and understanding of how imaging findings influence decisions by others e.g. surgeons, pathologists, oncologists, etc
I. Screening
Knowledge and understanding of the aims, objectives and principles of population Breast Screening.
Knowledge and understanding of the risks and benefits of screening to the population and the individual including those related to age factors, family history, and hormone replacement therapy.
Knowledge and understanding of the objectives and principles of Quality Assurance
Understanding of the principles and techniques used in audit and research, including the value of clinical trials and basic biostatistics.
Knowledge and understanding of legal liability and processes.
J. Practical training
The trainee must obtain a substantial experience in all clinical, imaging and
interventional techniques that are listed above.
Minimum experience per month of training
• Interpretation of screening mammograms 300 cases
• Interpretation of symptomatic cases including ultrasound 80 cases
• Experience of image guided procedures 20 cases