Leaders in Breast Health: Dr. Georgia Spear, NorthShore University HealthSystem

Dr. Georgia Spear, Chief Breast Imaging at NorthShore University HealthSystem is an advocate for personalized breast cancer screening and informing patients of their breast density, screening options, and associated risks. She was instrumental in the establishment of the Illinois Breast Density Reporting Law, serves as an Illinois state representative of the ACR Radiology Advocacy Network, and is a trustee and legislative committee member of the Chicago Radiological Society. 

Dr. Spear spoke with Dr. Eliot Siegel, one of our Clinical Advisory Board Members, on the impact of COVID-19 on her practice at NorthShore University HealthSystem in the early stages of the pandemic, and her perspective on the potential values of A.I. in breast screening. 

Dr. Siegel

Because it’s considered a non-essential service in times of crisis, breast cancer screening took a big hit. There’s increasingly more discussion of the impending increase in breast cancer cases in the coming years as the delays and missed mammography exams mount due to COVID-19 restrictions. Across the globe, COVID-19 has hit health systems hard, but some have been hit harder than others. Health systems have had to manage with COVID-19 restrictions in widely varying local COVID-19 responses.

What impact has it had in your mammography facility practice? I know we’ve seen some really significant impacts at the University of Maryland in the VA. What impact has it had for you on patient volumes, rescheduling exams, prioritization, work flows, clinical staff burnout, budget staffing, etc.?

Dr. Spear

We are in this unprecedented global pandemic that none of us have ever seen before and when this came upon us in March 2020, I think we were just unprepared to know how to tackle this from the best angle. Our goal as breast imagers is to detect breast cancer early, when it’s manageable and treatable, to prevent advanced-stage disease and really make an impact on patient care and patient mortality. From the get-go, one of the main priorities switched to not only being able to accommodate our patients but to really ensure the safety of our patients and our staff as we were going through this. 

As you know, there were no written guidelines to guide us through this, so we had to educate ourselves quickly on the rapidly changing initiatives and ensure that our staff, patients, physicians, and everyone in the breast centers had appropriate personal protective equipment to ensure that they could tackle this safely and then accommodate a large volume of patients.

I would say that our approach has changed over time. Initially, again, with safety in mind, we had to suspend screening mammograms to ensure that we could adequately take care of patients with social distancing measures, etc. We actually petitioned to stop screening mammograms for four weeks in April 2020. The goal with that particular decision, which had an economic and patient-care impact, was to ensure that we could focus our energies to take care of diagnostic patients, perform biopsies and localization procedures for urgent surgeries, while in the meantime ensuring that we could secure adequate personal protective equipment for our staff and our patients to proceed. 

Those four weeks really were quite shocking; it’s never happened in the history of our practice and we definitely had to reprioritize. Our patients were all notified that they had to be rescheduled. They were worried to come in, quite frankly, with stay-at-home orders in place.

Once that four-week period went by, we were able to secure more protective equipment and find really good workflow accommodations to accommodate this crisis.

Above and beyond that, we really started to focus on taking care of diagnosis and biopsy procedures and slowly reintroducing screening into our practice. That happened in early May and, as you can imagine, that evolved.

The thought was that we could maybe get to 50%, 60%, or 70% of our prior volumes in maybe a year. Well, the reality is, with all of these measures in place – opening up early exams in the morning starting at 6:00 a.m. and ending at 7:00 p.m. and opening up Saturdays and Sundays — we reached 97% of our pre-COVID volumes by October 2020, which is a feat in and of itself. It took a real effort, by our technologists, staffing and scheduling, physicians, and really the whole breast practice to accommodate all of these changes. 

At the end of the day, the goal is to ensure that we get these patients in so that we prevent advanced stage disease. We don’t want women to miss out on their mammograms. So, the way we’ve tackled it is by conveying the message that we can do it safely, that we can bring them in, adequately image them, and give them results.

I worry because not every center in the country has the resources or the ability to accommodate patients at this capacity. I worry what kind of impact this is going to have for women across the nation with regards to access to medical care. I feel that the privilege is ours in an urban center to be able to make some accommodations that may not be as accessible in rural settings or other settings that don’t have the resources that we have, but I still think it’s a work in progress. 

Dr. Siegel

Congratulations on being able to achieve that 97% and being able to stay in operation. One of the tasks that our hospital asked us to do is answer the question: What would happen if your technologists or radiologists, or both, had an outbreak of COVID-19 and you were down to half staff? How would you handle something like that, and do you have contingency plans? How would you choose who could come and who wouldn’t come? Would you triage screening patients? How would you triage diagnostic patients? How would you deal as we get to this sort of second wave or second half of the first wave?

Dr. Spear

That’s a great question. We’re constantly working on these types of contingency plans because we worry that, if there is an outbreak, we would have to make accommodations quickly and effectively to ensure the safety of all.

One of the plans that we set in place initially was triaging patients based on the diagnostic urgency of their care. BI-RADS fours and fives with suspicious findings were prioritized during the time that we were initiating our screeners again and trying to accommodate patients effectively. Short-term follow-ups were pushed a little bit further down the line. But really prioritizing based on highly suspicious and suspicious lesions to ensure that we catch those cancers was our main priority. 

One of the really rewarding parts of my job has been acting as a cheerleader and coaching people to keep moving through this because the pandemic has effects of burnout that affect all of us. It affects physicians greatly, being able to accommodate volumes to such capacity, the speed with which we read, and the number of cases that we have to read in a day, then accommodating for maybe a colleague who has had an exposure and has to quarantine. Finding resources to fill those gaps is really important. Burnout is real.

One of the measures that we’ve also taken is prioritizing the patients that are visiting us that day for diagnostics and procedures. Screening exams and reading those screening exams, although a big priority, can wait. It can be triaged a bit lower. So just focus on getting these patients through and performing your best quality care for those. The screening patients might have to wait a few extra days to have the reading of their mammogram, but we do have to make some compromises in order to provide the best care we can for everyone. 

Dr. Siegel

It’s been suggested that A.I. may, in many ways, revolutionizes the practice of radiology and, as you know, mammography has been an early adopter. As we look at more applications for deep learning in trying to reduce no-shows, enhance workflow, optimize image quality, provide feedback, and be able to actually help in diagnosis, do you see A.I. having a role potentially during the pandemic and afterwards?

Dr. Spear

Absolutely. I think A.I. is one of the most exciting parts of our careers in breast imaging. Early on, it was computer-aided detection (CAD) and lesion characterization, then we started to shift gears and we now have large-volume supplemental screening in our practice as well. 

How can A.I. help us triage and risk stratify our patients so that we know we’re not overestimating or underestimating risk, or overutilizing or underutilizing our resources? Because both have significant repercussions.

You can see with overutilization you really tie up your resources. With underutilization you may miss a cancer that you could have otherwise found using supplemental screening. A.I. has so many different roles when you talk about it at that level. It’s more of, “can we stratify patients based on breast density which is a major known-risk factor, and utilize that?”

If we can objectively measure breast density, take that interpretation variation out of the radiologist’s pocket and have A.I. help us in that realm, then we can stratify in that way. Then when you look one step further into the quality of our images, you want to optimize that so you can optimize your interpretation. 

So, how can A.I. help us better effectively standardize that operation and then analyze all of our results so we can maximize our efficiency, maximize our interpretation abilities and workflow and be able to serve patients at the best capacity that we can, which is finding those breast cancers early and keeping efficiency in our practice.

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