American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Standard 2.8: Breast Imaging

The Breast Program Leadership Committee (BPLC) is required to adopt nationally recognized mammography screening guidelines and advise and educate the medical community affiliated with the breast center on the selected guidelines.

Definition and Requirements

Federal law mandates that mammography must be performed at Mammography Quality Standards Act (MQSA)-certified facilities.

Screening mammography is an exam performed on an asymptomatic woman to detect early, clinically unsuspected breast cancer.

Diagnostic imaging/Ultrasound and/or MRI is used to evaluate a patient with abnormal clinical findings that have been found by the patient or their doctor. Diagnostic imaging can also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening exam.

Medical community, for the purposes of this standard, is defined as all providers who regularly refer to the breast center.

Process Requirements

Mammographic Screening

There are several guidelines published suggesting when to start and stop screening mammography and how frequently it should be performed. The BPLC is required to adopt nationally recognized screening mammography guidelines that include:

  1. Women of average risk should begin routine, annual screening as early as age 40 but no later than age 45.
  2. Screening under age 40 may occur for women who are at increased risk for breast cancer.
  3. The screening schedule should continue as long as the woman is in good health.

The BPLC will advise and educate the medical community who refer patients to the breast center on the selected guidelines annually.

Diagnostic Imaging

Centers performing breast magnetic resonance imaging (MRI) must have the capacity to perform all of the following:

  • Mammographic correlation
  • Directed breast ultrasound
  • MRI-guided intervention

If the center does not have the capacity to perform all of the above services, the center must have an established referral relationship with a local facility that can provide these services. The National Accreditation Program for Breast Centers (NAPBC) strongly recommends that the referred facility is accredited by the American College of Radiology (ACR) for breast MRI.

Documentation

Complete all required standard fields in the Survey Application Record (SAR).

Mammographic Screening

The BPLC adopts nationally recognized screening mammography guidelines as outlined above.

In the BPLC meeting minutes, document when and how the medical community affiliated with the breast center was advised and educated regarding the selected guidelines. Mechanisms include, but are not limited to, letters, lectures, small group sessions, and newsletters.

Diagnostic Imaging

For breast MRI, provide documentation of Breast Imaging Center of Excellence (BICOE) accreditation or ACR accreditation. If the center refers breast MRI services to a local facility, the surveyor will review the referral relationship.

Evaluation

The surveyor will review and discuss the required documentation during the site visit.

Rating Compliance

Compliance

  1. The BPLC adopts nationally recognized mammography screening guidelines.
  2. The BPLC has advised and educated the medical community who refer patients to the breast center on the adopted mammography screening guidelines annually.
  3. Centers performing breast MRI meet one of the following criteria:
    1. BICOE accreditation
    2. ACR accreditation for breast MRI
    3. Has a referral relationship with a local facility to provide all breast MRI services

Noncompliance

The center does not fulfill one or more of the compliance criteria.

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