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The Mammographer's Role In Addressing Special Needs.

Nearly 180 000 women in the United States were diagnosed with breast cancer in 1998 and almost 50 000 American women died from the disease that year. Only lung cancer causes more cancer deaths in American women.[1] Unlike lung cancer, however, little is known about reducing breast cancer risk. Therefore, the fight against breast cancer is focused on early detection, and mammography is widely considered to be the single most effective tool. Screening mammography allows detection of breast cancer while still in its earliest, most treatable stages, reducing the breast cancer mortality rate between 30% and 50%.[2-5]

Because breast cancer strikes so many women and because mammography has proven so useful in diagnosing the disease, government and other health agencies have established mammography guidelines. The American College of Radiology and the American Cancer Society both recommend annual screening mammograms beginning at age 40.

Equitable Care and the Special Needs Mammography Patient

Much of radiologic technologists' education centers on working with "average" patients. Patients with other needs are sometimes mentioned, but because they are perceived to be few in number their care may not be emphasized. However, a significant portion of mammography patients have special needs that mammographers may need to take into account. These patients include the elderly, those with certain physical or mental conditions, patients with breast implants, patients who have had breast cancer surgery and men referred for mammography.

Based on the ASRT Code of Ethics, radiologic technologists ensure that each patient receives equitable care regardless of personal characteristics.[6] The first, second, third and eighth tenets particularly address the care and treatment of all patients. (See Table 1.)

Table 1

American Society of Radiologic Technologists' Code of Ethics(*)

1. The radiologic technologist conducts himself/herself in a professional manner, responds to patient needs, and supports colleagues and associates in providing quality patient care.

2. The radiologic technologist acts to advance the principal objective of the profession to provide services to humanity with full respect for the dignity of mankind.

3. The radiologic technologist delivers patient care and service unrestricted by concerns of personal attributes or the nature of the disease or illness, and without discrimination, regardless of sex, race, creed, religion, or socioeconomic status.

4. The radiologic technologist practices technology founded upon theoretical knowledge and concepts, utilizes equipment and accessories consistent with the purpose for which they have been designed, and employs procedures and techniques appropriately.

5. The radiologic technologist assesses situations, exercises care, discretion and judgment, assumes responsibility for professional decisions, and acts in the best interest of the patient.

6. The radiologic technologist acts as an agent through observation and communication to obtain pertinent information for the physician to aid in the diagnosis and treatment management of the patient, and recognizes that interpretation and diagnosis are outside the scope of practice for the profession.

7. The radiologic technologist utilizes equipment and accessories, employs techniques and procedures, performs services in accordance with an accepted standard of practice, and demonstrates expertise in limiting the radiation exposure to the patient, self and other members of the health care team.

8. The radiologic technologist practices ethical conduct appropriate to the profession, and protects the patient's right to quality radiologic technology care.

9. The radiologic technologist respects confidences entrusted in the course of professional practice, protects the patient's right to privacy, and reveals confidential information only as required by law or to protect the welfare of the individual or the community.

10. The radiologic technologist continually strives to improve knowledge and skills by participating in educational and professional activities, sharing knowledge with colleagues, and investigating new and innovative aspects of professional practice. One means available to improve knowledge and skills is through professional continuing education.

(*) Adopted by the American Society of Radiologic Technologists and the American Registry of Radiologic Technologists

In addition to respecting the rights of all patients, technologists have a responsibility to provide quality care to each patient. For mammographers, this may mean modifying a normal procedure to accommodate a patient's unique characteristics or abilities. For example, it may be necessary to adapt the equipment or positioning to obtain the requested image. Alternate projections or positions also may be needed instead of, or in addition to, the standard mediolateral oblique (MLO) and craniocaudal (CC) projections. Therefore, in-depth, up-to-date knowledge about mammographic procedures, equipment and patient positioning is crucial.

Mammographers and their patients work together as a team to obtain useful mammograms.[7] Many patients with physical limitations have learned to compensate, and they often can suggest alternate positioning or other adjustments. The key to success with mammography patients who have special needs is to stay focused on the goal of producing quality images. Realizing that every patient has special characteristics, the mammographer uses his or her knowledge, flexibility and compassion to adjust to those needs.

Basic Positioning

The 2 most requested mammographic projections are the craniocaudal (CC) and mediolateral oblique (MLO). The CC projection is used to demonstrate the medial aspect of the breast and as much lateral tissue as possible. To perform this examination, the mammographer positions the assembly so the central ray is directed from the superior to the inferior aspect of the breast. The C-arm should be positioned at a 0 [degree] angle.

The patient stands facing the image receptor with the edge of the film cassette firmly against the chest wall. The arm on the unaffected side should be raised, with the hand holding the handlebar. The patient's head should be turned away from the breast being examined, and the patient should lean into the unit.

The mammographer lifts the breast onto the image receptor, elevating the inframammary fold. The height of the image receptor is adjusted so that the inferior surface of the breast lies comfortably on the receptor. The mammographer uses both hands to lift the breast up and out onto the image receptor. The breast is positioned perpendicular to the chest wall with the nipple centered on the receptor and in profile. The height of the receptor should be checked both medially and laterally.

The mammographer holds the breast in place while applying compression, sliding his or her hand away from the patient's chest wall as the paddle is lowered. The opposite breast should be placed over the corner of the receptor to improve imaging of the medial breast tissue. The patient's arm on the side being examined should hang relaxed with the hand rotated externally. The mammographer instructs the patient to hold his or her breath and the exposure is made.[2] Figure 1 illustrates a properly positioned CC projection.

[Figure 1 ILLUSTRATION OMITTED]

The MLO projection images the deep structures in the upper outer quadrant of the breast, where 50% of breast cancers are found. When positioning the assembly for an MLO, the C-arm should be rotated so that the receptor is parallel to the patient's pectoral muscle, usually at an angle between 30 [degrees] and 60 [degrees]. The central ray is directed from the superior medial to the inferior lateral aspect of the breast, approximately at the level of the nipple.

To position the patient for an MLO mammogram, the mammographer pulls the breast away from the chest wall and places it on top of the receptor. The lateral aspect of the breast should be on the receptor with the nipple in profile. The axillary tail, pectoral muscle and inframammary crease all should be included in the image. When positioned correctly, the compression device skims the sternum parallel to the pectoral muscle. (See Fig. 2.) The upper edge of the compression device should be directly under the clavicle or skimming the clavicle. The mammographer should check the compression by feeling the superior and inferior edges of the breast. It may be necessary for the patient to hold her opposite breast out of the way during exposure.[7]

[Figure 2 ILLUSTRATION OMITTED]

Special Populations

Older Adults

Mammography for adults age 65 and older poses a unique set of challenges. Although between 12% and 13% of the current U.S. population is older than 65, this group makes up 40% to 50% of medical, surgical and psychiatric inpatients in acute-care hospitals.[8] By the year 2030, older adults are expected to account for 18% of the American population.[9] Although they make up a large percentage of patients, older adults are mentioned only rarely in the radiographic positioning literature.[10] Most positioning techniques in use today (other than mammography techniques) were established more than 50 years ago, when less than 7% of the American population was older than 65.[11]

A recent study conducted to assess the attitudes of radiologic technologists toward older patients[10] revealed that many technologists stereotype these patients as childlike. The author wrote that such an attitude reflects "a prevalent form of discrimination against the elderly in our society called `infantilization,' the depiction of old age as a `second childhood.' Infantilization puts the elderly into a category of `post-adulthood.' It is one of many popular stereotypes of elderly people that represents them as incompetent, weak, useless and powerless. This is not the nurturing and healing approach that we should take toward our patients."[10]

The author reminded readers that the radiology department is often a frightening place for patients who are young and relatively healthy. Older patients can find it even more frightening and sometimes dangerous. Equipment often makes it difficult for older patients to move around freely or hear well. Procedures that are mildly painful or difficult for younger patients can be extremely painful for the elderly, as well as posing a higher risk of harm for them.

Because the mammogram takes place with only the patient and the mammographer in the room, it is essential for the mammographer to understand and address issues facing elderly patients. Mammographers' responsibility to older patients is no different than their responsibility to younger patients, except that they should understand the unique challenges faced by this group.

Although statistics show that women's susceptibility to breast cancer increases with age,[12] women are less likely to have mammograms as they age. According to the 1990 National Health Interview Survey,[13] only 28% of women in their 60s and 18% of women in their 70s had a mammogram during the previous year. Several factors contribute to the low percentages of older women who undergo mammograms. Some studies have found that older women, particularly those older than 65, are less likely to understand their susceptibility to breast cancer.[14-16] A similar study[17] of women older than 65 found that many simply did not believe that any screening method, including mammography, could detect a cancer that was not found by their physician during an examination.

Patients are not the only ones who do not understand the increasing risk of breast cancer in older women. Physicians are often at fault by failing to refer older patients for mammograms. Studies[18,19] illustrate that physicians recommend mammography less frequently for older patients than younger ones.

Most of the challenges faced by older adult patients, and thus by the technologists who work with them, are a result of the biological changes that accompany aging. These challenges include:[20]

* Changes in vision, including decreased depth perception and peripheral vision, as well as decreased ability to adjust to changes in light intensity. These changes can affect the patient's ability to see the technologist and understand instructions and visual cues.

* Changes in hearing, including an increased sensitivity to loud noises, difficulty in locating sounds and difficulty in distinguishing background noise from foreground noise. These changes can detract from the patient's ability to hear the technologist and understand instructions.

* Changes in the ability to maintain body temperature, which can result in hypothermia when the room temperature is lower than 70 [degrees] F.

* Changes in the ability to maintain balance and a resultant fear of falling, coupled with a tendency to fall more often. These challenges can make standing for a mammogram difficult.

Mammographers should try to assess each patient's abilities and limitations as quickly as possible. This assessment includes watching how the patient moves, talking with the patient and listening carefully to determine whether or not the patient can hear clearly, and asking for confirmation of visual cues. Mammographers can assist elderly patients by adjusting the room lights to make it easier for older patients to see their way around. Likewise, mammographers should ensure that the room is kept at a reasonable temperature for all patients, or that warm blankets are available for patients who are sensitive to cold temperatures. Mammographers also should be prepared to help elderly patients get to or around the equipment, if necessary.

Patients with Physical Challenges

A variety of physical challenges and characteristics require special attention from mammographers. Many of these do not fall into the category of physical disabilities, but are complications associated with individual physical characteristics, such as a protruding abdomen, very small or very large breasts, obesity, kyphosis, pectus excavatum (an abnormally depressed sternum), breast implants and prior breast cancer surgery or biopsies. Working with patients who have one or more of these characteristics requires flexibility and imagination on the mammographer's part.

* Protruding abdomen. It is often difficult to obtain the standard MLO mammogram on a patient with a protruding abdomen. Some mammographers find it easier to perform a lateromedial oblique (LMO) or true reverse oblique projection. This procedure also is useful for examining the medial side of the breast.

For an LMO, the beam is directed from the breast's lower, outer aspect to its upper, inner aspect. The angle of the equipment ranges between 40 [degrees] and 60 [degrees]. The patient's sternum should be placed along the edge of the image receptor, with the arm on the side being imaged resting atop the handlebars or raised over the top of the image receptor. The mammographer pulls the medial aspect of the breast up and positions it on the image receptor in the lateral medial position. The compression device should skim the rib cage while compression is being applied. When compression is complete, the upper outer corner of the compression device should be below the humerus and at the level of the axilla. (See Fig. 3.)[7]

[Figure 3 ILLUSTRATION OMITTED]

* Small breasts. It is often beneficial to use a caudocranial (reverse CC or FB, "from below") projection with patients who have very small breasts. This is because it is easier to compress the inferior portion of the breast than the superior portion, as is done when obtaining a craniocaudal mammogram. For the reverse CC, the patient should be erect, facing the mammography unit. The mammographer rotates the x-ray tube assembly 180 [degrees]. The image receptor should be against the chest wall superior to the breast.

To position the breast, the mammographer centers the breast's superior surface on the image receptor, holding the breast up in position while compression is applied. It is important to remember that the nipple should be seen in profile, and the mammographer should ensure that there is no abdominal tissue superimposed on the breast tissue. Both the medial and lateral surfaces of the breast should be checked for tautness after compression.[2] Figure 4 illustrates proper positioning for the caudocranial projection.

[Figure 4 ILLUSTRATION OMITTED]

* Obesity and large breasts. In obese patients or those with large breasts, the exaggerated craniocaudal lateral projection (XCCL) often is performed. This allows better imaging of the lateral aspect of very large breasts, which is not always possible with a standard CC projection.[22] The XCCL is helpful in imaging patients whose breast tissue seems to "wrap around" the chest.

To obtain the XCCL, the patient should be in a position similar to that used for the CC projection, except that he or she is rotated to emphasize the lateral aspect of the breast. If necessary, the x-ray tube assembly can be angled upward 5 [degrees] to ensure contact between the lateral portion of the breast and the image receptor. The breast should be held in position while compression is applied. The mammographer then directs the central ray from the superior to the inferior lateral aspect of the breast, midway between the nipple and the lateral breast tissue.[7,20] (See Fig. 5.)

[Figure 5 ILLUSTRATION OMITTED]

* Kyphosis. Kyphosis is an exaggeration of the normal posterior curve of the spine, commonly known as "humpback," "widow's hump" or "dowager's hump." It can be a result of disease, malignancy, compression fracture, arthritis or a congenital anomaly.

One challenge with patients who have kyphosis is achieving adequate compression. Mammographers may find it easier to perform a reverse CC projection on these patients. If the equipment cannot be rotated for a reverse CC, the CC projection should be performed. For either procedure, the mammographer should encourage the patient to relax the side of the body that is being examined. When the patient is relaxed, it often is easier to manipulate the breast tissue onto the receptor and compress it.

If it is difficult to perform an MLO projection on a patient with kyphosis, a lateromedial oblique (reverse oblique or LMO) projection may be used.[7] Another possibility is a 90 [degrees] lateromedial projection for the lower half of the breast. This projection often is called the true or straight lateral projection.

To obtain the true lateral projection, the patient faces the cassette holder with sternum against it. The arm on the side being examined is lifted over the edge of the cassette holder, with the elbow flexed to relax the pectoral muscle. The mammographer places the medial aspect of the breast against the center of the cassette holder, then lifts the breast up and over onto the cassette holder, pulling the lateral and inferior tissue up and toward the midline as for an MLO.

The breast is centered on the cassette holder with the nipple in profile, and the patient is rotated toward the cassette holder. The mammographer holds the breast in position and applies compression. Immediately before the compression paddle contacts the lateral breast, the mammographer rotates the patient further medially to help bring lateral tissue forward. The breast should be in the true lateral position. (See Fig. 6.)

[Figure 6 ILLUSTRATION OMITTED]

When the final position is achieved, the compression paddle is brought down past the latissimus dorsi, skimming the rib cage. The mammographer gently pulls the abdominal tissue down to open the inframammary fold. The central ray should be directed from the lateral to the medial aspect, centered midway between the superior and inferior portions of the breast. The mammographer lifts the arm 90 [degrees] and places the top of the cassette holder at the level of the suprasternal notch. In this examination, most of the breast is demonstrated, although the axillary tail may not be as visible as with an MLO.[20]

* Patients with pacemakers. Patients with pacemakers also present a challenge for the mammographer. The 2 best choices for such patients are the same as for patients with kyphosis: the LMO projection and a 90 [degrees] lateromedial projection.

* Pectus excavatum. It can be difficult to obtain a good mammogram on a patient with pectus excavatum or depressed sternum. The medial breast tissue on these patients is not always demonstrated using other projections, so a 90 [degrees] lateromedial projection often is used.

* Implants. Breasts with implants usually are evaluated using the standard CC and MLO projections plus modified CC and MLO projections. These modified examinations (also known as implant-displaced or ID views) call for displacement of the implant to allow visualization of the breast tissue. The mammographer is responsible for manipulating both the breast and the implant to capture the best image.[7]

Standard MLO and CC mammograms of breasts with implants are taken first to illustrate the posterior breast tissue around the margins of the implant. Compression is used only to ensure immobilization of the breast and implant. The patient is positioned as usual for the standard CC. Because of the implant, the mammographer should select manual exposure factors and apply only limited compression. To obtain the standard MLO projection, the patient is positioned as usual. Again, manual exposure should be selected and only limited compression applied.

For the modified mammograms, the mammographer must first pull the breast tissue forward, then push the implant back toward the chest wall. Patient positioning for the modified CC projection is the same as tot the standard CC projection. The mammographer manipulates the breast tissue forward and applies compression, making sure the implant does not slide forward. (See Fig. 7.) The edge of the compression device should skim the implant. The mammographer can position the photo cell under the patient's breast tissue and use the automatic exposure control (AEC) if there is adequate breast tissue to cover the photo cell.

[Figure 7 ILLUSTRATION OMITTED]

To obtain the modified MLO, the patient is positioned as for the standard MLO projection. The mammographer then manipulates the breast tissue forward, simultaneously pushing the implant back toward the chest wall. Compression is applied, with the paddle sliding along the border of the implant. The AEC can be used for this examination as well.[2] Figure 8 shows positioning for an implant-displaced MLO projection.

[Figure 8 ILLUSTRATION OMITTED]

In some patients with implants, it may be helpful to use the anteroposterior (chest wall) projection to evaluate the breast tissue behind the implants. Using this projection, the chest wall, retromammary space, axilla and the upper structures of the breast can be imaged. It is obtained by turning the patient toward the receptor 10 [degrees] to 30 [degrees]. The arm on the side being examined is abducted away from the body at a 90 [degrees] angle and placed behind the top of the cassette holder, with the elbow flexed and the hand resting on the handlebar. The x-ray assembly is turned 90 [degrees]. The image receptor is raised so that it includes the superior aspect of the head of the humerus. The patient is positioned so that the axilla, upper arm, posterior ribs and breast are over the image receptor. The mammographer directs the central ray from the anterior to the posterior aspect of the patient at a 90 [degrees] angle, perpendicular to the ribs. (See Fig. 9.)

[Figure 9 ILLUSTRATION OMITTED]

Adjustments in exposure factors must be made for this projection. Depending on the kind of image preferred by the radiologist and the equipment available, the selected kVp will range from 25 to 45, and a change in filtration usually is required. A manual exposure is preferred, as the AP projection requires exposure factors that may overpenetrate the breast tissue.

Some patients with subpectoral implants complain of discomfort while conventional mammograms are being obtained. Likewise, patients with fibrous encapsulated implants can experience pain. Their implants may restrict the amount of breast tissue that can be manipulated by the mammographer. As a result, the superior and inferior tissue may not be imaged. In these cases, a 90 [degrees] lateral projection also is acquired.

* Previous breast cancer surgery. Patients who have had any kind of surgery for breast cancer are advised to return for mammograms on a regular basis. These mammograms are performed to check for recurrence of cancer in 2 areas: along the incision in the chest wall and in the axilla. One of the projections often requested for postsurgical patients is the anteroposterior projection. (See Fig. 9.)

Many patients who have had breast surgery are highly knowledgeable about mammography and often do not need detailed explanations. Nevertheless, the mammographer still should ask whether the patient has questions about the procedure. As with any other patient, the mammographer should explain every step of the process, pausing at regular intervals to ask for questions.

It is important to remember that postsurgical patients often are frightened about the possibility of finding more cancer and having to undergo further surgery. Sometimes, they are so afraid that they do not return for follow-up mammograms. Others do not return because they are embarrassed about their appearance.

Mammographers should be aware of the differences between a normal breast and a postsurgical breast. One such difference is visible thickening and deformity of the skin on the breast, especially after radiation therapy. The removal of breast tissue also can lead to an asymmetrical appearance of the breasts.[23]

Although the breast tissue of some postbiopsy patients shows no significant change in mammographic appearance, other patients' breasts do show changes. In the first year after biopsy, a spiculated mass or fat necrosis is seen in a minority of patients. These masses, visible on film at the surgical site, sometimes appear to be malignancies. Such masses usually remain the same size or become smaller over time. They also may appear to become less dense. To closely monitor such masses, women usually are referred for mammograms every 6 months during the first 2 to 3 years after a biopsy. If no mammographic changes are seen in a few years, biopsy patients are advised to resume annual mammograms.[23]

Other unusual mammographic findings may be apparent after a lumpectomy. A collection of fluid may be found, appearing as a dense, oval mass with clear margins. Scar tissue also can cause a suspicious image, presenting itself differently in various mammographic projections. Edema may occur, enlarging the breast and making it difficult to achieve adequate compression and obtain good images. In such cases, the density of the breast also increases. Most of these changes occur within 2 years after surgery.[23]

Patients Complaining of Pain

Some patients positioned for an MLO projection complain about pain when compression is applied. The following steps are suggested to correct this situation:[7]

* Release compression.

* Ask the patient to remain in position.

* Walk behind the patient and lift his or her arm or axillary area and reposition the arm. Often, the patient's latissimus dorsi muscle and pectoral muscle have been incorrectly positioned on the image receptor. The pectoral muscle is the only muscle that should be on the receptor.

* Reposition the breast.

* Check the height of the image receptor. It should be lowered if necessary. When positioned correctly, the top of the receptor will be parallel to the patient's arm when abducted 90 [degrees] from the body.

This procedure often is necessary in the MLO, either because the incorrect angle was selected or because the mammographer did not lift the breast medially before placing it on the compression device.[7]

Patients with Mental Disabilities

People with mental disabilities are seen by others in a variety of ways. Some people are comfortable and confident working with almost anyone, including those with a mental disability. Others are frightened by or uncomfortable with people who have a mental illness or disability. Regardless of a mammographer's personal comfort level when working with patients who have mental disabilities, it is important to remember that the ASRT Code of Ethics requires all technologists to treat their patients with respect. Because the range of mental disabilities is so large, it is difficult to generalize about these conditions. However, some guidelines can be given.

Perhaps the single most important thing a mammographer can do to facilitate working with a patient who has a mental disability is to establish and maintain effective communication. The first step in effective communication is using clear, simple, understandable language. Using easy-to-understand words reduces uncertainties and makes it more likely that the patient will follow directions correctly.[24] Clear language also is a useful tool when attempting to build rapport with a patient.[25] Trust between patient and mammographer can help make the examination go smoothly and alleviate patients' fears.

The amount of information the patient receives during a mammogram can be overwhelming, regardless of mental ability. It is important that the mammographer takes care to explain the procedure in sufficient detail. However, it also is important not to overwhelm the patient with unnecessary and confusing information. All explanations should be presented in the clearest possible language to ensure comprehension.

As with every patient, the mammographer should encourage questions about the procedure. Creating a feeling of openness and receptivity makes it possible for patients to share their expectations and fears about mammography. Knowing some of what the patient is thinking enables the mammographer to address concerns and explain things more clearly. This kind of personal communication creates better rapport than communicating only the bare facts. It is a significant step toward making the patient feel more in control of the situation, which allows him or her to more fully participate and cooperate.

In addition to providing basic information about the procedure and encouraging questions, the mammographer can congratulate the patient for following directions quickly and correctly. For example, the mammographer might say, "Good job, Ms. Jones. You held perfectly still for that one!" Positive reinforcement helps maintain rapport and encourages the patient to continue cooperating with the procedure.

Men

Male breast cancers account for 1% to 2% of all breast cancers.[26] Because all the types of breast cancer found in women also occur in men, some men are referred for mammography. The most common finding in men is gynecomastia, defined simply as "enlargement of breast tissue in the male."[30] Gynecomastia can occur either unilaterally or bilaterally. For this reason, both breasts often are imaged for comparison.[23]

Obtaining useful images of male breasts can be challenging for a number of reasons. The first difficulty stems from the fact that most male breasts are considerably smaller and less prominent than most female breasts. Second, male breasts may contain a different arrangement of fat and muscle tissue than women's breasts. Finally, male patients often are embarrassed about being referred for a mammogram because the examination often is seen as one reserved for women.[7]

The basic approach to positioning a male breast is the same as that used to position a small female breast.[7,28] Both MLO and CC projections usually are requested for male patients, although other projections can be helpful as well. Large amounts of muscle tissue can make it difficult to obtain a useful CC projection of some male breasts. In such cases, a caudocranial projection often is obtained instead.[7]

Obtaining an MLO projection with a male patient is similar to obtaining the MLO with a female patient. The tube angle should be adjusted to match the angle of the pectoral muscle. The mammographer should raise the C-arm so that the corner of the film is in the hollow of the patient's axilla. The pectoral muscle should be in front and the latissimus dorsi muscle behind the edge of the cassette holder. To open the inframammary told, the mammographer pulls down on the abdominal tissue.

When placing the breast tissue on the film holder, the mammographer should use the same technique as with female patients, maneuvering from the mobile lateral border and spreading up and out while engaging the compression paddle. When the patient is positioned, the superior edge of the paddle should be directly below the head of the patient's humerus. In some cases, mammographers can use their hands to properly spread the breast tissue onto the film holder. When the breast is very thin, it may be easier to use a rubber spatula to hold it firmly on the film holder so that the mammographer does not catch his or her hands under the paddle. In some facilities, mammographers use paddles that are about half the width of compression paddles usually used in imaging women's breasts.

To obtain the reverse CC projection, the mammographer rotates the C-arm 180 [degrees] then positions the patient facing the unit with one leg on each side of the tube head. The patient should abduct his arm away from his body and drape it over the underside of the cassette holder. The mammographer then ensures that the patient's inframammary fold is elevated, and adjusts the height of the C-arm. The superior border of the breast should be in contact with the cassette holder. The patient extends his neck forward and rests his chin on his hand on the underside of the film holder. The mammographer spreads the patient's breast up and out onto the film holder while engaging the compression paddle. During the procedure, the patient should be instructed to lean forward so that his abdomen does not interfere with the beam.[26]

Patients in Wheelchairs or on Stretchers

The following directions are suggested for mammographers working with patients on stretchers.[7]

To obtain the CC projection, the patient should remain recumbent on the stretcher. He or she should be turned on the side opposite the one being examined. The mammographer rotates the x-ray tube assembly 90 [degrees]. The inferior surface of the breast is then positioned onto the image receptor, much like the positioning for an upright CC projection. The mammographer holds the breast in place while compression is applied.

Obtaining a reverse CC projection is very similar to obtaining a CC projection. The patient remains recumbent on the stretcher, turned on the side opposite the one being examined. The x-ray tube assembly is rotated 90 [degrees]. The superior surface of the breast is positioned onto the receptor. The mammographer must hold the breast in place while compression is applied. (See Fig. 10.)

[Figure 10 ILLUSTRATION OMITTED]

To obtain a lateromedial projection, the x-ray tube is positioned at a 0 [degrees] angle. The patient should lie on the side opposite the breast being examined, with the image receptor against the sternum and the breast lying on the image receptor. Compression is applied to the lateral aspect of the breast.

Some patients on stretchers can sit up, making it possible to obtain a standard MLO projection. The back of the stretcher is raised to support the patient and the mammographer positions the x-ray tube assembly parallel to the patient's pectoral muscle. The receptor should be positioned between the patient and the back of the stretcher, with the patient's humerus resting on top of the image receptor. The breast is positioned on the image receptor and compression is applied.

Positioning patients in wheelchairs poses another challenge. First, mammographers should take care to lock the brakes before leaving a patient alone. In addition, because the mammographer will ask the patient to remain as motionless as possible, it is helpful to prop up the patient's back using pillows. Mammographers often find it helpful to work in teams of 2 when imaging patients in wheelchairs. One person steadies the patient and positions the breast while the other sets the technique on the control panel and manages the compression paddle.

When positioning a patient in a wheelchair for the CC projection, the mammographer should determine whether the patient can wrap his or her arms around the underside of the cassette holder and hold its edges. The mammographer then can lean the patient forward, which facilitates pulling the patient's breast away from the chest wall and positioning it on the cassette holder.

An MLO or LMO projection often is obtained in addition to the CC projection for patients in wheelchairs. When positioning for both of these projections, the patient should be leaning slightly forward to make it easier for the mammographer to correctly position the breast away from the chest wall and abdomen. Again, the patient should be propped up with pillows behind his or her back, if possible.

Conclusion

Special needs patients present with a variety of physical and mental characteristics that can make the mammographer's job more challenging. Fortunately, mammographers have an array of tools and techniques to make the procedure go as smoothly as possible, including alternate positions, less commonly used projections and clear communication. These enable mammographers to achieve their primary goal: obtaining the best possible images for every patient while providing excellent patient care.

The Mammographer's Role In Addressing Special Needs

DRI0000011 Expiration Date October 31, 2002(*) Approved for 1.0 Cat. A CE credit

To receive Category A continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Transfer your responses to the answer sheet on page 43 and then follow the directions for submitting the answer sheet to the American Society of Radiologic Technologists.

(*) Your answer sheet for this Directed Reading must be received by the ASRT on or before this date.
1. Screening mammography has reduced the breast
   cancer mortality rate by:

   a. 10% to 20%.
   b. 20% to 30%.
   c. 30% to 50%.
   d. 50% to 70%.

2. According to the American Cancer Society, women
   age 40 and older should have screening mammograms:

   a. as soon as they develop symptoms.
   b. twice a year.
   c. annually.
   d. once every 2 years.

3. The standard projections requested in mammography
   are the:

   a. craniocaudal and mediolateral oblique.
   b. lateromedial oblique and caudocranial.
   c. craniocaudal and caudocranial.
   d. mediolateral oblique and lateromedial oblique.

4. The percentage of medical, surgical and psychiatric
   inpatients in acute-care hospitals who are age
   65 and older is:

   a. 10 to 15.
   b. 25.
   c. 40 to 50.
   d. 65.

5. "Infantilization" is:

   a. a form of discrimination against infants.
   b. making infants feel important.
   c. a form of discrimination against the elderly.
   d. a term used to describe the increase in the
      percentage of inpatients who are 65 and older.

6. Which of the following are mentioned as issues
   mammographers should be aware of with their
   older patients?

   a. changes in diet and appetite.
   b. changes in vision and hearing.
   c. changes in urination and bowel movements.
   d. changes in health and life insurance.

7. To obtain a lateromedial oblique projection, the
   mammographer rotates the assembly:

   a. 10 [degrees] to 30 [degrees].
   b. 40 [degrees] to 60 [degrees].
   c. 60 [degrees] to 80 [degrees].
   d. 180 [degrees].

8. When the patient is properly positioned for the
   LMO projection, the upper outer corner of the
   compression device should be:

   a. directly inferior to the affected nipple.
   b. at the bend of the elbow.
   c. level with the top of the shoulder.
   d. below the humerus and at the level of the axilla.

9. Which projection is mentioned as being useful for
   small breasts?

   a. craniocaudal (CC).
   b. caudocranial (reverse CC).
   c. rolled CC.
   d. exaggerated CC.

10. The XCCL examination is especially helpful when
   imaging very large breasts because:

   a. it allows imaging of the lateral aspect of the
      breast.
   b. it allows imaging of the medial aspect of the
      breast.
   c. it magnifies an area of interest.
   d. less compression is needed.

11. When positioning a patient for a 90 [degrees] lateromedial
   projection, the patient is rotated immediately
   before the compression paddle contacts the lateral
   aspect of the breast. This is done to:

   a. keep the arm on the patient's other side from
      getting in the way.
   b. keep the nipple in profile.
   c. help bring lateral tissue forward.
   d. lessen the discomfort caused by compression.

12. Which alternate projection is recommended when
   it is difficult to compress the breast of a patient
   with kyphosis?

   a. reverse CC.
   b. XCCL.
   c. tangential (TAN).
   d. ID MLO.

13. The 2 best projections for patients with pacemakers
   are:

   a. CC and MLO.
   b. LMO and reverse CC.
   c. LMO and 90 [degrees] lateromedial.
   d. XCCL and CC.

14. When obtaining modified CC and MLO projections
   on a patient with breast implants, the mammographer
   should:

   a. manipulate the implant so it is directly under
      the compression paddle.
   b. apply limited compression.
   c. manipulate the breast tissue forward and the
      implant backward.
   d. be sure all of the implant is included in the
      image.

15. In the anteroposterior projection, kVp should
   range from:

   a. 10 to 20.
   b. 25 to 45.
   c. 50 to 60.
   d. 75 to 85.

16. For the first 2 to 3 years following a biopsy, women
   usually are referred for mammography every:

   a. month.
   b. 3 months.
   c. 6 months.
   d. year.

17. Mammographic findings after lumpectomy can
   include:

   1. a collection of fluid.
   2. scar tissue that presents differently in different
      projections.
   3. increased density.

   a. 1 and 2.
   b. 1 and 3.
   c. 2 and 3.
   d. 1, 2 and 3.

18. When working with patients who have a mental
   disability, mammographers should:

   a. use clear, understandable language; encourage
      questions; and praise the patient for following
      directions.
   b. provide a highly detailed and technical
      explanation of the procedure.
   c. use medical jargon.
   d. speak loudly.

19. Mammographers who have difficulty holding a
   male breast in position while applying compression
   should use:

   a. a larger paddle.
   b. less compression.
   c. latex gloves.
   d. a rubber spatula.

20. A patient on a stretcher who is properly positioned
   for a CC projection will be lying:

   a. on the side being examined.
   b. face down.
   c. on the side opposite the one being examined.
   d. with his or her head elevated 45 [degrees].


Reference No. DRI0000011

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Barbara Kamm, M.A., is a doctoral student in Organizational Learning and Instructional Technologies at the University of New Mexico. She lives in Albuquerque, NM.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.

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Date:Sep 1, 2000
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