Evaluation of Office Ultrasound Usage among Australian and NewZealand Breast Surgeons

Michael T. Law • James Kollias • Ian Bennett

Published online: 7 May 2013

� Societe Internationale de Chirurgie 2013

Abstract

Background Surgeon performed ultrasound (US) is being

increasingly embraced by breast surgeons worldwide as an

integral part of patient assessment. The extent of its

application within Australia and New Zealand is not well

documented. The present study aimed to evaluate its cur-

rent usage patterns and to determine suitable future training

models.

Methods An online survey was sent to members of Breast

Surgeons of Australia and New Zealand (BreastSurgANZ)

between July and September 2010, with emphases on

practice demographics, access to US equipment, usage,

biopsy patterns, and training.

Results Of the 126 surveys sent, 59 were returned. The

majority of respondents were metropolitan based (64 %),

worked in both public and private sectors (71 %), and

practiced endocrine or general surgery (85 %), as well as

breast surgery. A preponderance of surgeons had access to

equipment (63 %), performed at least 1 US monthly

(63 %), but did not perform regular guided biopsies. Rural

practice did not affect access or usage patterns. Most

respondents underwent structured US training (73 %),

which was associated with greater US and biopsy usage,

biopsy complexity, intraoperative applications, and cross

discipline applications (p \ 0.03). Most surgeons favored a

structured training program for future trainees (83 %).

Conclusions The majority of breast surgeons from Aus-

tralia and New Zealand have adopted office US to varying

degrees. Geographic variation did not lead to access

inequity and variation in scanning patterns. Formal US

training may result in a wider scope of clinical applications

by increasing operator confidence and is the preferred

model within a specialist breast surgical curriculum.

Introduction

Technological advances in portable ultrasound (US) in

recent years have resulted in the equipment becoming more

compact, demonstrating improved image quality, and being

more affordable. As a result, increasing numbers of sur-

geons worldwide are using office-based US as an integrated

clinical assessment tool. In particular, office US has been

shown to be highly accurate in the assessment of breast

lesions, with the added benefit of convenience to patients

[1]. However, it is well recognized that appropriate training

and accreditation are crucial in the establishment and

maintenance of quality and professional standards in the

context of emerging technologies.

Australian and New Zealand (ANZ) breast surgeons are

rapidly embracing office US in their everyday practice.

However, the true extent of its clinical application and the

level of US training and experience in this region have not

been well documented. The aim of the present study was to

evaluate office US training and usage pattern among ANZ

surgeons and to determine the preferred US training model

for future breast surgery trainees.

M. T. Law (&)

Breast and Endocrine Surgery Unit, Maroondah Hospital,

Eastern Health, Davey Drive, Ringwood East, Melbourne,

VIC 3135, Australia

e-mail: mlaw.besurg@gmail.com

J. Kollias

Department of Surgery, Royal Adelaide Hospital and Adelaide

University, Adelaide, SA, Australia

I. Bennett

Breast and Endocrine Unit, Princess Alexandra Hospital,

Brisbane, QLD, Australia

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World J Surg (2013) 37:2148–2154

DOI 10.1007/s00268-013-2076-8

Fig. 1 Ultrasound (US) usage

survey

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Methods

This survey targeted all registered members of Breast

Surgeons of Australia and New Zealand (BreastSur-

gANZ)—the key breast surgery interest group in ANZ,

with membership consisting of dedicated specialist breast

surgeons and general surgeons whose main interest is

breast surgery.

An electronic survey was created using an online survey

service (www.surveymonkey.com). The survey (Fig. 1)

had 12 multiple-choice questions and was subdivided into

four main sections, focusing on

• Nature of practice

• Office US equipment access

• Office US and biopsy number and complexity

• Office US experience and training

The link to the survey was delivered electronically to all

members of BreastSurgANZ between July and September

2010, after we obtained permission from the BreastSurgANZ

Fig. 1 continued

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123

Council to use the electronic mailing list. To ensure that each

member only completed one survey, the respondent’s IP

address was recorded upon submission of a completed survey.

The results were analyzed with standard statistical

analysis, including the use of the chi-square test for dif-

ferences between groups. p values \0.05 were deemed

significant.

Results

Of the 126 surveys sent, 59 were returned (46.8 %). Most

respondents completed the survey in full (86.4 %), but 8

did not answer all questions as requested.

Nature of practice

The majority of surgeons surveyed practiced in metropol-

itan settings (64.4 %). Over 70 % worked in both the

public and private sectors, with around 10 % working

exclusively in one sector (Table 1). Most respondents

worked in subspecialty practices (59.3 %), either in breast

surgery alone or combined with endocrine surgery.

Access to office US equipment

Approximately 62.7 % of respondents had ready access to

US equipment, with 47 % reporting full-time access

(Fig. 2). Regional practices did not appear to have issues

with access (p = 0.11). Availability of US units across

public and private sectors were similar. Surgeons in sub-

specialty practices were more likely to have better access

(p = 0.01), with over 77 % having shared or full-time use

compared to only 44 % among the general surgical group.

Office US usage patterns

Office US was used by 62.7 % of respondents on a regular

basis, with 22 % performing over 20 scans a month

(Fig. 3). However, over 50 % did not perform any form of

US guided biopsies (Fig. 4). Of those reporting regular US

guided biopsy use, 71.4 % actually performed 5 or fewer

biopsies a month, the majority of which were fine needle

aspirations. A direct relationship existed between US

access and number, and in turn, biopsy volume (p \ 0.01).

However, usage patterns were unaffected by practice

location, private/public sectors, or subspecialization.

Intraoperative applications, such as assisting in lesion

localization, remained infrequent, with \17 % reporting

routine application. Nonetheless, those in subspecialty

practices were more likely to use US for lesion localization

(p = 0.04), with 22.9 % routinely performing their own

intraoperative localization compared to 9.1 % in the gen-

eral surgical group.Table 1 Practice demographics

Number %

Practice specialties

Breast only 9 15.2

Breast and endocrine 26 44.1

General surgery 24 40.7

Nature of practice

Private only 6 10.2

Public only 7 11.9

Mixed public and private 42 71.2

Practice location

Metropolitan 38 64.4

Regional 15 25.4

Nonresponders not shown Fig. 3 Office US performed per month

Fig. 2 Access to US equipment

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As expected, surgeons in breast and endocrine practices

were the largest group to employ office US in other non-

breast settings (69 %) (p = 0.03). Just over half of general

surgeons surveyed reported similar cross-discipline use,

with 19 % applying the technology to two or more other

specialties.

Experience and training

Almost half of respondents (47.6 %) had less than 1 year

of clinical experience with office US, but 72.9 % had

received structured US training through workshops or post-

fellowship training and had earned accreditation, such as

the Certificate in Clinician Performed US (CCPU) (Fig. 5).

Structured training in turn demonstrated strong associations

with greater US number (p \ 0.01), biopsy number

(p \ 0.01) and complexity (p = 0.03), and intraoperative

(p \ 0.01) and cross-discipline applications (p = 0.01).

Not surprisingly, surgeons with greater experience reported

greater US (p \ 0.01) and biopsy numbers (p \ 0.03) and

higher intraoperative use (p \ 0.01).

No significant regional differences in the extent of

training and clinical experiences were observed, but sur-

geons in subspecialty practices were more likely to have

undergone structured training when compared to the gen-

eral surgical group (88.6 vs 60 %; p = 0.01).

Structured US training (CCPU or post-fellowship

training) was stated by 83.1 % of respondents as the pre-

ferred model for office US training for future breast

trainees (Fig. 6). Surgeons in subspecialty practices

(100 %; p \ 0.01), and those who have undergone such

structured training programs (95.4 %; p = 0.04), in par-

ticular, favored this model. Interestingly, strong regional

differences were observed, with over 97 % of metropolitan

surgeons supporting a structured training approach com-

pared to only 64 % of regional surgeons (p \ 0.01).

Discussion

Office US is rapidly becoming a vital part of clinical

assessment in many surgical specialties. It is useful in a

number of clinical surgical scenarios, including image-

guided aspirations of postoperative seromas, drainage of

symptomatic cysts, and follow-up of benign lesions that

have undergone previous diagnostic imaging. It has been

demonstrated that surgeons can achieve excellent sono-

graphic performance skills in specialized fields with

appropriate training [2].. Surgeon performed breast US has

been shown to be accurate and effective in the diagnosis of

breast lesions [1]. Whitehouse et al. [3] reported 98.3 %

sensitivity and 91.7 % specificity for surgeon performed

breast US, a level of performance comparable with that

achieved by radiologists. Breast US is now becoming the

most common office US performed by surgeons [4].

The ANZ breast surgeons have embraced office US in

their practices, with over two thirds of respondents in this

survey reporting routine US use and over 67 % having

ready access to US equipment. This compared favorably to

a similar American survey, where 58 % of surgeons

reported US use [4].

Surgeon performed breast US and image-guided biopsy

is efficient and cost effective. Rahman et al. [5] demon-

strated that average time to diagnosis with surgeon per-

formed US and biopsy was 1 day, compared to 23 days for

a radiology group. Furthermore, cost of care was reduced

Fig. 4 Office US-guided biopsy per month

Fig. 5 Office US training received by respondents

Fig. 6 Preferred US training model

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by U.S. $262.50 with associated excellent patient satis-

faction. Office-based US allows surgeons to better integrate

imaging and clinical findings and target biopsy of lesions

based on clinical presentations. It may also help guide

optimal surgical management [6]. It is important to

emphasize, however, that office-based US should not be

seen as replacement for a full imaging workup of symp-

tomatic breast patients by radiologists. Also, the usual

expectation is that the two specialities would work in close

cooperation, as evidenced in many major rapid breast

diagnostic units worldwide. The role of US in screening is

not well defined [7] and this is not an area in which most

breast surgeons using office US would have an interest,

especially given the time constraints in a typical busy

surgical practice.

Practice locations have been reported in other specialties

to influence office US access and usage patterns [8]. Our

series indicated that such issues were not observed in rural

practices in ANZ. One might expect to see a greater degree

of cross disciplinary applications among rural respondents

due to the limitation of US access through radiology ser-

vices in regional areas, as well as to a larger proportion of

regional respondents in general surgical practice. The

results of the present study did not demonstrate any sig-

nificant trends, with 70 % of metropolitan surgeons

reporting cross-disciplinary use, versus 66.7 % of rural

surgeons.

Portable, high-resolution US devices have become

increasingly affordable in the last few years. This has

probably led to the recent increase in US use by surgeons in

Australia and New Zealand. The results of the present study

have shown that *47 % of the surgeons surveyed reporting

\1 year of clinical experience. Expectedly, we found that

surgeons tend to perform greater numbers of scans and

guided biopsies with increasing experience. Many series

such as those reported by Cabasares [9] and Heiken and

Velasco [10] have demonstrated that experienced surgeons

are capable of performing US guided percutaneous biopsy

with the same level of accuracy as radiologists.

Core or vacuum-assisted biopsy has been advocated

since 2005 at the Second International Consensus Confer-

ence on Image-Detected Breast Cancer as the preferred

diagnostic modality for tissue diagnosis [11]. Our study

demonstrated that \40 % of respondents performed US-

guided core biopsy or vacuum biopsy as their regular office

biopsy modality of choice, with the remainder preferring

fine-needle aspiration biopsy (FNA). Several barriers may

explain the findings: (1) the traditional perception that FNA

is easier to perform than core biopsies, (2) equipment

required for FNA is more readily available than that for

core biopsy, (3) FNA requires less time to perform than

core biopsy in the office setting [12]. Although not spe-

cifically investigated in this survey, respondents who may

be less experienced in office US would most likely perform

US-guided biopsy on selective simple lesions using less

complex techniques and refer patients requiring more

complex biopsies to radiologists. This pattern is expected

to shift with accumulation of experience among ANZ

breast surgeons practicing in office US. Surgeons wishing

to adopt office-US guided biopsies regularly need to take

into account equipment, staff, and time requirements when

planning to incorporate office-US technology in their

everyday practices. Furthermore, consideration needs to be

given to storage of images and reporting of US and biop-

sies to satisfy local medicolegal obligations. Various pro-

fessional organizations such as the Australasian Society for

US in Medicine (ASUM) have established guidelines with

respect to minimum reporting requirements [13].

Training was reported to be another key influence on US

usage. Surgeons who received structured training were

more likely to have a broader scope of US use, such as

intraoperatively and in cross-disciplinary applications.

However, the extent of intraoperative use remained low,

and may be related to limited availability of US units

within operating suites. It has been demonstrated that

surgeon use of intraoperative localization for impalpable

breast lesions led to lower re-excision rates in breast-con-

serving surgery [7] and has many other advantages

including better appreciation of needle trajectory and dis-

tance in relation to the lesion, as well as time economy.

The ANZ breast surgeons had variable training in office

US, with close to three quarters surveyed having attended

some form of structured training program. This reflected an

increasing enrolment in US courses and workshops, which

have gained popularity only in the last 5 years within the

region. The American College of Surgeons has been con-

ducting successful US courses since the late 1990s, with

breast US having the longest history [4]. We found that

surgeons in subspecialty practices were more likely to have

undergone such structured programs, probably because,

until recently, US workshops and courses were more

widely offered through specialty sections. Workshops are

now commonly available as part of major general surgical

meetings, such as the Annual Scientific Congress of the

Royal Australasian College of Surgeons (RACS), Austra-

lian Society of Breast Diseases (ASBD), and General

Surgeon Australia (GSA) annual scientific meetings.

Formal training in US is crucial in credentialing and

maintenance of standards. Structured training had been

shown to improve operator confidence and minimizes

complications, particularly when practiced by the least

experienced [14, 15]. Law and Bennett [16] validated the

effectiveness of a breast US workshop format based on

theory and practical components, demonstrating significant

improvements in participants of all levels of prior

experience.

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As a structured training model was overwhelmingly

favored by ANZ breast surgeons, it was not surprising that

those who had participated in such programs appreciated

the benefits and recommended a similar format for future

trainees. Rural surgeons appeared less enthusiastic about

the model despite the fact that majority have in fact

received structured training themselves. Two structured

training formats were proposed in this survey:

• Formal certification such as Certificate in Clinicians

Performed US (CCPU) administered by independent

bodies such as ASUM

• US training as part of accredited breast post-fellowship

training curriculum

There were similar levels of support for both models.

Both ASUM [17] and the American College of Radiolo-

gists (ACR) [18] stipulated that an ideal program should

consist of set hours of workshop teaching with both theory

and practical components, followed by supervised clinical

practice with regular re-credentialing through a logbook

system. In practice, the two models can be combined by

incorporating CCPU as the core component of an accred-

ited post-fellowship program.

Conclusions

Office US is being used increasingly by ANZ breast sur-

geons, the popularity of which parallels overseas trends.

This technology not only facilitates diagnosis but also

provides great convenience to patients through a one-stop

approach. Most ANZ breast surgeons have participated in

structured training programs, which in turn translate to

broader clinical applications, increased operator compe-

tency, confidence, and safety.

The preferred model of US training for breast surgeons

in the future ultimately involves a combination of struc-

tured workshops and a period of clinical supervision and

should become an integral component within a specialist

breast training curriculum.

Acknowledgments The authors are grateful to the BreastSurgANZ

Council for support in providing access to the membership mailing

list and distributing the survey.

Conflict of interest No conflicts of interest to declare

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