RADIOLOGICJournal of the American Society of Radiologic Technologists Volume 88, Number 4 March/April 2017

T E C H N O L O G Y

M A M M O G R A P H Y & B R E A S T S O N O G R A P H Y E D I T I O N

D I R E C T E D R E A D I N G A R T I C L E S

Managing Multiple

Generations in the WorkplacePAGE 379

Precision Medicine in

Breast CancerPAGE 401M

P E E R - R E V I E W E D A R T I C L E S

Student Perceptions of

Online Radiologic Science CoursesPAGE 366

University Student Awareness of

Skin Cancer: Behaviors, Recognition,

and PreventionPAGE 373

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RADIOLOGICT E C H N O L O G Y

RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

An Official JournalRadiologic Technology (ISSN 0033-8397) is the official scholarly/professional journal of the American Society of Radiologic Technologists. It is published bimonthly at 15000 Central Ave SE, Albuquerque, NM 87123-3909. Months of issue are January/February, March/April, May/June, July/August, September/October, and November/December. Periodical class postage paid at Albuquerque, NM 87123-3909, and at additional mailing offices. Printed in the United States. © 2017 American Society of Radiologic Technologists.

The research and information in Radiologic Technology are generally accepted as factual at the time of publication. However, the ASRT and authors disclaim responsibility for any new or contradictory data that may become available after publication. Opinions expressed in the journal are those of the authors and do not necessarily reflect the views or policies of the ASRT.

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Rights ReservedAll articles, illustrations, and other materials carried herein are pending copyright under U.S. copyright laws, and all rights thereto are reserved by the publisher, the American Society of Radiologic Technologists. Any and all copying or reproduction of the contents herein for general distribution, for advertising or promotion, for creating new collective works or for resale is expressly forbidden without prior written approval by the publisher and, in some cases, the authors.

Copying for personal use only through application and payment of a per-copy fee as required by the Copyright Clearance Center, under permission of Sections 107 and 108 of the U.S. copyright laws. Violators will be prosecuted.

Errata Page 178 of the “Medical Imaging and Infertility” Directed Reading, which appeared in the November/December 2016 issue, erroneously stated that Figure 8 was courtesy of Samia Long, AS, R.T.(R). The image actually is courtesy of Bontrager KL, Lampignano J, eds. Textbook of Radiographic Positioning and Related Anatomy. 8th ed. St Louis, MO; Mosby; 2014.

Thank you to the author who called this to our attention.

363

RADIOLOGICT E C H N O L O G Y

Radiologic Technology Editorial Review Board

Submissions

Submissions from radiologic science professionals and researchers are encouraged. Visit asrt.msubmit.net to upload a manuscript. Author guidelines are available at asrt.org/authorguide.

RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Chairman James Johnston, PhD, R.T.(R)(CV), FASRTjames.johnston@mwsu.eduMidwestern State University, Wichita Falls, Texas

Members Jessica Curtis, BSRS, R.T.(R)(CT)jessica.r.curtis@gmail.comOregon State University, Corvallis, Oregon

Cheryl DuBose, EdD, R.T.(R)(CT)(MR)(QM) cdubose@astate.eduArkansas State University, Jonesboro, Arkansas

Daniel DeMaio, MEd, R.T.(R)(CT)ddemaio@hartford.eduUniversity of Hartford, West Hartford, Connecticut

Kelli Haynes, MSRS, R.T.(R)haynesk@nsula.eduNorthwestern State University, Shreveport, Louisiana

Jonathan Havrda, MPH, CR A, R.T.(R)(CT)(BD)jonhavs@gmail.comCottage Hospital, Woodsville, New Hampshire

Rebecca L Ludwig, PhD, R.T.(R)(QM), FASRT, FAEIRSludwig.rebecca@spcollege.eduSt Petersburg College, St Petersburg, Florida

Vice Chairman Tricia Leggett, DHEd, R.T.(R)(QM)tleggett@zanestate.eduZane State College, Zanesville, Ohio

Richard J Merschen, EdS, R.T.(R)(CV), RCISrichardmerschen@verizon.netJefferson School of Health Professions, Philadelphia, Pennsylvania

Quentin Moore, MPH, R.T.(R)(T)(QM)quentin.moore@mercycollege.eduMercy College of Ohio, Toledo, Ohio

Carmen T Saunders, MBA, MA, R.T.(R)(M), CR Acarmen.saunders@csun.eduCalifornia State University, Northridge, California

George Tolekidis, MS, R.T.(R)(CT)(N)(T), CNMT, CMDrwr1911@gmail.comRush University Medical Center, Chicago, Illinois

Beth Vealé, PhD, R.T.(R)(QM)beth.veale@mwsu.eduMidwestern State University, Wichita Falls, Texas

Jennifer Yates, EdD, R.T.(R)(M)(BD)jyates@peralta.eduMerritt College, Oakland, California

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Radiologic Technology Journal Staff

Julie Hinds, scientific journal managing editorSherri Mostaghni, associate editorLisa Kisner, publications managerKatherine Ott, senior professional development editorEllen Lipman, director of professional developmentTaylor Henry, graphic designerMyron King, graphic designerMarge Montreuil, graphic designerLaura Reed, graphic design manager

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ContentsRADIOLOGICT E C H N O L O G Y

RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

P E E R - R E V I E W E D A R T I C L E S

Student Perceptions of Online Radiologic Science CoursesErika Papillion, Laura Aaron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366

University Student Awareness of Skin Cancer: Behaviors, Recognition, and PreventionMegan Trad, Lawrence Estaville . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

D I R E C T E D R E A D I N G A R T I C L E S

Managing Multiple Generations in the WorkplaceKevin R Clark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Precision Medicine in Breast CancerTeresa G Odle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401M

C O L U M N S

Research & TechnologyImplantable Infusion Pumps in the MR Environment . . . . . . . . . . . . . . . . . . . . . . . . . . 427BookshelfHistorical Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .428 Management ToolboxAutomating Breast Imaging Wait-time Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431Professional ReviewIntracranial Deposition of Intravenous Gadolinium Contrast . . . . . . . . . . . . . . . . . .435Focus on SafetyUltrasound Safety: Can We Do Better? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .440Practice FundamentalsScaphoid Imaging and Its Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .444Patient CareImage Gently Think A-Head Campaign Focuses on Pediatric Head CT Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .446Advances in TechnologyThe EOS Imaging System: Promising Technology in Skeletal Imaging . . . . . . . . .448Teaching TechniquesA Protégé’s Guide to Working With the Perfect Mentor . . . . . . . . . . . . . . . . . . . . . . . 451Writing & ResearchThe Pros and Cons of Writing With Coauthors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .453My PerspectiveTo Serve Is to Advocate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .456Technical QueryMetal Mayhem in Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458Open ForumThoughts on Shielding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .460BackscatterWhat’s Inside . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464

This symbol indicates expanded content .

O N T H E C O V E R

The painting, “Knee Evolution,” by Kaitlin Walsh, portrays 3 artistic renditions of the knee joint . The jux-taposition of a newborn knee (top), a healthy adult knee (middle), and an aging knee joint with osteoarthritis (bottom) highlights the structural changes of our bodies as we age .

Volume 88, Number 4 March/April 2017

366

Peer Review

RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Keywords radiologic science courses, online learning, student satisfaction, learner comprehension, distance education, faculty interactions

Student Perceptions of Online Radiologic Science CoursesErika Papillion, MSRS, R.T.(R)Laura Aaron, PhD, R.T.(R)(M)(QM), FASRT

Online courses are classes that do not require face-to-face meetings or on-campus activity; all learning elements are delivered online by facilitating student interactions with course

content, the instructor, and classmates.1 Over the past several years, students have validated the significance of online learning in higher education. According to the 2014 Sloan Consortium report, online enrollments have increased at frequencies substantially greater than those of higher education overall, with nearly 7.1 million stu-dents taking at least 1 online course.2 Although online learning has increased in higher education overall, it has not been implemented extensively in the radiologic

sciences, perhaps because of faculty-expressed barriers concerning online course delivery in radiologic science curriculums.3,4 Despite these concerns, a 2013 study by Kowalczyk and Copley revealed a 30% increase in the adoption of online courses in radiologic science pro-grams between 2009 and 2012.5 These findings indi-cate a need to explore this growing instructional plat-form and to identify the course characteristics that help ensure student comprehension. Although faculty approval and support are critical to the success of any online educational curriculum, learner satisfaction and comprehension is a valuable commodity for developing online courses.6

Purpose To evaluate student perceptions of the effectiveness of online radiologic science courses by examining various learning activities and course characteristics experienced in the online learning environment.

Methods A researcher-designed electronic survey was used to obtain results from students enrolled in the clinical portion of a radiologic science program that offers online courses. The survey consisted of elements associated with demograph-ics, experience, and perceptions related to online radiologic science courses. Surveys were sent to 35 program directors of Joint Review Committee on Education in Radiologic Technology–accredited associate and bachelor's degree programs with requests to share the survey with students.

Results The 38 students who participated in the survey identified 4 course characteristics most important for effective online radiologic science courses: a well-organized course, timely instructor feedback, a variety of learning activities, and informative documents, such as course syllabus, calendar, and rubrics.

Discussion Learner satisfaction is a successful indicator of engagement in online courses. Descriptive statistical analysis indicated that elements related to the instructor’s role is one of the most important components of effectiveness in online radiologic science courses. This role includes providing an organized course with informative documents, a variety of learn-ing activities, and timely feedback and communication.

Conclusion Although online courses should provide many meaningful learning activities that appeal to a wide range of learning styles, the nature of the course affects the types of learning activities used and therefore could decrease the ability to vary learning activities.

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Papillion, Aaron

Radiologic science educators and students concur that online course offerings benefit education programs as well as students.3,4,15 These benefits include increased student enrollment because of accessibility, less travel, program expansion beyond immediate geographical regions, and the convenience of learning at any time.3,4 In addition, studies have shown that online learning components enhance and encourage self-directed, life-long learning.15,16

Despite these benefits, apprehension still exists. For every piece of research that demonstrates comparable outcomes, other research exists that demonstrates barriers to the integration of online radiologic science courses among students and faculty.3,4,7 Faculty in Britt’s study, for example, identified lack of preparation time, limited student-instructor contact, and unfamil-iar technology as disadvantages to online courses.3 Similarly, respondents in Rosenkoetter’s study identi-fied assessment methods, conversion of content, lack of communication, and cheating as barriers to implement-ing online radiologic science courses.4 Interestingly, previous studies confirmed that students and faculty agree that some radiologic science courses are unsuit-able for online delivery.3,4 A 2008 study of online radiologic science educators revealed 3 distinct barriers: information technology training and support followed by student-related and institutional barriers.7 Many respondents in this study did not feel adequately trained in using online technology and felt they lacked the nec-essary technological and institutional/peer support for delivering online courses.7 Respondents also indicated online security as well as student engagement and inter-est as barriers to online radiologic science courses.7 To provide quality online educational experiences for radiologic science students, it is important to identify methods of overcoming these perceived barriers.

Unlike in face-to-face courses, instructors in online learning environments are unable to visibly assess student comprehension or satisfaction. Student percep-tions have been observed as critical in determining the characteristics that support comprehension in online courses.6,14 Many elements in course design have been shown to contribute to student perceptions of efficacy in online education. Researchers affirm that online courses should allow students to make independent

Studies show that student outcomes in online radiologic science courses are comparable to those of traditional courses.3,7,8 Researchers also have evaluated perceived barriers, overall acceptance, and methods for enhancing the development of online radiologic science courses.9,10 Although few studies have focused on overall student perception of online radiologic science learn-ing environments, research in other curriculums has demonstrated that student perception and satisfaction are precursors to motivation, which strengthens engage-ment and increases comprehension in online learning environments.11-13 Evaluating student perceptions might enhance the online learning environment by provid-ing faculty with valuable information when designing online radiologic science courses.

Literature ReviewStudies, although scant, have demonstrated outcome

comparisons of online vs traditional radiologic science courses consistent with findings in other disciplines. A study by Britt that evaluated student perceptions of grade differences between online and traditional courses indicated nearly even attitudes.3 Nearly half of students indicated a difference in grades between the 2 course formats, whereas a little more than half reported no difference. Comparably, in 2008 Johnston found that, overall, online learners received higher course grades than did students in the same traditional course.7 Johnston suggested that this finding supported the concept that online students interact more with course content, which resulted in deeper comprehen-sion. A similar study by Cook evaluated exam scores of students in a traditional radiologic science positioning course with its online equivalent and found no signifi-cant differences in the 2 formats.8 Each of these studies validates that radiologic science students can obtain satisfactory results in online courses. Nevertheless, many researchers suggest that many factors—not just outcomes—must be examined to determine compre-hension in the online environment.12,14

Researchers have suggested that specific factors, such as benefits, barriers, and online learner require-ments, should be evaluated when developing online courses. Many in the radiologic science profession have acknowledged numerous benefits of online education.

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Student Perceptions of Online Radiologic Science Courses

directors were sent the request; 2 emails came back as undeliverable. The survey link and an explanation of the study were sent to students enrolled in the clinical portion of those programs that participated. A reminder email was sent to the program directors 1 month later to request additional participation. Results were ana-lyzed using descriptive statistics.

ResultsThirty-eight students responded to the survey. Of

these, 82% were women and 53% were aged between 19 and 23 years. The respondents were divided equally between associate and bachelor’s degree programs and 58% self-identified as seniors in their programs. Forty-three percent of the respondents had taken 1 to 2 online radiologic science courses; 8% had taken more than 6. The most common learning style selected by the participants was kinesthetic (46%). Table 1 shows the demographic characteristics of the participants.

Figure 1 illustrates the types of online courses the respondents had taken. Medical terminology was the most commonly taken online course, with 74% of stu-dents indicating having participated. Sectional anatomy (38%), introduction to radiology (35%), and ethics (32%) were other commonly taken online courses. Figure 2 demonstrates the types of learning activities employed in online courses taken by the respondents. Quizzes and exams (94%), discussion boards (81%), and textbook readings (75%) were the most common activi-ties. To determine whether various learning activities in the online radiologic science courses support compre-hension and retention of course content, participants were asked to rank the following items:

� Feedback from quizzes, exams, and assignments. � Interaction with classmates in group projects or

discussion boards. � Supplemental learning materials, such as online

resources, videos, articles, additional reading materials, or a combination of these materials.

� Research and writing assignments.Respondents ranked these learning activities from 1 (least supportive) to 4 (most supportive). A mean was calculated to determine which activities were perceived as supportive and unsupportive. Results indicated that respondents identified feedback from quizzes and exams

choices during the learning process, supported by effective learning elements.15,16 Similarly, studies indi-cate that encouraging independent learning through instructor interaction and feedback is important to the online learner.12,17 Equally, after studying student evaluations of online courses, Jones found that students want an organized and structured course, clear expecta-tions, relevant and useful learning materials, frequent interaction, and timely feedback from the instructor.18 Moreover, studies have indicated that online learners value not only interaction with the instructor, but peer interaction as well.12,13,18 In addition, online students perceived sound course design, clear course instruc-tions and expectations, adequate learning materials, and instructor-provided resources as effective learning elements.12

With the growth of online education, specifically in the radiologic sciences, it is imperative that educators persistently strive to provide sound learning opportuni-ties for students enrolled in online courses.

Identifying student perceptions has proven to provide essential information for increasing engage-ment and comprehension in online courses. Educator commitment to modifying and adapting teaching methods based on student requirements is essential for the advancement of online learning in radiologic sci-ence curriculums. Researchers recommend studying perceptions of the needs and characteristics of online radiologic science students to achieve better course design.3,9

MethodsAn electronic survey, designed by the research-

ers, was conducted to evaluate student perceptions of effective learning elements in online radiologic sci-ences courses. The survey consisted of items related to demographic information and student experiences and perceptions related to online radiologic sciences cours-es. After receiving approval from the Northwestern State University institutional review board, program directors of the Joint Review Committee on Education in Radiologic Technology–accredited associate and bachelor degree programs that were identified as having a distance education component were asked to share the survey with their students. Thirty-five program

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Papillion, Aaron

to 5 5 strongly agree) corresponding to various course characteristics to determine which are important to students in online radiologic science courses. Table 2 displays the mean rating of each characteristic. Results demonstrate that respondents perceive that the fol-lowing course characteristics are most important for effective online radiologic science courses:

� A well-organized course. � Timely instructor feedback. � Documents, such as course syllabus, calendar, and

rubrics. � A variety of learning activities.

When asked whether respondents would recom-mend an online radiologic science course to a friend, 58% would, based on their experience with an online radiologic science course. Some of the comments from students supporting online learning include: “While I have not taken many radiology classes online, I have

(mean 5 3.23) as most supportive for comprehension and retention. Respondents perceived supplemental learning materials (mean 5 2.88) the next most supportive learn-ing activity. Research and writing assignments followed, with a mean ranking of 2.58, whereas interaction with classmates in group projects and discussion boards was perceived as the least supportive learning activity, as indi-cated by a 2.13 mean ranking.

Respondents were asked to select the most appropri-ate Likert-scaled responses (from 1 5 strongly disagree

Table 1

Respondent Demographics (n=38)a

Demographic n(%)

Age

19-23 20 (53)

24-28 9 (24)

29-33 1 (3)

$34 8 (21)

Sex

Men 7 (18)

Women 31 (82)

Degree Upon Graduation

Associate 19 (50)

Bachelor’s 19 (50)

Classification

Sophomore 4 (11)

Junior 12 (32)

Senior 22 (58)

No. Online Classes Taken

1-2 16 (43)

3-4 11 (30)

5-6 7 (19)

6 3 (8)

Learning Style

Kinesthetic 17 (46)

Read/Write 9 (24)

Aural 4 (11)

Visual 7 (19)a The sum of the percentages might not equal 100% because of rounding.

Types of Online Radiologic Sciences Courses Taken

Medical TerminologySectional Anatomy

Introduction to RadiologyEthics

Quality ManagementOther

Radiation ProtectionPathology

Equipment & PhysicsPositioning & Anatomy

Radiographic ProceduresResearch Methods

PharmacologyDigital Imaging

0 5 10 15 20 25

Online Radiologic Sciences Learning Activities

Quizzes/Exams

Discussion Boards

Textbook Readings

Research and/or Writing Assignments

Online Resources

You Tube or Other Video Resources

Voice Enhanced Slide Shows

Group Project

Video Lectures

Other

0 5 10 15 20 25 30 35 40

Figure 1.

Figure 2.

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a variety of learning activities, and informative docu-ments, such as a syllabus, calendar, and rubric. These results are congruent with previous findings on the instructor’s role in course organization and design.12,16,18

Although participants linked various learning activi-ties with greater comprehension in online radiologic science courses, study results showed a disproportion-ate variety in the types of online learning activities, with the majority being quizzes and exams, discus-sion boards, and textbook readings. More than 90% of respondents indicated that quizzes and exams were used as a learning activity in online radiologic science courses. This finding possibly supports results indicat-ing that feedback from quizzes and exams contributed more to comprehension than any other learning activ-ity. A previous study of radiologic science educators indicated that discussion boards were one of the most often used learning activities.5 Likewise, discussion boards were indicated as one of the most commonly employed learning activities in this study. However, the majority of participants perceived discussion boards as a least supportive method to comprehension. In fact, participants in this study indicated that learning activities involving peer interaction contributed least to comprehension in the online learning environment than any other learning activity. These results con-tradict those of previous researchers regarding peer interaction in online learning environments.12,13,18 These findings suggest that online courses should provide more meaningful learning activities that connect course content with peer and instructor communication, as demonstrated in previous research.12,13,17,18

Most students indicated having a kinesthetic, or hands-on, learning style. However, the most frequent learning activities encountered by participants in this study involved reading and writing, not hands-on activities. Although the radiologic science curriculum includes many traditional courses where hands-on strategies comprise a large portion of learning activi-ties, incorporating these strategies into online courses can be difficult. Nevertheless, researchers suggest incorporating a multitude of learning activities in the online learning environment to appeal to a wide range of learning styles.13 However, considering that medi-cal terminology was the course most commonly taken

taken many online classes and found that if they are properly structured they can be a good learning venue.” Another student stated, “I think the online classes I have taken are fine to take online, but there are some, such as procedures, physics, and image formation, that I believe should be taught in class.” Another student stated: “Online classes work well but only for students who are self-motivated to complete the tasks. Certain students may procrastinate and scramble to complete assignments last minute, not really learning anything.”

DiscussionLearner satisfaction has proved to be a successful

indicator of engagement in online courses.11-13 This study evaluated student perceptions of online radiologic science courses to determine the course characteristics that enhance comprehension in the online learn-ing environment. The findings were congruent with those of previous research.12,13,16-18 Results from this study imply that the instructor’s role is one of the most important components for comprehension in online radiologic science courses. This role involves provid-ing an organized course, timely instructor feedback,

Table 2

Student Perceptions of Course CharacteristicsOnline Course Characteristic Mean

A well-organized course is important for effective learning in online radiologic science courses.

4.74

Timely instructor feedback is necessary and supplements my understanding of course content.

4.6

Supplemental resources, when provided by the instructor, aid in my comprehension of online course content.

4.03

Interacting with classmates, through online learning activities and/or group projects, plays an important role in my comprehension in online courses.

3.34

Participation in online courses encourages me to be an independent learner.

3.97

Instructor-provided documents such as course syllabus, calendar, and rubrics supplement my ability to learn in online courses.

4.34

A variety of learning activities is necessary for comprehension in online radiologic science courses.

4.23

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should design a well-organized course with adequate and relevant course materials, foster meaningful engagement between students and content, and provide frequent and timely feedback. Furthermore, students indicated that a variety of learning activities contribute to comprehension in an online course but that many online courses lack the optimal variety needed. These results likely are connected to the faculty-related barri-ers mentioned. Faculty might be able to overcome these barriers by implementing the Quality Matters Rubric, which is a compilation of standards used to evaluate online course design.19

Future research should evaluate whether online radiologic science instructors assume the role that this study’s participants perceived as valuable for compre-hension in the online learning environment. Likewise, it might be beneficial to determine, on a larger scale, whether a variety of learning activities are being used in online radiologic science courses. In addition, a study determining the types of online learning activities suit-able for and applicable to course content and student learning styles might be useful.

Erika Papillion, MSRS, R.T.(R), is an online adjunct instructor for the School of Health Professions at the Univeristy of Louisiana at Monroe. She can be reached at papillion@ulm.edu.

Laura S Aaron, PhD, R.T.(R)(M)(QM), FASRT, serves as chair of the JRCERT board of directors and is director and professor of the School of Allied Health for Northwestern State University in Shreveport, Louisiana. Aaron was an ASRT Foundation professional research grant awardee in 2004 and 2009, and a Stern Scholarship recipient in 2003. She also is a former chairman of the Radiologic Technology Editorial Review Board. She can be reached at carwilel@nsula.edu.

Received March 4, 2016; accepted after revision September 29, 2016.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department, at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to publications@asrt.org.

© 2017 American Society of Radiologic Technologists

by participants in this study, it is safe to assume that the nature of the course affects the type of learning activity used and possibly decreases the ability to vary learning activities. This belief, perhaps, substanti-ates previous research findings about the perceived barriers to delivering radiologic science courses in an online format.3,4,9

LimitationsSeveral limitations affected the generalizability of

this study’s results. An email was sent to 35 program directors with instructions to forward the electronic survey to students for participation. However, only 38 students responded. Thus, the most evident limitation was the low number of respondents. This low response rate might be the result of a lack of student interest in participating, or it could be that students did not receive the forwarded email. In addition, surveys were sent only to students enrolled in the clinical portion of a radiologic science program. This also might have contributed to the low number of responses. Sending the survey to all radiologic science students enrolled in a program offering online courses might have yield-ed better results.

ConclusionNumerous studies have compared student out-

comes in online and face-to-face courses. Those studies in the radiologic sciences collectively indicated no significant difference in student outcomes when comparing online courses to traditional face-to-face formats.3,7,8 In addition, recent data shows continued growth in the adoption of online courses in radiologic science curriculums.5 As a result, researchers have dis-cussed the continual need to evaluate online learning in radiologic science curriculums to provide valuable information for adequate and efficient online cours-es.3-5,7-10 This study gauged the effectiveness of online radiologic science courses by evaluating student perceptions of specific learning activities and course characteristics.

The instructor’s role, congruent with previous research, was indicated as one of the most important components contributing to student comprehension in the online learning environment.12,13,16,18 Instructors

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courses. J Educ Bus. 2002;77(6):313-318. http://dx.doi .org/10.1080/08832320209599681

17. Bryant J, Bates AJ. Creating a constructivist online instruc-tional environment. TechTrends. 2015;59(2):17-22. http://dx.doi.org/10.1007/s11528-015-0834-1.

18. Jones SJ. Reading between the lines of online course evalua-tions: identifiable actions that improve student perceptions of teaching effectiveness and course value. J Asynchronous Learn Netw. 2012;16(1):49-58.

19. Higher ed course design rubric. Quality Matters website. https://www.qualitymatters.org/qa-resources/rubric -standards/higher-ed-rubric. Published 2014. Accessed September 8, 2016.

References1. Updated e-learning definitions. Online Learning

Consortium website. http://onlinelearningconsortium.org /updated-e-learning-definitions-2/. Published 2014. Accessed August 23, 2016.

2. Allen E, Seaman J. Grade change: tracking online education in the United States. http://www.onlinelearningsurvey .com/reports/gradechange.pdf. Published January 2014. Accessed November 8, 2014.

3. Britt R. Online education: a survey of faculty and students. Radiol Technol. 2006;77(3):183-190.

4. Rosenkoetter LE. Moving toward online courses. Radiography. 2007;13(4):271-275. http://dx.doi.org /10.1016/j.radi.2006.04.005.

5. Kowalczyk N, Copley S. Online course delivery modes and design methods in the radiologic sciences. Radiol Technol. 2013;85(1):27-36.

6. Martens R, Bastiaens T, Kirschner PA. New learning design in distance education: the impact on student perception and motivation. Distance Educ. 2007;28(1):81-93. http://dx.doi .org/10.1080/01587910701305327.

7. Johnston J. Effectiveness of online instruction in the radio-logic sciences. Radiol Technol. 2008;79(6):497-506.

8. Cook JA. Comparison of instructional methods: outcomes and attitudes. Radiol Sci Edu. 2011;16(2):3-14.

9. Kowalczyk NK. Perceived barriers to online educa-tion by radiologic science educators. Radiol Technol. 2014;85(5):486-493.

10. Wertz CI, Hobbs DL, Mickelsen W. Integrating technol-ogy into radiologic science education. Radiol Technol. 2014;86(1):23-31.

11. Sahin I, Shelley M. Considering student perceptions: the distance education student satisfaction model. Educational Technology & Society. 2008;11(3):216-223.

12. Reisetter M, Boris G. What works: student perceptions of effective elements in online learning. Q Rev Distance Educ. 2004;5(4):277-291.

13. Dixson M. Creating effective student engagement in online courses: what do students find engaging? J Scholarsh Teach Learn. 2010;10(2):1-13.

14. Moore JC. A synthesis of sloan-c effective practices. J Asynchronous Learn Netw. 2010;14(3):24-45.

15. Billings DM, Connors HR, Skiba DJ. Benchmarking best practices in Web-based nursing courses. ANS Adv Nurs Sci. 2001;23(3):41-52. http://dx.doi.org/10.1097/00012272 -200103000-00005.

16. Perreault H, Waldman L, Alexander M, Zhao J. Overcoming barriers to successful delivery of distance learning

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Keywords skin cancer, university students, cancer awareness, cancer prevention

Purpose Skin cancer is the most common cancer, and it often is preventable. The authors sought to evaluate behavior and knowledge regarding skin cancer among students at a Texas university.

Methods The authors recruited a diverse group of students in terms of sex, age, and ethnicity to participate in a survey regarding knowledge of skin cancer signs, use of tanning beds, and performance of self-assessment for skin cancer. Participating students could complete surveys in classrooms, at health fairs, or online via Survey Monkey. The authors examined data for the 3 variables in relation to sex, ethnicity, and age.

Results A total of 512 responses were completed. Female students completed 371 (72.46%) surveys, and male students completed 141 (27.54%). The ethnicity of student participants was nearly evenly split among whites, African Americans, and Hispanics. Ethnicity was the most significant factor influencing the knowledge of skin cancer and behaviors to prevent it. Specifically, Hispanic and African American students possessed a lower level of skin cancer awareness.

Discussion More female students than male students used tanning beds, and although use was self-reported as infrequent, the results imply that 4500 of the university’s students might use tanning beds, which is concerning if extrapolated to other university student populations in Texas.

Conclusion Behavioral intervention is critical in reducing students’ risk of skin cancer in later years, and university students must acquire knowledge to increase their awareness of skin health and to minimize their risk of developing skin cancer. Radiation therapists are uniquely positioned to share knowledge of skin cancer.

Megan Trad, PhD, MSRS, R.T.(T)Lawrence Estaville, PhD

Skin cancer is the most common form of cancer diagnosed in the United States; approximately 3.5 million basal and squamous cell carcinomas and 73 000 melanomas were diagnosed in

2015.1 Skin cancer prevention and screening education and research are abundant, and numerous cancer pre-vention campaigns have attempted to alter individuals’ behaviors concerning sun and tanning bed exposure.1-4 Research has shown that primary prevention is the most effective route to reducing the incidence of and mortality from skin cancer and that skin care education at an early age is the best protection.2 However, despite the abundance of evidence available, young adults have resisted changing their harmful behaviors.2

Literature ReviewUnprotected exposure to sunlight, especially dur-

ing peak sun hours, and the use of tanning beds are the top behaviors associated with an increased risk of skin cancer.2,3 The U.S. Department of Health and Human Services has categorized tanning beds as carcinogenic, yet use of these facilities remains high.4 In addition, the Centers for Disease Control and Prevention (CDC) has indicated that indoor tanning is especially dangerous during adolescence and early adulthood.5 Despite these warnings, the use of indoor tanning beds, specifically among college-aged individuals, is high.

Playforth et al reported in 2014 that 68% of stu-dents in the authors’ sample had used a tanning bed at

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the possibility of university students’ developing skin cancer at some time during their lives: use of tanning beds, awareness of skin cancer warning signs, and the frequency of skin cancer self-checks. The researchers chose 3 questions that address college students’ current behavior, recognition of skin cancer, and use of preven-tive measures to lower the risk of developing skin cancer. The study also examines trends related to sex, ethnicity, and age, thereby adding to the current literature.

MethodsThe objectives of the study were 3-fold: to under-

stand university student knowledge of skin cancer prevention and risks, to determine whether students know what skin cancer looks like, and to ascertain whether students are conducting skin self-checks. Three specific research questions guided this research:

1. Do differences exist in the use of tanning beds according to sex, age, or ethnicity (non–Hispanic white, Hispanic, and African American)?

2. Do differences exist in the ability to identify skin cancer according to sex, age, or ethnicity?

3. Do differences exist in the commitment to con-ducting skin cancer self-checks according to sex, age, or ethnicity?

A survey asked students at a large Texas public uni-versity (. 37 000 students) about their perceptions and knowledge of skin cancer, whether they use tanning salons, and whether they conduct self-examinations for skin cancer. The study was approved by the uni-versity’s institutional review board. During the 2014 to 2015 academic year, students completed the sur-vey 1 of 3 ways: in class, at health fairs, or online via Survey Monkey. This 3-pronged convenience sampling strategy enabled the recruitment of a diverse group of students, particularly regarding sex, age, and ethnicity.

The total number of responses ranged from 515 to 521 undergraduate students (depending on skipped questions). Students self-identified their ethnicity as non–Hispanic white (hereafter termed white), Hispanic, African American, Asian American, or other. The number of Asian American students was so small (n 5 21) that this group could not be included in the analysis because doing so would have skewed the results. Few students selected the “other” category

some point, and 80% indicated that having a tan was very important or somewhat important. Of those who ranked having a tan as important, most were women.3 In the same year, Jeong-Ju and Won-Moo reported that some college-aged women felt emotional benefits from using tanning beds that perpetuated their use even when the women understood the health dangers. In fact, the study found that college-aged women valued the positive emotional benefits of tanning more than the health benefits achieved through avoiding tanning.6

The literature indicates that educational programs outlining the risks of sun exposure and use of tanning beds can lower student risk of developing skin cancer if students comply with the prevention methods provid-ed.7-10 However, a 2008 CDC study about the use of sun protection methods—specifically wearing sun protec-tion factor (SPF) 15 or higher, wearing sun-protective clothing, and seeking shade—reported that only 60% of individuals 18 to 24 years used 1 or more of these methods on a regular basis. The low use of preventive methods underscores the need for more education for these young adults.5 Furthermore, it is important to begin identifying ways to encourage young adults to fol-low the suggested guidelines.

Rules and regulations can help guide individuals toward healthier lifestyle choices. For example, in 2013 the Texas legislature banned minors from using com-mercial tanning facilities, thereby attempting to reduce the number of future skin cancer cases.11 No such restrictions exist for college-aged adults at a time in their lives when they are more likely to engage in risky behavior, including placing themselves in greater jeop-ardy of developing cancer.

This study is an effort to better understand university student knowledge and perceptions about skin cancer—its prevention, behavior that could lead to skin cancer, and warning signs. Much of the research focuses on how sex differences affect levels of knowledge and lifestyle choices related to skin health. Very little research inves-tigates whether ethnicity or age are factors in skin cancer knowledge or in participation in healthy skin habits such as performing self-checks, annually visiting a dermatolo-gist, and avoiding tanning beds.

As a result of the literature review, this investiga-tion reports on 3 variables that could contribute to

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ResultsA total of 521 university students completed the

survey (6 students skipped survey questions resulting in different totals for some questions); of those, 371 (72.46%) were women and 141 (27.54%) were men. Regarding the question of ethnicity, 181 (35.35%) respondents self-identified as white, 182 (35.55%) as Hispanic, and 149 (29.10%) as African American. In identifying their academic classification, 123 (24.02%) self-identified as freshmen, 163 (31.84%) as sophomores, 139 (27.15%) as juniors, and 87 (16.99%) as seniors.

The student survey results showed that the use of tan-ning beds did not differ significantly between sexes, with 15% of women and 8% of men responding that they use tanning beds (χ2 5 4.3, P 5 .365). Use of tanning beds also did not differ significantly among academic clas-sifications; responses were positive for 12% of freshmen, 13% of sophomores, 12% of juniors, and 14% of seniors (χ2 5 4.4, P 5 .975). However, the participants in the 3 ethnic groups differed statistically in their use of tan-ning beds (χ2 5 24.4, P 5 .002). White students’ use of tanning beds (25%) differed moderately from Hispanic student use (8%; χ2 5 112, P 5 .018) and strongly from African Americans (5%; χ2 5 17.5, P 5 .002). The use of tanning beds did not differ statistically between Hispanic and African American students (χ2 5 2.6, P 5 .63).

In the students' self-reported ability to identify skin cancer (see Table), the evidence suggests a dif-ference between the sexes; 38% of female students reported that they knew what skin cancer looks like and 29% of male students responded that they could identify skin cancer (χ2 5 5.1, P 5 .077). No difference in self-reporting of skin cancer identifi-cation occurred among the student classifications: freshman, 34%; sophomore, 32%; junior, 43%; and senior, 41% (χ2 5 8.6, P 5 .196). The 3 ethnic groups differed moderately (χ2 5 9.7, P 5 .045), with more white students than African American or Hispanic students stating that they could identify a skin can-cer. Hispanic and African American self-reported ability knowledge did not differ significantly (χ2 5 3.9, P 5 .142).

Women (74%) and men (75%) in the survey did not differ in their reporting of never conducting self-checks for skin cancer, whereas 17% of women and 9%

(n 5 16); they, too, were not included in the analy-sis. Students who were health profession majors were removed to avoid bias in the results because these stu-dents should have more knowledge about skin cancer than do college students in general.

This research reports on 3 of the survey questions: � Do you use tanning salons? � Do you know what skin cancer looks like? � Do you conduct self-examinations for skin cancer?

The authors used a chi-square test (α 5 0.05) to inves-tigate categorical data about significant differences among the survey responses for sex, ethnicity (white, Hispanic, and African American), and student classification (an age surrogate). These questions were chosen to specifi-cally answer the research questions guiding the study. The sampled students did not receive prior education or training because this survey was designed to inform the researchers and readers whether students needed more education about skin cancer prevention and detection.

The primary limitation of this study is that it took place at only 1 university. Future research could survey multiple universities in the same state or in different states for analysis. Surveying a university with a larger Asian American student population in future research would allow them to be included in the analysis.

Table

Self-reported Ability to Identify Skin CancerCan You Identify Skin Cancer?

Know How (%)

Maybe (%)

Cannot (%)

Sex

Women 38 34 27

Men 29 28 43

Age/Classification

Freshmen 34 35 31

Sophomores 32 35 33

Juniors 43 26 31

Seniors 41 40 20

Ethnicity

White 39 33 28

African-American 26 28 47

Hispanic 30 37 33

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the surrogate for age (student classification) showed little difference in tanning bed usage, at approximately 12% across the 4 groups. Further, data did not differ for knowing what skin cancer looks like; roughly 33% to 40% responded they could discern skin cancer. Although the numeric trend showed that older students engage more often in skin cancer self-checks, no statisti-cal difference was found among age groups based on student classifications.

As indicated previously, ethnicity is not reported often as a variable in the literature regarding skin health knowledge. Ethnicity, however, was pronounced in its variability regarding the 3 hypotheses. White students’ responses differed from those of Hispanics and African Americans for each of the 3 variables. Two-thirds of the 12% of students who used tanning beds (approxi-mately 4500) students were white. Although this is not a surprising percentage, it has not been documented in previous research and is therefore a notable finding.

Responses to the question asking whether the students know what skin cancer looks like varied sig-nificantly, from 39% of white students to 25% of African American students. Forty-five percent of white students reported conducting self-checks for skin cancer, but fewer than 20% of Hispanics or African Americans indicated that they do. These findings are important, as it appears that white students, despite engaging in riskier behavior regarding skin health, also believe they have more knowl-edge of skin cancer appearance and say that they check for skin cancer more often. It is possible that the students who have darker skin color believe they are not as sus-ceptible to skin cancer as are those who have lighter skin, a belief that is inaccurate. The false feeling of protection based on skin color might lead individuals to forgo skin checks, an omission that could lead to a later-stage diag-nosis should skin cancer occur.

Implications for Radiation TherapistsThis research is important to radiation therapists,

who have been well educated on many aspects of can-cer, including screening, prevention, detection, and treatment. Radiation therapists, who have treated many patients for skin cancer, are acutely aware that anyone is at risk of developing skin cancer, regardless of their sex, age, or ethnicity. Because of these experiences, radiation

of men reported that they perform self-checks each year (χ2 5 4.4, P 5 .357). Although the numeric trend suggests that older students conduct skin self-checks more often than do younger students, student classi-fications did not statistically differ in performing skin self-checks: those reporting that they never conduct checks included 78% of freshmen, 75% of sophomores, 74% of juniors, and 66% of seniors (χ2 5 13.7, P 5 .319). However, the 3 ethnic groups—white, Hispanic, and African American—differed statistically in conducting skin self-checks (χ2 5 32.2, P 5 .000). The number of white students who never perform self-checks (55%) differed strongly from Hispanics who never perform them (81%; χ2 5 17.1, P 5 .002) and African Americans who never perform them (86%; χ2 5 25.1, P 5 .000). Responses from Hispanics and African Americans to this question did not statistically differ (χ2 5 1.0, P 5 .910).

DiscussionThe 3 specific research questions revealed:

� The use of tanning beds differs by ethnicity (white, Hispanic, and African American), but not by sex or age.

� The ability to identify skin cancer differs by sex and ethnicity, but not by age.

� Conducting skin cancer self-checks differs by eth-nicity, but not by sex or age.

According to their self-reporting, approximately 12% of students use tanning beds, and most are women who claim annual usage, which initially seems encourag-ing. Yet, this percentage also implies that of more than 37 000 students in the university, about 4500 use tan-ning beds, an estimate that is concerning, especially if extrapolated to other university student populations in Texas. Although the variability by sex in this study was not as statistically significant as shown in earlier research, the trend is toward higher use of tanning beds among female students. This study might have revealed a growing trend of male students’ use of tanning beds worthy of further investigation.

The finding that 38% of women who reported know-ing what cancer looks like was higher than the 28% of men who reported being able to identity skin cancer, yet three-quarters of both sexes surveyed claimed to have never conducted skin cancer self-checks. The data for

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3. Playforth FM, Larkin LJ, Schwartz LM. College students’ behaviors, perceptions, beliefs, and attitudes regarding tan-ning bed use and skin cancer. KAHPERD J. 2014;52:34-47.

4. FDA proposes tanning bed age restrictions and other impor-tant safety measures [news release]. Silver Spring, MD: U.S. Department of Health and Human Services, Food and Drug Administration; December 18, 2015. http://www.fda.gov /NewsEvents/ Newsroom/PressAnnouncements/ucm 477434.htm. Accessed August 31, 2016.

5. Indoor tanning is not safe. Centers for Disease Control and Prevention website. https://www.cdc.gov/cancer/skin/basic _info/indoor_tanning.htm. Updated August 25, 2016. Accessed August 31, 2016.

6. Yoo JJ, Hur WM. Body-tanning attitudes among female college students. Psychol Rep. 2014;114(2):585-596. doi:10.2466/06.07.PR0.114k21w5.

7. Robinson JK, Kim J, Rosenbaum S, Ortiz S. Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol. 2008;144(4):484-488. doi:10.1001/archderm.144.4.484.

8. Spradlin K, Bass M, Hyman W, Keathley R. Skin cancer: knowledge, behaviors, and attitudes of college students. South Med J. 2010;103(10):999-1003. doi:10.1097/SMJ.0b 013e3181eda64f.

9. Mosher CE, Danoff-Burg S. Addiction to indoor tanning: relation to anxiety, depression, and substance use. Arch Dermatol. 2010;146(4):412-417. doi:10.1001/archderma tol.2009.385.

10. Mahler HI, Kulik JA, Butler HA, Gerrard M, Gibbons FX. Social norms information enhances the efficacy of an appearance-based sun protection intervention. Soc Sci Med. 2008;67(2):321-329. doi:10.1016/j.socscimed.2008.03.037.

11. Indoor tanning restrictions for minors: a state by state com-parison. National Conference of State Legislatures website. http://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Accessed January 20, 2017.

therapists can use this knowledge to educate people, particularly college-age adults, to reduce their chances of developing cancer later in life. Ideally, doing so can create effective ways to share knowledge and diminish substantially the risk of cancer for future generations.

ConclusionMuch work remains in educating university students

about skin cancer, its warning signs, and the dangers of using tanning beds. Specifically, this study reveals that tanning bed usage is not specific to age, gender, or eth-nicity. Also, Hispanic and African American students need extra motivation to conduct monthly self-checks and to visit a dermatologist annually. More education is needed to determine how to better encourage young adults to adhere to guidelines and participate in preven-tive measures. College students are traversing a period in their lives in which behavioral intervention is critical if they are to reduce their risk of skin cancer in later years. It is imperative that these individuals acquire education to increase their awareness of skin health pro-tection measures and of ways to minimize their risk of developing skin cancer.

Megan Trad, PhD, MSRS, R.T.(T), is associate professor for the Texas State University Radiation Therapy Program in San Marcos. She can be reached at mt40@txstate.edu.

Lawrence Estaville, PhD, is professor in the department of geography for Texas State University in San Marcos.

Received July 5, 2016; accepted after revision October 6, 2016.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department, at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to publications@asrt.org.

© 2017 American Society of Radiologic Technologists

References1. Skin cancer facts. American Cancer Society website.

http://www.cancer.org/cancer/skin-cancer/prevention -and-early-detection.html. Revised April 19, 2016. Accessed August 31, 2016.

2. Lamanna LM. College students’ knowledge and attitudes about cancer and perceived risks of developing skin cancer. Dermatol Nurs. 2004;16(2):161-164, 175-176.

asrt.org/symposium

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Today’s workplace often includes workers from 4 distinct generations, and each generation brings a unique set of core values and characteristics to an organization. These generational differences can produce benefits, such as improved patient care, as well as challenges, such as conflict among employees. This article reviews current research on generational differences in educational settings and the workplace and discusses the implications of these findings for medical imaging and radiation therapy departments.

After completing this article, the reader should be able to:Identify the various generational cohorts in today’s workplace.Discuss distinguishing characteristics of each generation and describe their respective

workplace behaviors.Describe the challenges and opportunities associated with a diverse workplace.Explain common stereotypes associated with each generation.Discuss the effects of generational differences on medical imaging and radiation therapy

departments.

Kevin R Clark, EdD, R.T.(R)

Managing Multiple Generations in the Workplace

Today’s multigenerational work-force presents opportunities and challenges for medical imaging and radiation therapy

departments. Because some employees are working into their late 60s and 70s, it is common to see several generational cohorts working together, creating a unique work environment.1 Although multigenerational diversity among health care staff can result in sound decisions and improved patient care, varied attitudes, values, beliefs, work ethics, and expectations can present challenges, too. As multiple generations continue working side by side, manag-ers and organizations can promote a unified work environment by embrac-ing generational differences and encouraging mutual understanding and respect.2,3

Generations DefinedA generation is defined as a group

of individuals born and living con-temporaneously who share common

knowledge and experiences that affect their thoughts, attitudes, values, beliefs, and behaviors.4 Although no consensus exists regarding when 1 generation ends and another begins, experts agree that individuals who grew up in the same era experienced social and historical events that shaped similar characteris-tics and core values.2-7 Table 1 displays some of the historical and social events that influenced each generational cohort: veterans, baby boomers, genera-tion X, and generation Y. It is important to note that individuals from a specific generation might not exhibit all or even any of the characteristics ascribed to the group as a whole.7 In fact, individu-als might start to display characteristics of the next older generation as they advance in their careers.7

VeteransVeterans, also referred to as tradi-

tionalists and the silent generation, were born before 1946 and are the oldest gen-eration in American culture.7-9 About

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veterans are continuing to work later in life.1,2,5 In addi-tion, health care organizations have a vested interest in understanding this generation because most Medicare beneficiaries—a signficiant portion of the health care consumer and patient populations—are veterans.3,12

Baby BoomersBaby boomers were born between 1946 and 1964 and

are one of the largest generational cohorts in the United States, comprising about 76 million people.7-9 Those born between 1946 and 1955 are referred to as early boomers, and those born after 1955 are referred to as late boomers.8 Members of this generation grew up in a relatively steady state of free expression, economic prosperity, and an absence of world wars, although they lived through the Cold War era and the Vietnam War.8,9 As young adults, baby boomers experienced opportunities that were not available to their predecessors. Typically, they were the first in their families to earn college degrees, and their education translated into upward mobility.8 In school, baby boomers needed to collaborate and cooperate with their peers because there were so many of them. As a result, this generation possesses both teamwork and relationship-building skills.7

Generally well established in their careers and in positions of power and authority, baby boomers are extremely hard workers and are committed to their professional goals.8 In fact, this driven and dedicated generation’s motto is “living to work,”9 and they are credited with creating the term workaholic.4 In addi-tion, baby boomers are described as optimistic, friendly,

55 million veterans reside in the United States today.8 People from this generation grew up during the Great Depression, and many fought or were children during World War II.8,9 The hardships of the war and the econo-my deeply affected this generation’s values and opinions regarding family, religion, work, and government. For example, veterans are characterized as being patriotic and civic-minded because they witnessed business and government working together during the New Deal to conquer the Great Depression.7,8 They also learned to be resourceful to stretch limited funds and make small amounts of food and clothing last. Having overcome economic hardships, they developed a sense of pride and determination and, as a result, tend to work hard and prefer consistency and uniformity.8 Described as loyal and disciplined, veterans also value integrity, character, and sacrifice; respect authority and value boundaries between work and family life; and strive for financial security.7-9

Although some veterans train slowly, they make work a priority and are considered team players.3,10 They are loyal to their employers; expect the same in return; and believe promotions, raises, and recognition should be based on job tenure and seniority.7,8 They also mea-sure work ethic on punctuality and productivity.8,9 As expected, veterans often are unsure of and even resist using new technology.3,10

Most veterans have retired, and they constitute only 2% (3.7 million) of the U.S. workforce today.11 As a result, only limited research regarding their presence in the workforce is available. However, more and more

Table 1

Influential Historical and Social Events2-7

Veterans Baby Boomers Generation X Generation Y

Great DepressionWorld War IIPearl HarborD-DayKorean WarGolden Age of RadioRise of labor unions

Civil Rights MovementPolitical assassinationsVietnam WarCold WarNeil Armstrong’s moon landingWoodstockTelevision becomes dominant

media

Women’s Liberation MovementFirst personal computersAIDSChallenger disasterFall of Berlin WallRodney King beating

Operation Desert StormOklahoma City bombingO.J. Simpson trialDeath of Princess DianaSchool violence (Columbine

massacre)Digital Age (Internet, instant

messaging, wireless technology)September 11 events

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while working on independent projects.8 In fact, they do not align themselves with the philosophy of being a team member, but they will work with colleagues to achieve a common goal.9 They prefer to manage their own time, set their own limits, and complete their work without supervision.9 This generation also finds infor-mal policies regarding dress codes and workplace habits to be fun and motivating.8 They expect and embrace change and are technologically savvy.3

Generation X members represent approximately 34% (52.7 million) of the U.S. workforce today.11 Most thrive in a casual, friendly work environment; however, they desire to build portable careers by exploring employ-ment opportunities and changing jobs periodically to increase their marketability.3,8

Generation YMembers of generation Y, commonly referred to as

gen Yers, millennials, and nexters, were born between 1981 and 2000.7,8 This generation comprises about 80 million people and constitutes the largest gen-erational cohort in the United States today.13 Having grown up using computers, mobile phones, tablets, and other electronic devices, generation Y individuals are extremely technologically savvy and highly con-nected to the Internet.3,7,8,13

Unlike the latchkey children of generation X, gen-eration Y grew up being escorted and supervised by protective parents who were extremely cautious of dan-gers such as kidnapping, school violence, and drugs.13 The close interaction between parents and child gave rise to the term helicopter parents, meaning parents who are involved in every aspect of their children’s lives.7,8 In general, generation Y members are less independent, more community-oriented, and seek a sense of meaning in greater contexts.8 This generation also is motivated by money and described as being ambitious, having a short attention span, and wanting instant gratification.7-9

Compared with their predecessors, members of generation Y tend to be more social and confident as they seek a balance between their personal life and work.7-9 Although easily bored and impatient, they are motivated by their need for a sense of purpose and belonging to meaningful communities, and they typically enjoy experimenting and discovering new

and proud of their strong work ethic.7 They also work longer work weeks than prior generations did, and they believe continual learning and growth lead to success.8,9 Motivated by perks, prestige, and position, baby boom-ers want to be recognized for their contributions, and they view work as an exciting adventure.3,9,12

Baby boomers represent approximately 29% (44.6 million) of today’s U.S. workforce.11 The old-est members of this generation are considering their retirement options and are seeking ways and opportunities to make their elder years personally meaningful.8

Generation XMembers of generation X, also referred to as gen Xers,

busters, and the lost generation, were born between 1965 and 1980.3,7,8 Approximately 53 million members of the generation X cohort live in the United States.8,11,13 The term buster describes this generation because their birth rates were vastly lower than those of the baby boomers.8 The lost generation also describes this cohort because it was the first generation of latchkey children—those left at home with negligible parental supervision—and children exposed to daycare and divorce.8 Many parents of generation X were baby boomers with workaholic tendencies driven by personal gratification, authority, and status. In some cases, their work habits resulted in poor home lives, broken families, and absent parents.8 A lack of meaningful family relationships led generation X members to create nontraditional families by bonding with friends and colleagues.13

Given their upbringing, it is no surprise that generation X members expect to maintain a balance between work and family life and do not work exceptionally long hours for money or titles.8,9 Generally, they are less loyal to their employers and are more comfortable demanding flex-ible work arrangements.7-9 They also expect freedom and balance in their personal and professional lives, acknowl-edging that work contributes only a portion of the quality of life they seek to achieve.8 At times, generation X can be cynical, questioning authority and disliking direct super-vision.3,7,8 Often, they resist micromanaging bosses and find them to be distasteful and undesirable.8

Considered independent, self-reliant, and informal, generation X individuals multitask easily and excel

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real-world application scenarios over creative or reflective writing exercises.15 In addition, the students appreciated personable professors who tailored their lessons to the group of individuals in a specific class.15

Therrell and Dunneback acknowledged that their findings were consistent with the general characteristics of millennials, including short attention spans and the need for instant gratification.15 They also recognized the need for future studies involving larger samples to further investigate millennial students’ perspectives on teaching and learning in a variety of courses. Although this study assessed students’ preferences in the class-room setting only, it is possible that millennial students bring those preferences into the workplace.

The Digital DivideSalajan et al examined the perceptions of dental

students and instructors regarding the use of digital learning technologies in the online classroom.16 Most of the instructors were either veterans or baby boom-ers, and most of the students were from generation Y.16 The researchers wanted to explore the assumption that younger generations are more technologically savvy and skilled than older generations. Specifically, the participants rated their use of email, web brows-ers, e-texts, personal computers, laptops, and MP3 players, as well as the course management system at the beginning of the semester and then at the end of the semester after using the digital technologies in the online classroom.16

The results indicated a slight but not statistically significant intergenerational difference in faculty members’ perceived use of digital technologies, although the researchers did not investigate whether the difference was associated with generational differ-ences between the veteran and baby boomer cohorts.16 However, students’ perceptions of the technologies improved over the academic year and were statistically significant.16 Students appeared to be more adept at using digital technologies than were their professors.16 However, the researchers warned that this conclusion was drawn from perceptual data at a rather general level of confidence (ie, not expert use). In addition, both students and faculty members were less satisfied with the course management system at the end of the

approaches and solutions to problems.8 Often, this generation desires praise and support from employers to feel a sense of validation and belonging.8 In general, they expect more supervision and feedback, clear goals, and structure, and they learn best through men-toring programs.3,8

In the U.S. workforce, generation Y just surpasses generation X at 34% (53.5 million).11 They are attracted to companies and businesses that embrace technologi-cal advancements that change the way of doing business globally.8 Being entrepreneurial, this generation engages in many jobs with diverse career paths. Because they seek happiness in their work and personal life, those of genera-tion Y do not limit themselves to 1 job and 1 career.8

Training and EducationAs with the workforce, multigenerational differ-

ences often appear in educational and training settings. As higher education institutions continue to promote lifelong learning, classrooms are becoming more age-diverse.14 These classrooms expose future professionals to individuals from various generations and promote awareness of generational differences. As a result, edu-cation institutions and faculty must adapt to a changing classroom environment. To meet the needs of students and instructors, researchers are investigating various aspects of generational differences in the classroom, including learning preferences and technology use. This research can be used to design curricula, implement teaching strategies, and allocate resources.

Millennials’ PerspectivesUsing a mixed-methods approach, Therrell and

Dunneback conducted a study of 291 millennial college students regarding their perspectives on teaching and learning preferences.15 Their findings revealed that mil-lennial college students preferred is15:A caring, passionate, and enthusiastic instructor.Clearly communicated course expectations.Course examinations that test only the content

presented.Real work and practical applications of the content.Active learning strategies, such as role playing.Millennial students also preferred hands-on

activities with interactive lab assignments and enjoyed

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Facebook UseAlthough Facebook predominantly is known as a

site where family and friends can connect, it also is con-sidered a valuable educational tool because it enables peer feedback, interaction, and learning in a social environment.20 Manca and Ranieri identified 5 main educational uses of Facebook21:Supporting class discussions and helping students

engage in collaborative learning.Developing content.Sharing educational resources.Delivering content to expose students to extracur-

ricular resources.Supporting self-managed learning.Using Facebook as an educational tool is relatively

new, and little research exists regarding its benefits and challenges.20 To obtain descriptive statistics about the use of Facebook among college students, researchers conducted an exploratory study among 200 undergradu-ate psychology students, the majority of whom were members of generation Y. Of these, half were second-year students, and half were third-year students.20 Chi-square tests were performed to determine whether any differences existed between the 2 cohorts.20

The results suggested that most of the student par-ticipants were satisfied with Facebook and mainly used it to overcome boredom.20 All third-year students had a Facebook account, but only 65% of the second-year students acknowledged having a Facebook account. Students cited a lack of interest and an unwillingness to post personal information online as reasons for not having an account.20 Incidentally, the researchers con-cluded that the number of Facebook users and time spent online increase with younger-generation college students, making this social media site a potential edu-cational tool.20

Given the limited sample size of this study, which involved only 1 higher education institution, future studies with more participants and that collects qualita-tive data are warranted. Qualitative data would provide student and instructor perspectives on education and social media use and would help identify any advantag-es or disadvantages associated with using social media. Researchers also recommended analyzing other social media sites such as Twitter and Instagram.

academic year than at the beginning.16 The researchers attributed the decreased satisfaction to the burden of learning a new course management system along with the digital technologies at the time of the research study.

Although this study was limited by perceptual data, the sample size, and the inability to generalize the find-ings to a larger population, the researchers emphasized the trend in age-linked dynamics that affect technology use.16 Although some say it is common knowledge that younger generations are better at using technology than are older generations, Salajan et al believed that drawing a division between students and instructors might be more damaging than helpful in promoting a constructive learning environment that is conducive to student-teacher rapport.16

Face-to-Face vs Online ClassroomsAlthough researchers argue that younger generations

are competent technology users and can transfer their digital skills to the online classroom, some studies sug-gest that digital skills in the academic setting are not so automatic.16-19 Gros et al hypothesized that positive perceptions of technology-supported learning are not related to whether a student belongs to a technological-ly savvy generation; rather, perceptions are influenced mainly by the teaching model (face-to-face vs online education).17 To analyze students’ perceptions of infor-mation and communication technologies for learning, the researchers distributed questionnaires to a random sample of 1042 younger-generation students (genera-tions X and Y) and older-generation students (baby boomers) at 5 universities that provided either face-to-face education or online courses.

The results showed that baby boomer students in the online environment responded well to the course requirements and demonstrated competent digital skills, suggesting that the educational approach, wheth-er face-to-face or online, is a stronger influence than generation type on students’ perceptions of the useful-ness of technology-supported learning.17 Given their findings, the researchers suggested the need to consider how technology-rich learning environments can help develop students’ digital competencies, and not the other way around.17

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have been working for a longer period of time than have generations X or Y.

All 3 generations gave themselves high ratings for attendance and dress code compliance, but the baby boomers scored themselves the highest.22 Baby boomers also had the highest termination percentages, which could be attributed to having more years of work experience than generations X or Y.22 When asked to work overtime, 44% of baby boomers reported a willingness, 38% of the generation X cohort reported a willingness, and 41% of the generation Y cohort reported a willingness.22

Although the results of the study indicated some generational differences do exist in the workplace, the size of the differences for each generation in this study was small.22 In addition, the popular assumptions con-cerning each generation were not always consistent with respect to workplace behavior. The researchers acknowledged the study was limited because the data were self-reported.

Work EthicObserving an increase in turnover rates among baby

boomer, generation X, and generation Y nurses at an inpatient acute care facility, Jobe examined the increase to see whether it was directly related to the work ethic attributed to each generation.23 Specifically, Jobe mea-sured 7 dimensions of work ethic23:Self-reliance: striving for independence in one’s

daily work.Morality/ethics: believing in a just and moral

existence.Leisure: emphasizing nonwork activities.Hard work: believing in the virtues of hard work.Centrality of work: believing in work for work’s

sake and the importance of work.Wasted time: having attitudes and beliefs that

reflect active and productive use of time.Delay in gratification: being oriented toward the

future and the postponement of rewards.Of the 285 completed surveys, the data suggested

work-ethic similarities among the 3 generational cohorts with statistically significant intergenerational differences related to leisure, hard work, and delay of gratification.23 Generations X and Y, for example, placed more emphasis on leisure activities and hard

Workplace BehaviorGenerational differences in the workplace can pres-

ent potential benefits and challenges for organizations, particularly for managers and supervisors. Rather than relying on anecdotal evidence and broad assumptions, social scientists are accumulating empirical data regard-ing specific workplace behaviors of each generation. These studies not only have implications for recruit-ment, hiring, and retention, but also provide managers a basis for developing teamwork strategies.

Hiring and TurnoverBased on the work-related behaviors of baby boom-

ers, generation X, and generation Y, Becton et al tested 3 hypotheses in their research study22:Baby boomers will display fewer job mobility

behaviors than will generations X or Y.Baby boomers will exhibit more occurrences of

compliance and experience fewer instances of ter-mination than will generations X or Y.

Generation X will report less enthusiasm to work overtime than will baby boomers or generation Y.

To test these predictions, the researchers assessed the feedback of 8040 applicants at 2 organizations. Job mobility was measured by asking the applicants to specify the longest amount of time they spent at 1 job and how many jobs they held in the past 5 years.22 Compliance behaviors were measured by asking the applicants how their most recent supervisor would rate their attendance and their adherence to dress code policies.22 Terminations were assessed by asking the applicants how many times they had been fired.22 Finally, enthusiasm to work overtime was measured by asking the applicants how often their most recent super-visor would say they were willing to work overtime.22

The results provided full support for the first and third hypotheses and partial support for the second hypothesis.22 Regarding the first hypothesis, baby boomers spent an average of 73 months as the longest time spent at 1 job, with an average of 2 jobs held in the past 5 years; generation X averaged 49 months as the longest time spent at 1 job, with 3 jobs in the past 5 years; and generation Y averaged 23 months as the longest time spent at 1 job, with 3 jobs held in the past 5 years.22 Certainly, it could be argued that baby boomers

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of gender partiality in responses. However, given that younger employees have lower job satisfaction and higher turnover intentions compared with older employees, the researchers stressed that managers need to consider implementing strategies (eg, f lexible hours and adequate supervision) to address work-life balance for those younger employees.24

ExpectationsNewly licensed registered nurses from 3 generational

cohorts (baby boomers, generation X, and genera-tion Y) were surveyed regarding their work-related experiences, including their general characteristics and attitudes.25 Of the 2369 nurses in the sample, 251 (10.5%) were baby boomers, 1643 (68.8%) were gen-eration X, and 465 (19.4%) were generation Y.25 The researchers examined their work attitudes, attributes, and demographics, as well as their job satisfaction, organizational commitment, job search, and intention to stay in a job.25 No statistically significant intergenera-tional differences existed concerning intention to stay and job-search behavior.25 Incidentally, approximately two-thirds of the nurses in each generational cohort were employed in the same position as the previous year.25 However, findings revealed significant differ-ences among generations in several other areas25:Baby boomers reported higher work motivation

than did generations X and Y.Generation X demonstrated the highest levels

of work-to-family conflict (the degree to which employment hinders family life) and family-to-work conflict (the degree to which family life interferes with work).

Generation Y had greater levels of commitment to the organization, higher perceptions of promo-tional opportunities, and mentor and supervisor support than did baby boomers or generation X cohorts.

Unlike generations X and Y nurses, baby boomer nurses reported that they did not complete an employee orientation program,25 possibly because they were older and might have been perceived as less in need of a formal orientation program. Orientation is a vital part of new nurses’ adjustment to their organizations and their recognition in the profession. Compared with the

work than did baby boomers.23 This finding varied from the traditional view that younger generations are lazy. Generations X and Y also focused more on future career plans and delaying rewards than did baby boomers,23 possibly because baby boomers are nearing retirement and deferring rewards is no longer necessary to achieve their goals. Jobe recognized that changes in work ethic dimensions could lead to strategies for improving gen-erational conflict and decreasing job turnover rates.

A study assessing generational differences in work-place ethics and turnover intention found significant differences between generation Y and baby boomers regarding emotional exhaustion, job satisfaction, and turnover intention.24 As expected, individuals from generation Y indicated significantly lower job satisfac-tion and higher turnover intentions when they were exhausted than did baby boomers.24 These findings might be the result of differing interpretations of the state of emotional exhaustion and different perceptions of work centrality among the generations.

Known to place more importance on work-life balance and leisure, generation Y might attribute their emotional exhaustion to the job itself because they do not value work more than their personal life and leisure time.24 Conversely, baby boomers might be willing to endure emotional exhaustion because they highly value their job and workplace ethics.24 In addition, baby boomers place their current position and job as top priorities, whereas generation Y members might be willing to try other posi-tions before deciding on an ideal career.

The researchers were surprised not to find signifi-cant differences between generation X and the other generations regarding job satisfaction and turnover intention.24 This result might be because generation X individuals share distinct similarities with members of both generation Y and baby boomers. Generations X and Y highly value work-life balance and are not very loyal; on the other hand, generation X’s approach to their careers is similar to that of baby boomers.

Because this study was based on data from 1 branded hotel management company, its limited sample size cannot be generalized to other populations, including health care professionals. In addition, the research-ers acknowledged having more female than male respondents, and they did not consider the possibility

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Involvement in decision making.A financially rewarding job.Work-life balance.A climate of diversity.Continuous learning.Career advancement.Immediate feedback and recognition.All 3 generations placed importance on 7 of 10 work-

place factors, demonstrating that the generations were more alike than different.1 The findings suggested the most significant generational differences concerned career advancement opportunities, which generation Y valued more than did generation X and baby boomers.1 The training and development value and the decision-making value also were statistically significant for generation X and baby boomers.1

Although this study suggested that more similarities than differences exist among the generational cohorts, a limitation of the research was the unequal group sizes. The researchers recommended using the same group size for each generational cohort in future research. One key implication of these findings is that managers need to be educated and informed about generational differ-ences and similarities rather than making assumptions.1

TeamworkEffective teamwork can be fostered in an environ-

ment that acknowledges the values, talents, and work ethics of each generational cohort.3,26 Several research studies documented generation X preferences for work-ing alone.27-29 One study examined the attitudes of baby boomers and generation X on team formation.27 Using a survey design, the researchers discovered that members of generation X were more competitive, independent, and had a greater preference for working alone compared with baby boomers.27 In another study with similar results, baby boomers were more comfort-able working with others and favored teamwork more than did generation X.28 Medical imaging and radiation therapy managers should inquire whether generation X employees prefer working alone or with others when assigning workload and other tasks.

When team members do not respect and value one another’s generational differences, conflict, distress, and incivility are unavoidable.3 Leiter et al collected

other generations, a higher percentage of baby boom-ers worked in jobs other than as staff nurses.25 A much lower percentage of baby boomers worked in intensive care units, but reported higher work motivation than did generations X and Y.25 It could be inferred that the baby boomer nurses in this study were better prepared to move into management positions although they were new graduates.

Nurses from generation X rated higher in work-to-family conflict and family-to-work conflict than did the other groups.25 As expected, those from generation X struggled with finding a balance between home and work life. Those from generation Y reported greater organizational commitment and were more likely to work 12-hour shifts and the night shift than were the other generations.25 Nurses from generation Y also expressed the importance of training with an expe-rienced mentor and receiving support from direct supervisors.25

As organizations continue to provide and improve orientations for newly licensed nurses, it is important to mold these programs to support nurses at the start of their careers and encourage their ongoing commit-ment to the profession. Although this study focused on nursing graduates, these findings are applicable to new radiologic technologists and radiation therapists. Managers of medical imaging and radiation therapy departments should invest time and effort into provid-ing new graduates and new hires with adequate training and orientation that clearly state work expectations and encourages a commitment to the organization and pro-fession.

To evaluate the importance that different genera-tional cohorts place on specific workplace factors, Mencl and Lester distributed a survey to 636 employ-ees aged 18 and older across government, health care, manufacturing, technology, real estate, and nonprofit organizations.1 The researchers analyzed data from a final sample size of 505 respondents who represented 3 generations (baby boomers, n 273; generation X, n 144; and generation Y, n 88).1 The survey focused on 10 workplace factors1:Teamwork and collaboration.Flexible work arrangements.A challenging job.

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nurses.31 However, the researchers noted that individu-als from younger generations often required additional training on how best to communicate face-to-face.31 Finding ways to help younger generations become more comfortable with this type of communication is key to ensuring adequate patient care.

Perceptions of Other GenerationsIn a study by Gursoy et al that explored how each

generation perceives the other generations, managers from the baby boomer generation expressed a very low opinion of generations X and Y.32 They believed the younger employees had no work ethic and considered them to be slackers.32 Baby boomer employees did not have very high opinions of their generation X manag-ers. They indicated the generation X managers did not have the experience to lead, did not respect the baby boomers’ life experiences, and relied too heavily on technology.32

Generation X managers did not think highly of generation Y employees. They considered them to be slackers, but admitted that they were very quick learners.32 Generation X, however, had very high opin-ions of baby boomer employees. They found them to be very responsible and customer oriented, but the generation X managers acknowledged difficulty in earning respect from their baby boomer employees.32 Generation X managers also stated that baby boomers were slow learners and not efficient with technology.32 Incidentally, generation X employees found their baby boomer managers to be poor team players and some-what out of touch with innovative ideas because of their fear of change.32

This study relied on focus group sessions among a small group of hotel employees for data collection. Although 10 focus group sessions were conducted, find-ings cannot be generalized beyond the scope of this study. Descriptive statistics and data collected from a sample of health professionals might be beneficial for future studies involving generational differences.

ChallengesSome scholars have acknowledged the difficulty with

defining generations.33-35 As stated previously, no official years mark the beginning or end of a generation.2-7 As

survey responses from more than 500 nurses to ana-lyze the effects of generational differences and the implications for establishing a healthy work environ-ment that promotes teamwork and good retention rates.29 The cohort sample represented baby boomers and generation X. Survey responses revealed that gen-eration X experienced more incivility from coworkers and supervisors and overall higher levels of distress compared with baby boomers.29 The researchers concluded that negative social encounters at work contributed to nurses’ distress and suggested conflicts in values occur between baby boomer and generation X team members.29 Future research is warranted to include generation Y perspectives and contributions to teamwork.

Patient CareEach generational cohort brings benefits to patient

care within a health care organization.3 Growing up in an era when technology was not available, most vet-erans and baby boomers are aware of subtle cues and changes in a patient’s status long before a monitor or test shows patient deterioration.30 This type of experi-ence bolsters veteran and baby boomer health care providers as experts in their respective departments.3 Conversely, generations X and Y grew up using tech-nology and therefore can act as resources and assist older generations with better understanding and using technology in patient care.30 Overcoming generational differences among health care teams is important because generational issues can result in poor patient care, poorer outcomes, unsafe patient conditions, and decreased patient satisfaction.2,3,30

Generational differences also can affect how patients perceive their care.2,31 Veteran or baby boomer patients might expect face-to-face communication from phy-sicians, nurses, and other health care professionals, whereas generation X and Y patients might prefer to have electronic communications rather than face-to-face interactions.2,3,31

One research study questioned whether 1 generation was more caring than another based on an emotional intelligence proficiency.31 The results did not indicate substantive differences in emotional intelligence among the baby boomer, generation X, and generation Y

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Peng believed this might provide better research on generational differences and might explain conflicting results in previous studies.36

This subjective, continuous approach could help researchers better understand generational differences in the workplace. By treating generational differences as a series of variables rather than just 1 categorical construct, this alternative approach provides a more theoretical definition of generational differences and presents a more reliable measurement.36 This approach potentially could result in stronger predictions of the effect of generational differences on work attitudes and behaviors.36

StereotypesAnother challenge related to generational differences

in the workplace is the idea of publicizing generation-based stereotypes at work.33-35,37,38 Internalization of generational stereotypes could cause problems for individuals and organizations.34 Research has shown that stereotyping in the workplace results in negative job attitudes, poor mental health, and greater intentions to resign.34,39 Negative metastereotypes—what a par-ticular group believes those in other groups think about them—also can be exacerbated.34 Metastereotypes related to generational differences could cause individu-als to overcompensate to challenge the stereotype they believe others hold about them. To counteract these negative stereotypes, the focus should build on the positive aspects of diversity and on developing a more inclusive work envirionment.34

Costanza and Finkelstein acknowledged that ste-reotypes exist because people from one particular generation do not share the same qualities, person-alities, and values as members of other generational cohorts.33 For example, the veteran generation is stereo-typed as being conservative and disciplined.7-9,33 These individuals grew up during the Great Depression, which is thought to have instilled in them values of frugality and hard work.33 Most would agree that this is a logical outcome; however, not all people who emerged from tough financial times embraced frugality.33 As an exam-ple, Costanza and Finkelstein discussed veterans who achieved success later in their adult lives, spent money impulsively, eventually declared bankruptcy, and ended up living in poverty again.33

with any social construct (eg, race, gender, ethnicity), boundaries are debated, and differentiations change with time and circumstances. Costanza and Finkelstein stated that generational cohorts are influenced by piv-otal U.S. events and the assumption is that these events affected individuals in the same way no matter where they were geographically.33 For example, the events of September 11 occurred in the northeastern United States. While these events affected individuals through-out the country, the way the event was internalized and processed might have been more intense for those located near the tragedies.33,34 Costanza and Finkelstein believed defining generations to be the greatest chal-lenge.

A lack of theory to support generational differ-ences also presents a challenge. However, Cadiz et al argued that methodological limitations, such as small sample sizes, guide research, not a lack of theory.34 They mentioned several theories to support the concept of generational differences: social forces theory, social identity theories, and lifespan development theories. However, Cadiz et al believed the way generational cohorts were examined in the literature is f lawed. They suggested that a study involving generational differenc-es is only helpful if the following conditions are met34:The idea of being part of a specific generation

becomes a part of people’s social identity.A generation is identified with specific events that

truly have a formative effect on people.Reciprocal influences and exchanges within and

between generations are studied along with the differences.

An Alternative ApproachWang and Peng proposed an alternative approach

to understanding generational differences specific to conducting organizational research.36 They suggested allowing the participants to decide which generation they identify with. Using a survey, checklist, or open-ended questions, the participants could rate the extent to which they identify with each category or statement. An analysis of their responses would allow researchers to classify the participants accordingly and proceed with their original research. Rather than being associ-ated with a generation based on a birth date, Wang and

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are offered some protection by the Age Discrimination in Employment Act; however, generation Y individuals are too young to qualify for legal protection. Thus, it is not clear what would happen if an employer terminated a younger employee based on his or her perceptions of generation Y.41 As expected, proving a termination decision was based solely on generational membership would be challenging.

Legislation that prohibits generation-based dis-crimination is unlikely, although considerable evidence shows that people refrain from making employment decisions based on stereotypes they believe are neither permitted nor appropriate.41 Cox and Coulton stated it was possible an enlightened supervisor might resist the temptation to ascribe behavior to age given the cur-rent legislation protecting older workers; however, the supervisor might feel that attributing behavior to gen-erational differences is acceptable because legislation does not address the issue.41

OpportunitiesGenerational challenges and stereotypes within an

organization might abound, but positive opportunities also exist.3 A multigenerational team can be an asset to an organization.2,3 Each member brings unique strengths, viewpoints, and skills relative to his or her generational cohort.3 Health care leaders who have an understanding of generational differences and strengths can improve staff satisfaction and facilitate constructive working rela-tionships to increase morale and productivity.42

Strategies to Increase Morale and ProductivityNelsey and Brownie stressed the importance of cre-

ating a work environment where employees, regardless of their generational background, feel supported and valued.42 They believed this work atmosphere could result in increased morale and productivity. Assessing a nursing workforce, they suggested providing generation Y nurses with opportunities for continual improvement and personal growth because these individuals tend to be ambitious and career focused.42 Nurse managers can provide generation Y staff nurses with opportuni-ties to lead teams and attend professional development workshops that focus on career advancement and pro-motion.42 These opportunities would allow generation

To address stereotypes associated with generation Y, Rentz conducted a mixed-methods study using surveys and focus group sessions. He discovered that this genera-tion defied some of the general stereotypes associated with their generation but exhibited some stereotypi-cal features as well.37 Contrary to common complaints about their poor work ethic, managers rated generation Y employees as having high standards, working hard, following through, and being realistic about rewards and raises.37 They also accepted criticism, did not require extra praise, took initiative, and were self-directed and resourceful.37

Rentz also documented support for certain stereo-types associated with generation Y. These included leveraging technology, having a strong interest in what it takes to succeed in the company, being less interested in employee news and other facets of the big picture, and having an inflated sense of some of their abilities.37 Because generational stereotypes exist, Rentz suggested it was important to teach employees about generational differences and promote a work atmosphere of respect where all generations can contribute and feel valued.37

Despite the negative connotation, some scholars consider the use of such stereotypes as necessary and acceptable.35,38,40 When comparing human groups, whether it is men, women, ethnic groups, leaders, ser-vice workers, nurses, or generations, stereotyping can be helpful and is expected.35 In almost every case, vari-ances in traits exist within a group, and in most cases, the differences within the group are larger than the variances between groups.35,40 In addition, although stereotypes are key to understanding perceptions and identity in organizations, some researchers substitute the word stereotype with the more neutral term proto-type to minimize the negative connotation.38

Generation-based DiscriminationThe general perception that differences among

individuals relate to specific generational cohorts can pose some risk.41 Although it is tempting to consider these generational stereotypes as innocent mispercep-tions, they might, in fact, be quite harmful.41 Although age discrimination is prohibited by law, discrimination based on generational differences is not explicitly pro-hibited.41 Cox and Coulton noted that older individuals

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boomers, with their superior clinical knowledge and extensive clinical experience, are well positioned to act as mentors and preceptors, in particular to younger generation Y nursing graduates.42 Mentoring is effective only when both the mentors and mentees earn mutual respect and benefit from the coaching process. In addi-tion, because other research studies indicated younger generations train best with veterans, the possibility of veterans serving as mentors should be considered.2

In organizations without formal mentoring sys-tems, Nelsey and Brownie suggested encouraging new employees to seek mentors from other venues.42 In the health care setting, mentoring can help older employees feel valued by sharing their knowledge and expertise, and as mentees, younger generations can develop a sense of belonging and importance. Managers also can offer mentoring through one-on-one sessions, group pro-grams, discussion panels, and roundtable discussions.3

ACORN PreceptsACORN (accommodate, create, operate, respect,

and nourish) is an acronym for the 5 precepts or opera-tional ideas used by successful companies to develop solid organizations.5 The use of these 5 precepts sup-ports a generationally comfortable work environment where employees focus their energies on accomplishing the mission instead of on conflict.5 Table 2 explains each precept and provides an example of how managers can use these principles when dealing with a multigen-erational department.

Impact Within RadiologyBecause research pertaining to medical imaging

and radiation therapy is extremely limited—most of the research pertains to radiologists—it is difficult to examine the effects of generational differences within the profession.12,43

Perceptions Among RadiologistsThe American College of Radiology (ACR)

hosted a forum to discuss the effect of generational differences among practicing radiologists.12 Younger radiologists (generations X and Y) were perceived as being less committed to their profession than were prior generations.12 They more commonly viewed

Y nurses to feel important to the organization, and they potentially will work harder after receiving such recog-nition.

The researchers also suggested providing generation X nurses with opportunities to work independently on projects because nurses from this generation tend to be self-reliant and resist being micromanaged.42 Generation X nurses are less likely to view their supervi-sors in a negative manner when tackling self-directed tasks, and ultimately it can increase morale and produc-tivity within the organization. Other general strategies managers can use to supervise generation X employees include42:Providing staff incentives.Being supportive, trustworthy, professional, and

dependable.Demonstrating good communication skills.Meeting regularly with staff members to provide

feedback.Leading by example.Nelsey and Brownie noted that an awareness of

generational differences allows nursing managers to try various strategies to bridge those gaps, and they are likely to use the expertise of each group to optimize patient care and meet the needs of the organization.42

MentoringMentoring and continual support are essential to a

new employee’s successful transition and professional growth, especially in the health care setting. Mentoring often is used to increase retention and decrease turn-over rates.42 Nelsey and Brownie defined a skilled nurse mentor as one who assists new employees and less experienced staff by sharing clinical expertise and familiarizing them with the work setting.42 Of course, mentoring requires a commitment from both the men-tor and mentee and is based on mutual trust, teaching, coaching, counseling, and friendship.42 Understanding generational differences and the common characteris-tics associated with each cohort can result in effective mentoring.

New nursing graduates from generation Y are profes-sionally confident and outspoken yet require lengthy orientation and continual feedback as they make the transition to the clinical work environment.42 Baby

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different generations to help foster a harmonious and productive radiology workforce.12

Job Satisfaction Among Radiologists

Moriarity et al assessed generational differences related to workplace satisfaction and workplace charac-teristics among 1577 practicing radiologists from the baby boomer and generation X cohorts.43 Despite widely reported differences among generations, the findings indicated baby boomer and generation X radiologists shared simi-lar characteristics.

Workplace satisfaction among baby boomer and gen-eration X radiologists was 78% and 80%, respectively.43 Both generations indicated higher job satisfaction when they felt optimistic about the future of radiol-ogy, when they perceived a narrow difference between their desired and expected age of retirement, when they emphasized social interactions, and when they valued professionalism among their peers.43

Baby boomer radiologists displayed greater job satisfaction when they worked in an environment that valued diversity, whereas generation X radiologists were more satisfied if they were paid well and worked in an environment that promoted job security.43 No significant association was seen between satisfaction and generation, sex, practice setting, or additional administrative work.43 The researchers concluded that workplace satisfaction among radiologists was high, and the 2 dominant generations of practicing radi-ologists had similar workplace satisfaction rates and preferred workplace characteristics.43 A research study involving radiologic technologists and radiation thera-pists is warranted to see if the results would be similar.

nonworking hours as an opportunity to pursue voca-tional and family activities rather than an opportunity to advance their medical knowledge, clinical practice, or the profession.12 Older radiologists (veterans and baby boomers) believed this attitude potentially could compromise the strength and vitality of the radiology profession and professional organizations such as the ACR.12

Veteran radiologists were described as hard working and sacrificial; baby boomer radiologists were identified as being workaholics and efficient; generation X radi-ologists were characterized as needing balance between home and work life and preferring f lexible work hours; and generation Y radiologists were labeled as being goal oriented, collaborative, and multitaskers.12 In addition, veteran radiologists viewed work as an obligation, baby boomer radiologists viewed it as an exciting adventure, generation X radiologists viewed it as a contract, and generation Y radiologists viewed it as a means to an end.12

Ultimately, the ACR thought it was critical to appreciate the varied needs, desires, and motivators of

Table 2

ACORN Precepts5

Precept Definition Example

Accommodating employee differences

Meeting the needs of employees by accommodating their unique preferences.

Allowing generation X employees to decide whether they want to work alone or on a team.

Creating workplace choices

Allowing the workplace to shape the work performed to serve customers and employees.

Using multiple modes of communication per employees’ preferences.

Operating from a refined management style

Providing specific goals and measures to achieve and allowing employees freedom to complete the tasks in their chosen manner.

Verbalizing work expectations and providing new hires with adequate orientation.

Respecting competence and creativity

Assuming the best from all employees (from new staff members to the most seasoned).

Providing ample time for veterans and baby boomers to accept change and use new technology.

Nourishing retention Retaining employees by providing frequent feedback, rewards, and recognition; encouraging lateral movement.

Offering new hires mentoring programs and giving specific praise to generation Y employees.

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radiation therapist. If applicable, radiology managers should modify a veteran’s job duties to accommodate his or her abilities.

In summary, Johnson and Johnson suggested the fol-lowing tips for managing veteran employees4:Make them mentors to younger employees.Provide training for new systems and procedures.Accommodate their needs.Recognize and applaud their contributions.Give one-on-one support.

Managing Baby BoomersAlthough baby boomers are nearing retirement, they

should not be shunted to the side and ignored until they leave.4 They have wisdom and experience that can provide valuable information for managers as they make important decisions about daily operations in the department. Like veterans, baby boomers feel valued and appreciated when they are given the opportunity to mentor a younger technologist.2,42 Of course, with any mentoring relationship, mutual respect and trust are essential.42

Managers from younger generations are encouraged to lead baby boomers by respecting their experiences and service to the department, motivating them on their own terms, and arranging for recognition and credit.4 Younger managers can prove themselves to baby boomer technologists and therapists by being a working manager and assisting with examinations and treatments during busy times or when short staffed. In summary, suggested tips for managing baby boomers include4:Make them mentors.Do not ignore or give up on them.Ask for continuing contributions.Offer opportunities to volunteer.

Managing Generation XAlthough generation X employees tend to seek indi-

vidual recognition, this does not imply that they cannot or will not work well on teams.4 Johnson and Johnson argued that creating collegial teams where generation X employees work with colleagues to accomplish a common goal can benefit an organization.4 Providing a f lexible work schedule can be a difficult task for medical imaging and radiation therapy departments; however,

Leadership TacticsAs leaders of the department, managers need to

understand each generation, recognize the generation they belong to, and use each group’s unique charac-teristics to their advantage.3 Facilitating employees’ growth and development is an important part of lead-ership; however, the presence of a multigenerational department makes this difficult to achieve.44 Medical imaging and radiation therapy managers are encour-aged to lead multigenerational departments using the following tactics44:Seek ways to understand each cohort and accom-

modate differences in attitudes, values, and behaviors.

Cultivate generational strengths to motivate all employees in the department.

Develop the ability to be more sensitive to the strengths and weaknesses of each cohort, espe-cially in the area of technology advancement.

Promote tolerance to avoid generational conflict and to enrich teamwork skills.

Capitalize on generational differences to improve the overall quality of work and to enhance patient care outcomes.

Managing VeteransIn today’s struggling economy, many veterans have

remained in the workforce.1 As previously mentioned, veterans like to be recognized for their years of service and experience. Pairing them with a newly hired young technologist can boost their morale and promote long-term benefits for the department as well.2 Veterans know a plethora of shortcuts and tips to achieve the perfect image during difficult procedures, and younger technologists can gain a wealth of information by learn-ing from experienced technologists.

Considering the continual advancements in medi-cal imaging and radiation therapy technology, veterans might need additional training when learning new equipment or software. Veterans are hard workers and will take the time to learn the equipment, software, and procedures even if they involve new technology. Individual support when learning how to operate new radiographic or therapeutic equipment also might be beneficial to a veteran radiologic technologist or

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managers should offer generation Y technologists and therapists f lexibility in terms of work hours and sched-ule. In conclusion, suggestions for managing generation Y include the following4:Create opportunities to bond.Offer mentoring, coaching, and guidance.Give praise that is specific, significant, and sincere.Provide constructive, specific criticism in private.

Preparing for Generation ZGeneration Z, also known as gen Z, iGeneration, and

linksters, were born after 2000.7,8 An estimated 23 mil-lion people in the United States compose this generation, and the group is growing.7 Most of the characteristics that define this generation have yet to emerge; however, because they have been exposed to digital communica-tion and technology throughout their lifetime, they are described as being highly connected.7,8 They tend to inter-act electronically more than personally, and they might choose to text message someone even if they are standing next to him or her.7 The Box lists some of the historical and social events experienced by generation Z individuals.

Although young, it appears that generation Z will mobilize around causes and be more socially and envi-ronmentally aware than previous generations.8 Many older individuals from generation Z are beginning to enter the workforce, and they are the most techno-logically savvy of any generation. They are connected to their peers through social media, are intelligent and have higher IQ scores than members of previous generations, and generally are accepting of diverse pop-ulations.8 This is the largest home-schooled generation, and they require less direction and supervision because

staggering start times, rotating shifts, and allowing time off for various family functions are a few ways managers can offer f lexibility to generation X employees.

Generation X individuals have a slightly different take on work than baby boomers and veterans. Johnson and Johnson suggested more tips for leading genera-tion X employees because they believed attracting and retaining generation X individuals allows managers to become more aware of employee needs, more open to different ways of doing things, and more agile and adaptable.4 Their tips include the following4:Give them individual recognition.Create collegial teams.Support their lifestyle (work-home life).Provide f lexible work schedules.Vary their experiences.Challenge them.Reward action.Provide feedback.Allow them to be themselves.Have fun.

Managing Generation YGeneration Y employees have different work require-

ments and expectations than do their baby boomer and generation X managers. Understanding these differenc-es helps managers to be effective and their generation Y employees to f lourish. By creating opportunities to bond, radiology managers can provide generation Y technologists with the rapport they are accustomed to with their teachers and parents. Johnson and Johnson stressed that managers should insist generation Y employees follow the rules, complete their tasks, meet their deadlines, and produce quality work.4 If they meet goals, managers should applaud them for their service. If not, managers should help, coach, encourage, and even counsel them to establish that bond so generation Y employees know what is expected of them.

Medical imaging and radiation therapy managers should check in with generation Y technologists and therapists daily, offering praise when deserved and pro-viding corrective feedback when needed. Managers also should communicate specific work expectations; gener-ation Y employees need to be aware of what is expected of them and what their responsibilities are. If possible,

Box

Influential Historical and Social Events Experienced by Generation Z4,8

War on TerrorActive shooter incidentsSwine fluHurricane KatrinaiPods and iPadsFacebook and other social media sites2011 tsunami in Japan

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15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to publications@asrt.org.

© 2017 American Society of Radiologic Technologists

References1. Mencl J, Lester SW. More alike than different: what gener-

ations value and how the values affect employee workplace perceptions. J Leadersh Organ Stud. 2014;21(3):257-272. http://dx.doi.org/10.1177/1548051814529825.

2. Lipscomb VG. Intergenerational issues in nursing: learning from each generation. Clin J Oncol Nurs. 2010;14(3):267-269. http://dx.doi.org/10.1188/10.CJON.267-269.

3. Eastland R, Clark KR. Managing generational differences in radiology. Radiol Manage. 2015;37(3):52-56.

4. Johnson M, Johnson L. Signposts: Harbingers of things to come. In: Generations, Inc.: From Boomers to Linksters – Managing the Friction Between Generations at Work. New York, NY: AMACOM; 2010:6-18.

5. Hahn JA. Managing multiple generations: scenarios from the workplace. Nurs Forum. 2011;46(3):119-127. http://dx.doi.org/10.1111/j.1744-6198.2011.00223.x.

6. McCready V. Generational issues in supervision and administration. ASHA Lead. 2011;16:12-15. http://dx.doi .org/10.1044/leader.FTR1.16052011.12.

7. Smither S. Facing generational differences: understanding is key. Vet Team Brief. 2015;45-47.

8. Wiedmer T. Generations do differ: best practices in leading traditionalists, boomers, and generations X, Y, and Z. Delta Kappa Gamma Bull. 2015;82(1):51-58.

9. Hendricks JM, Cope VC. Generational diversity: what nurse managers need to know. J Adv Nurs. 2013;69(3):717-725. http://dx.doi.org/10.1111/j.1365-2648.2012.06079.x.

10. Sedrak M, Cahill TF. Age-related conflicts: the generational divide. Health Prog. 2011;92(4):30-35.

11. Fry R. Millennials surpass Gen Xers as the largest genera-tion in U.S. labor force. Pew Research Center website. http://www.pewresearch.org/fact-tank/2015/05/11/millennials-surpass-gen-xers-as-the-largest-generation-in-u-s-labor-force. Published May 11, 2015. Accessed April 14, 2016.

12. Krishnaraj A, Weinreb JC, Ellenbogen PH, Patti JA, Hillman BJ. Impact of generational differences on the future of radiology: proceedings of the 11th annual ACR Forum. J Am Coll Radiol. 2012;9(2):104-107. http://dx.doi.org/10.1016/j.jacr.2011.08.019.

13. Buahene AK, Kovary G; n-gen People Performance Inc. The road to performance success: understanding and managing the generational divide. http://www.ngenperformance .com/pdf/white/ManagingGenDivide.Overview.pdf. Published 2003. Accessed April 4, 2016.

they already have access to digital tools that enable them to do almost anything.8

Members of other generations must be able to work with and adjust to generation Z’s changing social skills that are driven by advancing technologies.4,8 This gen-eration can present themselves as an open book with very little concern about sharing private and personal matters. Like generation Y, individuals from generation Z are close to their parents and consider them to be their best friends.4

As more generation Z members enter the workforce, they easily can handle job requirements that involve technology but will have a tougher time with face-to-face communication with customers and coworkers.4 In addition, as higher education becomes more cost pro-hibitive, generation Z will seek alternative ways to enter their preferred, chosen professions.8

ConclusionMultiple generational cohorts coexist in the work-

place today. Each group brings different viewpoints, expectations, desires, dreams, values, and ideas about work and life. For health care organizations, these generational differences can enhance teamwork and improve patient care; they also can present challenges such as conf lict and stereotyping. By understanding generational differences, managers and organizations can foster a work environment that embraces diver-sity and promotes productivity. Because very little research on generational differences in the radiology workplace has been conducted, research specific to the medical imaging and radiation therapy professions is warranted.

Kevin R Clark, EdD, R.T.(R), is assistant professor and graduate coordinator with the department of radiologic sciences at Midwestern State University in Wichita Falls, Texas. He has a bachelor’s degree in radiologic technology, a master’s degree in instructional technology, a master’s in teaching with an emphasis in secondary mathematics, and a doctorate in educational leadership and management. He can be contacted at kevin.clark@mwsu.edu.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department, at

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27. Sirias D, Karp HB, Brotherton T. Comparing the levels of individualism/collectivism between baby boomers and generation X: implications for teamwork. Manage Res News. 2007;30(10):749-761. http://dx.doi.org/10.1108 /01409170710823467.

28. Yrle AC, Hartman SJ, Payne DM. Generation X: acceptance of others and teamwork implications. Team Perform Manage. 2005;11(5/6):188-199. http://dx.doi.org/10.1108/135275 90510617765.

29. Leiter MP, Price SL, Spence Laschinger HK. Generational differences in distress, attitudes and incivility among nurses. J Nurs Manag. 2010;18(8):970-980. http://dx.doi.org/10 .1111/j.1365-2834.2010.01168.x.

30. Conning D, Cook D. Bridging the generational divide in the PACU. The Dissector. 2012;40(1):27-30.

31. Codier E, Freel M, Kamikawa C, Morrison P. Emotional intelligence, caring, and generational differences in nurses. Int J Hum Caring. 2011;15(1):49-55.

32. Gursoy D, Maier TA, Chi CG. Generational differences: an examination of work values and generational gaps in the hos-pitality workforce. Int J Hospit Manag. 2008;27(3):448-458. http://dx.doi.org/10.1016/j.ijhm.2007.11.002.

33. Costanza DP, Finkelstein LM. Generationally based dif-ferences in the workplace: is there a there there? Ind Organ Psychol. 2015;8(3):308-323. http://dx.doi.org/10.1017/iop .2015.15.

34. Cadiz DM, Truxillo DM, Fraccaroli F. What are the benefits of focusing on generation-based differences and at what cost? Ind Organ Psychol. 2015;8(3):356-362. http://dx.doi .org/10.1017/iop.2015.49.

35. Campbell WK, Campbell SM, Siedor LE, Twenge JM. Generational differences are real and useful. Ind Organ Psychol. 2015;8(3):324-331. http://dx.doi.org/10.1017 /iop.2015.43.

36. Wang Y, Peng Y. An alternative approach to understanding generational differences. Ind Organ Psychol. 2015;8(3):390-395. http://dx.doi.org/10.1017/iop.2015.56.

37. Rentz KC. Beyond the generational stereotypes: a study of U.S. generation Y employees in context. Bus Prof Commun Q. 2015;78(2):136-166. http://dx.doi.org/10.1177/23 29490615576183.

38. Lyons S, Urick M, Kuron L, Schweitzer L. Generational dif-ferences in the workplace: there is complexity beyond the stereotypes. Ind Organ Psychol. 2015;8(3):346-356. http://dx.doi.org/10.1017/iop.2015.48.

39. von Hippel C, Kalokerinos EK, Henry JD. Stereotype threat among older employees: relationship with job attitudes and turnover intentions. Psychol Aging. 2013;28(1):17-27. http://dx.doi.org/10.1037/a0029825.

14. Sánchez M, Kaplan M. Intergenerational learning in higher education: making the case for multigenerational class-rooms. Educ Gerontol. 2014;40(7):473-485. http://dx.doi .org/10.1080/03601277.2013.844039.

15. Therrell JA, Dunneback SK. Millennial perspectives and priorities. J Scholarsh Teach Learn. 2015;15(5):49-63.

16. Salajan FD, Schönwetter DJ, Cleghorn BM. Student and fac-ulty inter-generational digital divide: fact or fiction? Comput Educ. 2010;55(3):1393-1403. http://dx.doi.org/10.1016/j .compedu.2010.06.017.

17. Gros B, Garcia I, Escofet A. Beyond the net generation debate: a comparison of digital learners in face-to-face and virtual universities. Int Rev Res Open Distance Learn. 2012;13(4):190-210. http://dx.doi.org/10.19173/irrodl.v13i4 .1305.

18. Bullen M, Morgan T, Qayyum A. Digital learners in higher education: generation is not the issue. Canadian J Learn Technol. 2011;37(1):1-24.

19. Romero M, Guitert M, Bullen M, Morgan T. Learning in digital: an approach to digital learners in the UOC scenario. Paper presented at: 2010 EDEN Conferences; June 2010; Valencia, Spain. http://www.eurodl.org/materials/spe-cial/2011/Best_of_EDEN_2010.pdf. Accessed April 14, 2016.

20. Čičević S, Samčović A, Nešić M. Exploring college students’ generational differences in Facebook usage. Comput Hum Behav. 2016;56:83-92.

21. Manca S, Ranieri M. Is it a tool suitable for learning? A critical review of the literature on Facebook as a technology-enhanced learning environment. J Comput Assist Learn. 2013;29(6):487-504. http://dx.doi.org/10.1111/jcal.12007.

22. Becton JB, Walker HJ, Jones-Farmer A. Generational differences in workplace behavior. J Appl Soc Psychol. 2014;44(3):175-189. http://dx.doi.org/10.1111/jasp.12208.

23. Jobe LL. Generational differences in work ethic among 3 generations of registered nurses. J Nurs Adm. 2014;44(5):303-308. http://dx.doi.org/10.1097/NNA .0000000000000071.

24. Lu ACC, Gursoy D. Impact of job burnout on satisfaction and turnover intention: do generational differences matter? [published online ahead of print July 15, 2013]. J Hosp Tour Res (Wash DC). 2013;40(2):1-26. http://dx.doi.org/10.11 77/1096348013495696.

25. Keepnews DM, Brewer CS, Kovner CT, Shin JH. Generational differences among newly licensed registered nurses. Nurs Outlook. 2010;58(3):155-163. http://dx.doi.org /10.1016/j.outlook.2009.11.001.

26. Lyons S, Kuron L. Generational differences in the work-place: a review of the evidence and directions for future research. J Organ Behav. 2014;35(S1):S139-S157. http://dx.doi.org/10.1002/job.1913.

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40. Zell E, Krizan Z, Teeter SR. Evaluating gender simi-larities and differences using metasynthesis. Am Psychol. 2015;70(1):10-20. http://dx.doi.org/10.1037/a0038208.

41. Cox CB, Coulton G. Fire all the boomers: how generational labeling legitimizes age discrimination. Ind Organ Psychol. 2015;8(3):372-376. http://dx.doi.org/10.1017/iop.2015.52.

42. Nelsey L, Brownie S. Effective leadership, teamwork and mentoring--essential elements in promoting generational cohesion in the nursing workforce and retaining nurses. Collegian. 2012;19(4):197-202. http://dx.doi.org/10.1016/j .colegn.2012.03.002.

43. Moriarity AK, Brown ML, Schultz LR. We have much in common: the similar inter-generational work preferences and career satisfaction among practicing radiologists. J Am Coll Radiol. 2014;11(4):362-368. http://dx.doi.org/10.10 16/j.jacr.2013.08.008.

44. Ahmad H, Ibrahim B. Leadership and the characteristic of different generational cohort towards job satisfaction. Procedia Soc Behav Sci. 2015;204:14-18. http://dx.doi.org/10 .1016/j.sbspro.2015.08.104.

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Read the preceding Directed Reading and choose the answer that is most correct based on the article.

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Managing Multiple Generations in the Workplace

1. Which of the following describes the environment baby boomers grew up in?

1. steady state of free expression2. economic prosperity3. world wars

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

2. Which generation dislikes direct supervision and resists micromanaging bosses?a. veteransb. baby boomersc. generation Xd. generation Y

3. Which generational cohort represents the largest group of workers in the U.S. workforce today?a. veteransb. baby boomersc. generation Xd. generation Y

4. In the study by Becton et al, which generational cohort scored themselves the highest with respect to attendance and dress code compliance?a. veteransb. baby boomersc. generation Xd. generation Y

5. In the study by Mencl and Lester, which workplace factor resulted in the most significant difference among the generational cohorts?a. career advancement opportunitiesb. involvement in decision makingc. work-life balanced. continuous learning

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10. Which generation of radiologists displayed greater job satisfaction based on job security and good compensation?a. veteransb. baby boomersc. generation Xd. generation Y

11. Which of the following are strategies for leading veteran employees?

1. using electronic communications such as email

2. providing training for new procedures3. giving one-on-one support

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

12. Which of the following describe generation Z?1. beginning to enter the workforce2. intelligent with high IQ scores3. the most technologically savvy generation

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

6. Which statement is true regarding the study by Gursoy et al on perceptions of other generations?a. Baby boomer managers believed younger

generation employees had a strong work ethic and considered them to be hard workers.

b. Baby boomer employees did not have high opinions of their generation X managers.

c. Generation X managers thought highly of generation Y employees.

d. Generation X managers said baby boomer employees were fast learners and good with technology.

7. Proving a termination decision was based solely on generational membership would be challenging.a. trueb. false

8. Strategies to increase morale and productivity among generation X employees include:

1. providing staff incentives.2. being supportive, trustworthy,

professional, and dependable.3. leading by example.

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

9. The American College of Radiology determined which generation of radiologists considered work to be a contract?a. veteransb. baby boomersc. generation Xd. generation Y

mailto:elipman@asrt.org

✁

Carefully cut or tear here.

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Breast cancer care has improved markedly in recent decades, but new advancements in diagnosis and treatment depend on translating genomics and precision medicine into clinical care. This article discusses the basics of genomics, breast cancer biomarkers and subtypes, and the effects of genomic advancements on future breast cancer diagnosis, treatment, and survival. The article also presents challenges related to introducing precision medicine into cancer care and the role of imaging in breast cancer diagnosis and treatment in precision medicine.

After completing this article, the reader should be able to:Describe genomic terms and concepts. Understand the role of genetics in the continuum of breast cancer care. List the genetic subtypes of breast cancer. Explain precision medicine and targeted treatment of breast cancer. List the challenges associated with incorporating genetics and precision medicine into

breast cancer care.

Teresa G Odle, BA, ELS

Precision Medicine in Breast Cancer

In 1928, Hermann Joseph Muller discovered the link between radia-tion and mutations. He and Thomas Hunt Morgan also noted a link

between radiation and cancer. These men were on the brink of discovering the genetic workings of cancer cells, but soon became rivals and both failed to accept the contribution genetics could make to medicine. Even though micro-scopic study of cancer cells in the 1940s showed mitosis in samples of cancer tis-sue, researchers could not determine why the normal division of cells became chaotic in malignant tissue.1

Early study of breast cancer and the human genome found 127 genes with mutations in 1 sample tissue from a 43-year-old woman.1 This early exam-ple showed the heterogeneity in breast cancer.1,2 For all living beings, genetic variation is the rule, not the exception.3 Although breast cancer detection and treatment have advanced in the past few decades and significantly improved survival, a cure for this increasingly

prevalent cancer in women remains elusive.2,4,5 The heterogeneous nature of breast cancer leads to wide variation in presentation, behavior, and therapeutic response, which in turn affects each individual’s prognosis (see Figure 1).6,7 Heterogeneity can relate to differences among tumors from 1 population to another, variations within a tumor, or temporal variability in tumor growth or treatment response.8

At the molecular level, multiple cells and interactions make up the complex and diverse nature of breast cancer, and cancer clearly is a genetic disease, whether the altered genes are inherited or acquired during a person’s lifetime.9,10 Studies have identified variations in how breast cancers express clinical biomarkers such as estrogen, and new sequencing methods also have shown that in some breast tumors, no 2 cells have identical genomic profiles.8 Research now focuses on identifying heretofore unknown molecular causes of breast cancer,2 which can lead to the

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epidermal growth factor receptor 2 (ERBB2, formerly HER2 or HER2/neu) markers and development of treatment targeted specifically for these breast cancer types has been an initial step in applying genomic knowledge to breast cancer care.13 For the most part, however, translation of genomic medicine to traditional clinical care has been sporadic and lacks structured coordination.14 Research continues to further identify genetic changes and features related to breast cancer, along with the complex interaction between genetics and lifestyle or environmental factors.15

Genetics and GenomicsGenomics is a relatively new term related to map-

ping of the human genome. The Human Genome Project began in 1990 and was completed in 2003. Collaborative efforts led to sequencing all 3 billion base pairs in the human genome. The term genome refers to a complete set of DNA instructions.16 Genetics, which is the study of how individual genes are composed and function to affect inherited traits or disorders, can be traced back to Gregor Mendel’s tracking of traits in pea plants in the 1800s.17,18 The World Health Organization defines genetics as “the study of heredity.”18

Genomics expands on genetics by including all genes and how they interact with one another and their envi-ronment. For example, genomics addresses the effect of lifestyle on gene interactions.17,18 In the context of breast cancer, genetic testing and counseling might assist with the diagnosis and care of women at risk for the breast and ovarian cancer susceptibility gene (BRCA1) muta-tion, but genomics includes the study of how genetic variants contribute to cancer development in women who have BRCA1 mutations.14,19 The term epigenetics refers to the study of lifestyle factors’ effects on gene expression.20

With 100 trillion cells containing DNA in each indi-vidual, mapping the genome or identifying the cause of cancerous cell growth can be an enormous task.15 Further, 99% of human genomes and DNA base pairs are the same for all people.15,21 Variations that cause diseases such as breast cancer make up only 1% of the genome.15 Each individual can inherit risk for disease from either biological parent’s chromosomes, which means there are 2 chances for variations.19 Analyzing

kind of personalized care that optimizes the benefits of breast cancer diagnosis and treatment while minimiz-ing any associated harms.11

A major step toward a cure—or at least improved survival for some women with the disease—rests with new approaches at the molecular level.4 Successful clon-ing of the human genome is opening the door to new opportunities in the diagnosis and treatment of disease. By identifying the genes involved in breast cancer devel-opment and recurrence, physicians can begin to treat patients using personalized approaches.12

As of the end of 2016, breast cancer was considered a set of at least 5 discrete subgroups based on molecular features.7 Identification of estrogen receptor and human

Figure 1. Across different cancer types, and even within the same tumor, cancer cells exhibit a wide variety of molecular structures and characteristics. This so-called heterogeneity poses difficult challenges to researchers trying to find better ways of managing the disease. This sample of clinical triple-negative breast cancer is stained for bone morphogenetic protein-11 (red); the Golgi marker GM130 (green); glycosylated proteins (white); and nuclei (blue), illustrating profound molecular heterogeneity. Widefield fluorescence microscopy was used to obtain the image. Image courtesy of Kevin Janes and the National Cancer Institute/University of Virginia Cancer Center.

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carry out the encoded function of a gene.1 MicroRNA (miRNA) is a short RNA molecule that might not code messages, but nonetheless is critical in gene expres-sion (see Figure 2).26 Epigenetically regulated miRNA molecules reside frequently within sites and genomic regions associated with cancer. When certain miRNAs normally associated with tumor suppression are down-regulated because of epigenetic modifications, cancer cells can be more highly malignant or likely to metas-tasize.26 Research has identified several miRNAs that affect breast cancer. For example, miR-21 is known to target and regulate tumor suppressors.27

Somatic vs Germline VariantsGermline variants, also called mutations, are

hereditary changes in DNA sequence, passed through biological germ, or reproductive, cells (sperm and egg). Somatic alterations can occur in any of the body’s cells other than germ cells, including tumor cells; somatic

and computing genetic alterations that contribute to cancer is a complex effort.22

Genetic Materials and TermsAlthough a gene carries information and genetic

materials, the mechanics of a gene’s function and even how genetic information reaches or activates within a cell is key to understanding cancer and other diseases.1

DNADNA, which is located primarily in a cell’s nucleus,

contains molecular codes that control growth, aging, and other processes or traits. DNA can replicate, or copy, itself to produce identical DNA in new and old cells that have divided.20,21 Cell-free DNA (cfDNA) con-tains nucleic acid fragments released during apoptosis, or programmed cell death. Cell-free DNA is found at higher levels in people with cancer than in healthy indi-viduals.8 Circulating tumor DNA (ctDNA) is a portion of cfDNA that is present in greater amounts in the bloodstream than actual circulating tumor cells. The ctDNA remains in the bloodstream only for a matter of hours.8 A gene is 1 section of DNA that contains com-plete instructions to make a specific protein. Genes are DNA sections with complete instructions for specific proteins.20,21

RNARibonucleic acid (RNA) provides the

blueprint for genes and is involved in gene activation. Transcription refers to the process of copying the RNA from a gene sequence, and translation involves the communica-tion between messenger RNA sequences and amino acids during protein synthesis.1,23 Messenger RNA (mRNA) molecules hold the genetic information that makes proteins.25

Hormones such as estrogen promote tran-scription by binding to estrogen receptors of some genes. Estrogen also can cause genomic instability, and elevated estrogen levels are associated with increased breast cancer risk.24

RNA provides the genetic messages that translate into proteins, which then

Figure 2. MicroRNAs (miRNAs) are small molecules critical to gene expression. Researchers are creating artificial miRNAs capable of binding to and silencing genes associated with cancer. Delivering such miRNAs to their target is another challenge. This image shows self-assembled nanoparticles (in red) carrying miRNAs to an aggressive breast tumor in a mouse model and sticking to the tumor target with the help of an adhesive glue. Image courtesy of Joao Conde, Nuria Oliva, and Natalie Artzi, and the National Cancer Institute/Koch Institute for Integrative Cancer Research at MIT.

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MicrobiomeA microbiome is the sum of genetic material in a cell

or other microbe. The term also applies to groups of genetic material that share an environment. Trillions of microbes live inside each human body and can change depending on lifestyle, illness, and the physical environ-ment. Recent study of the microbiome has found that some microbes live inside the body and cannot survive outside of its confines.32

EpigenomeThe epigenome includes chemical compounds on

genes that modify the genome to affect genomic behav-iors. Epigenetic markers are not part of DNA, but can pass among cells as cells divide or regenerate. Genes are permanent, but epigenetic expression can change depending on the influence of lifestyle and environ-ment.20,33 Epigenetic modifications have been found to affect many diseases, explaining differences in complex diseases such as breast cancer. Epigenetic changes could explain late onset of disease in some individuals or the variation in symptoms among people who have the same disease.26

BiomarkerA biomarker is a characteristic that can be measured

and evaluated as an indicator of normal biological or pathogenic processes, or pharmacologic responses.3 Typically, biomarkers are found in blood or urine test-ing or through biopsy of tumor cells.34 Also called tumor markers, biomarkers provide specific information about tumor cell make-up or behavior and likeliness to recur or respond to treatment.34 They are determined by bio-marker assays.35

Human Genome ProjectAn international consortium was formed in the

1980s with a goal of producing a reference sequence for the human genome. The U.S. Congress supplied funding for the project through the National Institutes of Health and the Department of Energy to encour-age coordination of genome mapping.36 Known as the Human Genome Project, the first draft of genomic sequencing was released in 2001, and the project was completed in 2003. By the final publication, the

variants also can cause cancer. Germline variants are passed on to offspring, but somatic variants are not transferred. Somatic variations also are called acquired variations or mutations.3,28 Mutation of the BRCA gene is an example of a germline variant in breast cancer (see Figure 3). An example of a somatic variant is tumor protein p 53 (TP53).29

ProteinsProteins are made up of amino acids and regulate

most cellular functions.1,6 They also are receptors for other proteins. Proteins affect cellular pathways (com-binations of genes working together) and the networks formed in cells, tissues, and organisms.1,6,22 For example, a number of specific proteins support DNA repair.30 By manufacturing enzymes, proteins can initiate biochemi-cal reactions in cells. Although proteins control chemical processes in cells, environmental and lifestyle factors also affect chemical processes.1,6,22 Increased cellular prolif-eration in cancer cells requires metabolic resources (eg, nutrients) and genetic materials (eg, protein) to create supportive cellular pathways.31

Classic BRCA1 Pedigree

Breast, dx 42

Ovarian, dx 49

Breast, dx 38

Ovarian, dx 53

Figure 3. Pedigree showing some of the classic features of a family with a deleterious BRCA1 mutation across 3 generations. The unaffected female subject (arrow) is shown as having an affected mother (breast cancer diagnosed at age 42 years), female cousin (breast cancer diag-nosed at age 38 years), maternal aunt (ovarian cancer diagnosed at age 53 years), and maternal grandmother (ovarian cancer diagnosed at age 49 years). BRCA1 families might exhibit some or all of these features. As an autosomal dominant syndrome, a deleterious BRCA1 mutation can be transmitted through maternal or paternal lineages, as depicted in the Figure. Image courtesy of the National Cancer Institute.

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their genetic risk for breast cancer and then are faced with making decisions about risk and preventive care before even developing cancer.13

Still, fewer than 10% of breast cancers are associated with hereditary breast and ovarian cancer syndromes. In-depth genetic testing of BRCA genes further targets the genomics behind the mutations’ effects on cancer cells by identifying germline mutations.44 Genomic information can enhance the use of traditional risk fac-tors in treatment and prognostic decisions.7,43

For example, being overweight or obese in the years following menopause is considered a risk factor. The reason most likely is that adipose tissue is the primary source of estrogen in women following menopause. Yet not every woman who is overweight develops cancer, nor do all women with breast cancer have high body mass indices (BMIs).43,46 Guo et al studied previously identified genetic sequences related to high BMI in European populations.46 According to the authors, these genetic changes are present from birth and not related to lifestyle or other outside factors. The authors noted they were surprised to find that women with a predicted high BMI based on genetics were less likely to have breast cancer than were controls, which suggests further study of this lifestyle risk factor is warranted.46

Other traditional risk factors for breast cancer include early menstruation, late or no pregnancy, inactivity, history of radiation treatment, dense breast tissue, and use of combination hormonal therapy. In addition, known genetic mutations responsible for breast cancer or family history play roles in genetic risk.43 Age also is a factor. Being older than 50 years increases risk of developing breast cancer, but develop-ing the disease at a younger age (typically # 45 years old) increases risk of poor prognosis.43,47

Azim et al showed that tumors differ biologically depending on whether they occur in younger or older ( 70 years) women. The breast cancers also differed in RNA and DNA make-up. Older patients’ tumors had more genetic mutations and more copy number varia-tions than younger ones. The variations are important in breast cancer biology.47 Although current methods help stratify individual risk factors for breast cancer, researchers are working on models that can identify multiple risk factors.42,48

consortium had sequenced 99% of the human genome with 99.99% accuracy.37 All data were made public to assist in medical research.38

Because cancer involves complex genomic changes, the National Cancer Institute has worked with the National Human Genome Research Institute to create the Cancer Genome Atlas. The project is designed to gather data from researchers and provide genomic information for new research. Containing data on the genes of normal tissue from more than 10 000 people, the atlas has mapped changes in genes for 33 cancers.39 The Cancer Genome Atlas Breast Cancer project began in 2013.40 Most future drug development likely will be based on genomics, largely because of human gene sequencing.38

Role of Genes in Breast CancerAlthough researchers do not entirely understand

how breast tissue changes from normal to malignant, they know enough to begin incorporating new therapies to target molecular changes in therapy development.41 Often, new efforts to understand the genomics behind breast cancer are combined with known risk or prog-nostic factors. For example, Evans et al reported that using information on a woman’s breast density and DNA in risk models on large populations of women resulted in more precise risk estimates than did tradi-tional screening methods.42

RiskCancer risk factors warn individuals about the

chance that they will develop cancer or have a poorer prognosis if cancer is diagnosed. Traditional clinical and pathologic risk factors guide screening and manage-ment decisions but do not address specific individual risk.7,43 These factors traditionally have been based on age, tumor type and size, histologic grade, and presence or absence of hormone receptors.7 Study of BRCA1 and BRCA2 mutations since their discovery late in the 20th century has advanced the risk stratification and role of genetic testing and counseling for women with breast and ovarian cancers.44,45 Carriers of variations learn of

For more information about the genome, watch the video at asrt.org/as.rt?8UN8Fv.

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death.5 Worldwide, people with breast cancer typically want to know the cause. Much of the information they receive on risk factors for the disease, and especially on remaining free of cancer following initial treatment, comes from media, social media, and similar sources. When women are looking to modify lifestyle to remain healthy and prevent recurrence or adverse treatment effects, they look for factors they can control.52

Many studies have reported on the value of hormone receptor expression in prognosis.29 Studies also have consistently shown that a patient’s baseline ctDNA status affects prognosis for breast cancer.40 As research continues, genetic expression profiling of breast tumors could identify subgroups of patients and more indi-vidualized management of their disease and prognosis.7 Research involving large-scale genomics already has revealed that breast cancer is a group of molecular sub-types that are associated with different responses to treatment and prognoses.53

Physicians caring for breast cancer patients also should be able to provide evidence-based information to support women’s desire to control their disease. For example, dietary intake of certain minerals affects genomic stability. Availability of key micronutrients can affect stability pathways, including how an individual’s body and cells react to exposure to carcinogens or the ability of DNA to repair itself. Al-saran et al reported that most adults do not receive the recommended levels of zinc from their diets, including an average of less than half the recommended amount for U.S. adults.48 The trace element is critical in the formation or function of proteins and transcription factors associated with DNA damage response and repair, along with tumor suppres-sor gene regulation.48

Evidence already exists regarding the psychosocial benefits of predictive testing for women who have a family history of genetic breast cancer and for high lev-els of long-term distress in patients and survivors with positive BRCA breast cancer results; genetic informa-tion and counseling can support decision-making for women and how they can reduce their risk.54,55

Germline MutationsCancer from germline mutations, or inherited

cancer, makes up only 5% to 10% of all cancers.56 A

Recurrence and MetastasisAs many as one-third of patients who have breast

cancer experience a recurrence of the malignancy, and the recurrence often results in death.40 Those who have a local-regional recurrence average an 80% 5-year survival rate vs a 25% 5-year rate for women with metastases.5 Genomics is improving the understanding of recurrence risk and could one day contribute to the assessment of a tumor’s history and prognosis, along with its potential to metastasize.5,49 Under current methods, morphology and physical properties of a tumor often guide treatment and recurrence prediction. Disease staging information and changes in tumor size help physicians determine treat-ment effectiveness. More recent studies have identified biomarkers, or biological indicators (such as metabo-lites) that help predict recurrence and other prognostic factors. Chen et al recently identified cellular pathways associated with risk.49 A cellular pathway involves molec-ular mechanisms made up of or regulated by genes.41 All 8 pathways the researchers found relate to drug response and immune regulation.49

Tumors that are estrogen receptor (ER)-positive and ERBB2-positive represent some of the most com-mon types of breast cancer. Although endocrine therapy has been used to treat many patients with these types of tumors successfully, risk of recurrence has remained significantly high. This percentage includes women who have had extensive surveillance and monitoring. Knudsen et al added cyclin dependent kinase (CDK) 4 and 6 inhib-itors to treatment and found that the combination therapy suppressed genes associated with recurrence and induced a class of genes found to improve survival.50

Up to 30% of breast cancer recurrences present as metastases. Traditional theories describe the complex interaction of malignant cell soiling and seeding.51 Metastatic tumors are made up of cells from the pri-mary cancer, but research now shows that the genomic profiles of cells from primary tumors and metastatic ones can be markedly different. Researchers theorize that as the disease progresses, the genomics of cancer cells evolve, leading to these differences.8,51

Prognosis and SurvivalMounting evidence shows that underlying tumor

biology affects risk of breast cancer recurrence or

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allele mutation have more than a 2-fold relative risk of breast cancer.

ATM serine/theonine kinase (ATM) gene muta-tions are associated with a condition called ataxia-telangiectasia, which makes children who have the mutation more susceptible to can-cer. The protein kinase on ATM is involved in complex functions of DNA repair. The gene’s contribution to elevated breast cancer risk varies, depending on the type of mutation carried.

BRCA-interacting protein C-terminal helicase 1 (BRIP1) is a rare mutation associated with breast cancer risk. The gene affects DNA repair and BRCA1 gene activities.

Neurofibromatosis type 1 increases the risk of tumors in carriers and can cause a moderate increase in breast cancer risk.

Partner and localizer of BRCA2 (PALB2) can increase risk in some carriers of this mutation that affects how a protein on the gene interacts with BRCA2.

Some genes, such as fibroblast growth factor 2 (FGF2) and vascular endothelial growth factor (VEGF), are known to promote growth of endothelial cells and angiogenesis. This means variation in the genes can be associated with multiple cancers.4 Even with current research, at least three-fourths of cases of familial breast cancer have no known associated gene.

Breast Cancer Molecular SubtypesTraditionally, genetic testing in breast cancer

focused on identified gene mutations that increased risk of inherited breast cancer, primarily BRCA1 and BRCA2.58 In 2000 and 2001, researchers used gene expression analyses and other methods to attempt to explain the variation among breast cancer types. The analyses were based on 496 genes that helped separate naturally occurring molecular subtypes.6,7 These sub-types, organized by cell line, help predict a patient’s prognosis and response to therapy and form the basis for integrating genomics into traditional breast cancer research and care.

The early subtypes identified included basal-like, luminal A, luminal B, normal-like, and ERBB2-positive (HER2-enriched). Later, the normal-like (also called

germline mutation in the BRCA1 or BRCA2 gene increases lifetime risk of breast, ovarian, and other cancers.57 When normal, both genes produce proteins that suppress cell growth of tumors by helping repair DNA and keeping the genetic material in cells stable. When the genes are mutated, tumor suppressor protein production is halted or the resulting protein does not function as it should in DNA repair. Fewer than 10% of all breast cancers occur because of hereditary genetic mutations; BRCA-related breast cancers make up nearly 20% of those hereditary cancers. In addition, ovarian cancer, fallopian tube cancer, male breast cancer, and others are associated with BRCA mutations.58

As many as 45% of families who have mul-tiple breast cancer diagnoses are linked to BRCA1.42 Recommendations for genetic testing for BRCA vary, but typically, genetic testing for this mutation is based on family history of breast cancer before age 50 years, both breast and ovarian cancers occurring in the same family, and other signs.57,58

The high penetrance gene TP53 has been associated with more human cancer than any other somatic genetic alteration.59 The TP53 mutation can cause a condition called Li-Fraumeni syndrome. The syndrome is associ-ated with increased risk for breast cancer, along with brain tumors, soft tissue sarcoma, and osteosarcoma. The breast cancer risk from TP53 variations is particu-larly high in carriers younger than 30 years.

Less is known about the degree of breast cancer risk from other genes known to increase risk. Notably, the phosphatase and tensin homolog (PTEN) gene, which leads to Cowden disease, also is linked to breast cancer. Serine/theonine kinase 11 (LKB1/STK11) mutations can lead to breast cancer and Peutz-Jeghers syndrome. A mutation that is known to cause gastric cancer also can increase familial breast cancer; the gene is cadherin, type 1 (CDH1).42 Among other possible breast cancer susceptibility genes are42: Checkpoint kinase 2 (CHEK2) is a rare mutation

that affects a protein involved in DNA repair. Studies have shown that a specific variation in CHEK2 causes truncated protein; although the mutation is present in about 1.1% of healthy people, about 5.5% of people with familial breast cancer have the mutation. Carriers of the CHEK2

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tumor suppressor, malignant cells can grow unchecked by senescence or apoptosis.59

Research continues to identify and add molecular characterization to common and rare morphological sub-types of cancer. For example, the osteoclastic giant cells of infiltrating ductal carcinoma are positive for the cluster of differentiation 68 (CD68) molecule, and the tumor cells usually are positive for hormone receptors but nega-tive for ERBB2.7 Further, efforts to discover and record all cancer-causing genomic alterations in the Cancer Genome Atlas continue, but no research has outlined the correlation between cell lines and tumor tissues and all known genomic factors, namely copy number variations, mutations, and gene and protein expression. Still, steps are being made to compare all available genomic charac-teristics of these molecular subtypes.60

Luminal ALuminal A breast cancers are called ER-positive

cancers because most of the subtype’s tumors have positive estrogen status.5,53 The tumors tend to be progesterone receptor (PR)-positive and negative for ERBB2.53,61 Overall, luminal A breast cancer tends to be low grade when diagnosed and associated with a favor-able prognosis.60

unclassified) subtype was eliminated, and triple-negative breast cancer was added to the basal-like subtype (see Table).6,7,53 The classification of breast cancer into molecular subtypes is a fluid process, likely to change as genomic studies continue.7,27

In general, the molecular characteristics that define breast cancer subtypes involve the status of protein expression for estrogen, progesterone, and ERBB2, and other select biomarkers.60 Molecular subtypes comple-ment, but do not always match or overlap, more traditional breast cancer classifications. For example, molecular subtypes can include ER status or be part of a traditional histologic classification (eg, ductal carcinoma, infiltrating lobular carcinoma).53 Most cases of breast cancer are posi-tive for ER and ER-. ER- is encoded by the estrogen receptor 1 (ESR1) gene, binds to estrogen, and through a series of processes, is thought to support the response of estrogen to normal cells and breast cancer cells.27

Other findings from gene expression profiling are identifying genes common in several cancers. An exam-ple is mutation of the TP53 gene, which affects a tumor suppressor protein. When functioning normally, the factor encoded on TP53 arrests processes related to cell growth, senescence (aging), and genetically determined cell death (apoptosis). When a mutation affects the

Table

Breast Cancer Molecular Subtypes7,60,61,79

SubtypeTypical Immunochemistry Profile Characteristics

ApproximatePrevalence (%)a

Luminal A ER/PR/ERBB2/Ki-67b Low-grade tumor. Associated with low recurrence and good prognosis. 24

Luminal B (HER2)

ER/PR/ERBB/Ki-67 Progesterone can be negative in some luminal cancers. Higher grade than luminal A. Can have high recurrence risk. Prognosis worse than luminal A but better than luminal B (ERBB).

39

Luminal B (HER2)

ER/PR/ERBB2/Ki-67 Poor prognosis. 14

ERBB2 (HER2)

ER/PR/HER2 Often seen in ductal carcinoma in situ. Associated with poor outcomes. 11

Basal-like/triple negative

ER/PR/ERBB2/basal marker

Overlap between intrinsic basal-like tumors and triple-negative breast cancer. Triple-negative cancers can include special, typically rare, histologic subtypes. BRCA− and associated with poor prognosis.

12

aPrevalence of subtype as percentage of all breast tumors and based on multiple data sources.bERBB2 is synonymous with HER2/neu. The literature often uses HER2.Abbreviations: ER, estrogen receptor; PR, progesterone receptor; Ki-67 is a protein on the marker of proliferation gene MK167.

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percentage is highest in women who are younger (17%-49%) and those considered high risk (12%-62%).57 Overall, triple-negative breast cancer makes up 12% to 15% of all invasive breast cancers and is more com-mon among young women and African Americans.57 The prognosis for patients with triple-negative cancer is worse than for other subtypes because the cancer acts more aggressively and presents a greater likeli-hood of relapse, even when found in early stages.62 As of February 2016, there were no targeted therapies avail-able to improve outcome among these patients.63

BiomarkersThe molecular subtype grouping is a step toward

improved treatment and prognostication,34 and cell lines that better describe genetics of breast cancer are an important step. However, genomics can provide more information. With biomarkers, researchers begin to link genetic materials to the mechanisms that drive or suppress specific subtypes of cancer.53 In addition to heterogeneity among cancer types, it is evident from cytogenic studies that various biomarkers are expressed within a specific breast tumor.8

To be effective, prognostic biomarkers should be highly specific and appropriately sensitive for the type of tumor being evaluated.5 In 2015, the American Society of Clinical Oncology (ASCO) updated guidelines regard-ing use of biomarkers in breast cancer care. Specifically, the guidelines emphasize that biomarker tests should have clinical utility and guide the choice of specific treat-ment. This means that benefits from conducting the tests outweigh potential harms. For example, identifying a bio-marker leads to a targeted treatment that either improves patient survival or a patient’s quality of life. In addition, the evidence supporting use of a specific biomarker should be reliable and from studies that are well designed and implemented.35

As of February 2016, the most common biomark-ers for breast cancer were ER, PR, and ERBB2.34 The 3 biomarkers are assessed as part of standard practice.8 Many biomarkers of genetic mutations and drug response are under study as genomic knowledge expands.49,60 Examples of these include: A protein called Ki-67, which is on the marker of

proliferation gene MK167, is gaining acceptance as

Research has identified GATA-binding protein 3 (GATA3) mutations as influencers of ER-regulated tran-scription and binding of ER to DNA. The GATA3 gene upregulates ER- and other protooncogenes that promote tumorigenesis in luminal cancer.47 Using multigene sig-natures can help clinicians differentiate among luminal A breast cancers and improve prognosis for patients.61

Luminal BLuminal B breast cancer also is ER-positive but

PR-negative or low in progesterone receptors. Luminal B cancers are further divided into ERBB2-negative or ERBB2-positive types. Although luminal A and B breast cancers share common characteristics, subtle differ-ences can affect prognosis and effectiveness of existing or developing therapies. Genomic characteristics of luminal A cancers are absent in luminal B tumor cells. Multigene expression can determine recurrence risk, which can be high in luminal B breast cancer.61 Luminal B cancer cells tend to proliferate faster than luminal A cells and are associated with greater risk of recurrence and worse prognosis.5,7,53

ERBB2-positiveThe ERBB2 receptor is expressed in up to 25% of

breast cancers. This receptor affects cell prolifera-tion and epithelial cell survival.62 Breast cancers that overexpress ERBB2 (HER2) also are called nonluminal cancers.61 They are distinct in that they are positive for ERBB2, but can be ER positive or negative. Ductal carcinoma in situ tumors are often of this molecular subtype and associated with a poor prognosis.7

Basal-like/Triple NegativeBasal-like breast cancer usually is triple negative,

which means it lacks gene expression for ER, PR, and ERBB2.61 The cells in basal-like carcinomas have high mitosis and proliferation rates, and the tumors often are large and medullary.7 Rarely, a tumor in this group shows the signs of basal-like cancer such as high molec-ular weight cytokeratins, but not all triple-negative breast tumors have the basal-like phenotype, and not all basal-like cancers are triple negative.7

A large proportion of patients with triple-nega-tive breast cancer also have BRCA mutations. The

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take place each year. To date, screening programs have followed primarily evidence-based clinical guidelines. In breast cancer, mammography is the foundation of screening; other imaging methods such as magnetic resonance (MR) imaging are recommended for women at high risk of breast cancer. An increasing demand for personalized screening from patients and harm/benefit ratios is introducing new frameworks for screening that incorporate molecular diagnostics.11

Genetic testing and counseling already is available for patients at risk for or known to have hereditary cancer risk (germline variations). Physicians typically offer genetic counseling and, if appropriate, testing for women with a strong family history of breast cancer who might carry the BRCA gene mutations.10,45,54 Genetic testing has not been used for widespread screening, and the cost is high, even for patients at risk for BRCA mutations.57

The differences are particularly clear among coun-tries, with varied implementation of genomic medicine. In many high-income countries, women might have genetic testing for breast cancer risk when they have no sign or diagnosis of breast cancer. In South Africa, how-ever, genetic testing has been available for more than a decade, but to conserve resources only women already known to have breast cancer undergo the testing.13

Still, more efficient and less expensive technology can sequence an entire genome and reveal the DNA in a tumor.10 Although screening guidelines have evolved over the years to consider new findings on breast cancer risk (such as age), they still categorize individuals by large groups. As breast cancer genomics continue to advance, tailoring of screening likely will follow, which should help support women’s preferences and lead to higher benefit-to-harm ratios.11

Genetic CounselingThose individuals with a strong family history of

breast or ovarian cancer can be referred for genetic counseling to help them make informed decisions about their health and cancer risk in a confidential and neutral environment. A genetic counselor and a team of physician and genetic specialists are involved in gathering information and counseling an individual.28 The process facilitates decision-making for patients and their physicians, and provides some psychosocial

a breast cancer biomarker and has been identified as an indicator of cell proliferation. Large studies have shown that cancers positive for Ki-67 were associ-ated with greater likelihood of relapse and poorer prognosis than those negative for the protein.29

The study of transcription in tumor specimens before immunotherapy is initiated and following treatment has helped define molecular path-ways that lead to immune-mediated rejection of tumors. The biomarkers related to immune responses could help improve prognosis in patients with ERBB2-positive tumors.64

Huang et al used a blood-based metabolomics method to identify metabolites associated with breast cancer pathways. Taurine is a metabolite associated with insulin and glucose-binding in cells and an indicator of alanine and glutamate metabolism. Hypotaurine is associated with oxidative stress and membrane damage, known processes in malignancy.31

Marcotte et al found that phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutations are markers for bromodo-main and extraterminal domain protein inhibitor (BETi) resistance. BETi domain proteins regulate transcription of certain genes involved in breast cancer growth.40,53 The PIK3CA mutations occur most often in luminal tumors.53

Gouri et al emphasized the ability of 2 com-pounds in the plasminogen-activator system (urokinase-type plasminogen activator [hPA] and plasminogen activator inhibitor-1 [PAI-1]) to predict metastasis and improve the precision of breast cancer care. Plasminogen is an inac-tive substance that converts into active plasmin. Plasmin affects several physiological processes, including degradation of the proteins on cell sur-faces that help protect cells or promote cellular activities. As a result, plasmin has multiple effects during cancer invasion and mestastasis.4

Molecular DiagnosticsScreening for breast cancer is common in the United

States and around the world; in the United States alone, nearly 37 million breast cancer screening examinations

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Gene expression profiles identify all genes in a cell or tissue (such as a tumor biopsy sample) that make mRNA. The profiles are used to help diagnose cancer and other diseases and evaluate treatment response.25 MammaPrint and Oncotype are examples of gene expression profile tests.65 Prediction Analysis for Microarrays (PAM50) is a common gene expression profile for breast cancer.60 A breast cancer patient might have gene expression profiling and immunohistochem-istry tests as appropriate to provide information on the molecular subtype of cancer and risk of recurrence. Tests to determine recurrence risk usually are con-ducted after surgery and incorporated into histological findings and grade.65

Multigene panel tests, whole-exome sequencing, and whole-genome sequencing tests are appearing rapidly on the market and being included in breast cancer man-agement.28 Several multigene tests are used clinically.61 Tumor sequencing can include germline DNA sequences to help distinguish among somatic and inherited DNA alterations; many tumor-based panels also help evalu-ate familial cancer risk. Targeted multigene testing can include several known genes.28 Physicians use the 21-gene Recurrent Score (Oncotype DX, Genomic Health) to help guide decisions about adjuvant chemotherapy or endocrine therapy.66 The tests provide prognostic and predictive information.61 Sequencing tests for tumors can help identify germline pathogenic variants.28

Biomarker tests, or assays, test for a number of characteristics of biomarkers, such as amplification or mutations in the gene that activate processes like over-expression. Panel tests, which are similar to standard laboratory tests such as complete blood count, test for biomarkers that could indicate several types of breast cancer. Biomarker assays also can compare results for a patient with an algorithm, or signature, that helps to categorize prognosis.12

Next-generation sequencing is a method to process multiple DNA sequences at one time in an individual and identify several types of genomic alterations, such as deletions.28 The technology, which promises more rapid turnaround than alternative tests, is becom-ing available in an increasing number of diagnostic laboratories.45 At least 10 genes associated with breast cancer risk can be identified through next-generation

support as patients face potentially troublesome find-ings and difficult decisions.54 Typically, the counseling involves assessing one or several family members’ risk of genetic diseases such as breast cancer because of the BRCA mutation. After assessing family and medical history, the counselor recommends appropriate tests to learn more about an individual’s genetic risk for cancer and provides education on how to reduce risk or prevent cancer.28

ClinicalUse of genomic tests for clinical prognosis has

increased. According to Goldhirsch et al, the tests have changed treatment decisions in up to 30% of cases.61 Often, the findings of biomarker assays or gene profil-ing tests are combined with clinical information and cancer registry or atlas data for improved prediction.65 Clinical trials continue to evaluate the usefulness of the score results for making informed therapeutic deci-sions.66 Somatic variants that lead to cancer typically can be found and measured from blood, cancer tissue, and secreted f luid samples.12

Immunohistochemistry tests measure a tumor sample’s protein expression levels, including ER, PR, ERBB2, and Ki-67 proteins.65 Germline testing attempts to identify suspected genetic variants associ-ated with hereditary cancer risk. The tests can include generally suspected genes or target a specific disease such as breast cancer.28 For germline mutations, link-age analyses help to localize genes that increase the risk of cancer. The analysis compares the genotypes of affected and unaffected individuals to find evidence of inherited genetic markers. Linkage analysis is designed to uncover rare genetic variants, but some individuals with familial cancer risk develop a cancer that is not part of the germline mutations but occurs sporadically because of other risk factors or somatic mutations.

Genome-wide association studies are used to identify alleles common to cancer susceptibility. The test surveys the entire genome to pinpoint prevalent variations in phenotypes;67 however, among more than several thousand genetic variants identified for common diseases, few have been translated to new ther-apy.68 The studies most often are used in research; their relevance to clinical care remains unknown.67

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testing for ER, PR, and ERBB2 biomarkers as appropri-ate.35 For example, molecular diagnostics are unlikely to change treatment plans or prognosis in patients with ER-positive, ERBB2-negative disease, no lymph node involvement, and a small tumor ( 1 cm). It is unlikely that physicians would order chemotherapy to treat these patients. Conversely, patients at high risk because of a tumor larger than 5 cm, inflammatory breast cancer, extensive lymph node involvement, or low ER positivity would most likely be given chemotherapy regardless of additional molecular findings.60,61

A priority of the guidelines is to determine the most appropriate use of testing to guide systemic therapy deci-sions.35 On its patient information website, the society recommended 5 tests to determine recurrence risk for early-stage breast cancer positive for ER or PR, but nega-tive for ERBB2. These include Oncotype DX and PAM50 testing. The recommendations also suggested that several tests not be used because research on their effectiveness for predicting recurrence was lacking. These include MammaPrint, Mammastrat, and Ki-67 testing.34

Even with guidelines, however, new tests are being developed at a rapid pace, including panels for germ-line and somatic mutations. The rapid introduction of new technology can be confusing to physicians and patients.12 In addition, some guidelines recom-mend a particular test or assay for certain biomarkers, and another test or assay for additional biomarkers.65 Collaboration between health care organizations, government agencies, researchers, and pharmaceuti-cal companies is improving the database of genetic information available, which can improve testing util-ity.68

Research continues on the clinical utility of several genetic tests. Cardoso et al reported that use of the 70-gene signature MammaPrint test for women with early-stage breast cancer who are at high clinical risk but low genomic risk for recurrence can avoid unneces-sary chemotherapy. The authors found that women in this group could forgo chemotherapy, and the 5-year survival rate was only 1.5% lower than for women who received chemotherapy. The authors suggested that the 70-gene signature is most effective for patients who would like to forgo chemotherapy if their genetic risk is low.69,70 The authors will follow up on the study’s patient

sequencing.45 Research with whole-genome sequencing has shown that primary breast cancer can be explained by genetic differences in disseminated tumor cells.8 Physicians hope that next-generation sequencing can find additional biomarkers in somatic and germline mutations. One day, these findings could guide treat-ment decisions.40

Germline mutations can be identified from blood samples, but tumor cells typically are evaluated using formalin-fixed, paraffin-embedded clinical specimens. The amount of DNA isolated from these samples can be limited and affect results.44 The National Cancer Institute has funded several clinical trials designed to apply new genomic technologies to samples from biopsies of metastatic tumors, which could help target therapy.12

Guidelines on TestingDebate is ongoing regarding the clinical use of genet-

ic testing.40 Molecular diagnostics are not necessary for most patients with low-risk (ER-positive, ERBB2-negative) breast cancer. Likewise, patients known to be at high risk for recurrence, metastasis, or mortality (eg, inflammatory breast cancer or tumors 5 cm) might not need molecular diagnostics because they should receive chemotherapy regardless, at least until such time that more precisely targeted therapy for multiple gene signatures becomes available.61

Germline genetic testing already has proven useful to identify inherited forms of cancer, but the usefulness of somatic testing for indicators such as drug sensitivity remains controversial.40 There is little to no regulatory oversight for genetic testing of cancer, and bad biomarker tests are unhelpful and even harmful. The tests should have analytical validity based on well-defined and accu-rate information. Clinical validity also is important; this involves how well the test results can help divide a popula-tion based on outcome differences. Clinical utility means reliable evidence shows that the assay’s results can affect treatment decisions or patient outcome.12

ASCO has stated that tests for risk of breast cancer or recurrence should be clinically useful, particularly beyond standard indicators already in place, and that the benefits of the tests outweigh potential harms. As of February 2016, the society’s recommendations included

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Targeted Breast Cancer TreatmentGenetic tests such as tumor sequencing detect

the somatic variants in DNA that form the basis for precision medicine. By identifying driver mutations, the tests allow physicians to treat cancers with more specific, targeted therapy.28 Researchers are beginning to understand the variation in primary tumor genetic features and those of metastatic tumors in women with late-stage breast cancer.8 Circulating tumor DNA levels in a patient’s plasma can demonstrate changes in tumor burden and therefore assist physicians with real-time evaluation of treatment response in women who have metastatic breast cancer.8

Evolving Treatment ApproachUse of current treatments such as adjuvant chemo-

therapy, and even the application of clinical guidelines are somewhat objective and can vary widely.69 Typically, treatment decisions for women with breast cancer are based on morphological characteristics of a tumor and hormone receptor or ERBB2 status.69 Endocrine ther-apy works partly by suppressing cell cycle progression. The addition of CDK4 and CDK6 inhibitors, which halt or slow cell proliferation in many types of cancer, could help block cell cycle progression, especially in cancer that is ER-positive and ERBB2-negative.50 There are fewer systemic treatment choices for breast cancer patients with tumors that do not express these hormone and oncogene targets.7

A precision medicine model can identify markers that indicate how aggressively a recently diagnosed breast cancer will behave and how well it will respond to available therapies.4 This ability can improve treat-ment of aggressive or late-stage breast cancer and help address overtreatment. Many patients receive chemo-therapy and other treatments that have toxic adverse effects and little to no benefit. Using molecular signa-tures, clinicians can spare specific patients unnecessary adjuvant therapy.69 In addition, researchers have found a potential genetic predisposition to development of late tissue complications in the breast following radia-tion therapy. The genetic link appears to be in DNA methyltransferase enzymes. These enzymes possibly play a role in fibrogenesis and radiation response and could more accurately predict long-term effects in

population to determine whether the minor difference in survival rates continues as more time passes.69

Efforts are underway to implement a more structured approach to biomarker testing. The potential of incorpo-rating molecular and genetic information into targeted treatment is essential to precision medicine, but only if the tests are accurate, necessary, and effective.3

Precision MedicineIn 2014, President Barack Obama announced in his

State of the Union address that we were entering an era of precision medicine. Also called personalized medicine, precision medicine has many complex nuances, but boils down to moving from standard to customized treat-ment,4 or providing “the right therapy to the right patient at the right time, schedule, and dose.”12 President Obama announced the Precision Medicine Initiative early in 2015; the goal of the initiative is to “account for individual variability in genetics and environment.”14,59 The Precision Medicine Initiative aims to recruit 1 million volunteers to contribute longitudinal genetic information.68

In June 2016, Vice President Joe Biden announced the launch of an open-access database of genomic and clinical data from cancer patients. The new database, called the Genomic Data Commons, is managed by the National Cancer Institute. It began with detailed clinical data on 12 000 patients and is likely to grow as research-ers add information on the molecular nature of cancers. The initial data comes from existing sources such as the Cancer Genome Atlas, but the goal is to add to the data-base and make it easily available to scientists.71

Precision medicine can address the variation in patient response to therapy and tailor cancer screening strategies.72,73 The approach should prove particularly useful for addressing the heterogeneity of breast can-cer.4,72 Breast cancer care has led the way in personalized medicine with development of molecular subtypes that are beginning to replace the traditional morphology-based TNM (tumor, node, metastasis) staging system.4 As understanding of cancer biology and how genetic and molecular factors affect cancer risk, tumor growth, and metastasis improves, precision medicine should become more effective and lead to a better understand-ing of where and how to treat—or not treat—each individual patient’s disease.72

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patients with luminal A breast cancer typically receive endocrine therapy, but the usefulness of cytotoxic ther-apy varies widely among patients.61 Tests such as gene profiling that provide molecular subtype information typically are performed before surgery or neoadjuvant therapy to help with treatment decisions or follow-ing surgery on the primary tumor to guide decisions regarding chemotherapy.65

Clinical trials have investigated mechanistic target of rapamycin (mTOR) inhibitors such as everolimus and a steroidal agent called exemestane as combination treat-ment for postmenopausal women who have metastatic luminal cancer. ERBB2-enriched tumors now can be treated with a combination of trastuzumab and pertu-zumab to reduce levels of ERBB proteins and improve therapeutic response. Basal-like tumors with BRCA mutations could soon be treated with poly adenosine diphosphate-ribose polymerase (PARP) inhibitors.62 In general, clinical decisions based on molecular subtype

breast cancer survivors who have undergone radiation therapy.74

Current genomic research is focused on treatment for late-stage tumors and supporting less aggressive treat-ment when possible to improve quality of life for patients and survivors. Use of genomic tests for prognosis has helped physicians alter treatment in up to 30% of cases worldwide.61 As a result, there has been a decrease in use of adjuvant chemotherapy in breast cancer patients. Likewise, genomic studies are showing that residual disease following chemotherapy is less of a concern in patients with luminal A or hormone-receptor-positive, ERBB2-positive disease than for those with nonluminal ERBB2-positive and triple-negative subtypes of breast cancer (see Figure 4).61

The use of trastuzumab for ERBB2-amplified breast cancer has greatly improved breast cancer care.40,62 The monoclonal antibody targets the ERBB2 extracellular domain and has led to significant improvements in the prognosis for patients with ERBB2-positive breast cancer.62 Clinical trials have shown the effectiveness of neratinib, a tyrosine kinase inhibitor ,as a single agent to support trastuzumab therapy, and more trials on the therapy are underway. Researchers also are study-ing how ESR1 and PIK3CA variations affect patient response to endocrine therapy and patient survival.40

Current national guidelines recommend that carriers of PALB2 mutations discuss prophylactic mastectomy with their physicians and that those having the BRCA1, BRCA 2, BRCA1 interacting protein C-terminal heli-case 1 (BRIP1), RAD51C, and RAD51D variations, or are carriers of Lynch syndrome consider prophylactic salpingo-oopherectomy.45 By adding biopsy of meta-static cancer to identify multiple features present in metastatic cells, clinicians can target therapy based on the heterogeneity between primary cancer and metastatic cells.8 In addition, by identifying specific molecular drivers of cancer in patients, physicians can tailor treatment based less on anatomical site (ie, the breast) and more on specific molecular targets of indi-vidual tumors.3

Molecular Subtype TherapiesBasing therapy decisions on molecular subtypes can

make targeted treatment more precise. For example,

Figure 4. A triple-negative breast cancer cell undergoing retraction and apoptosis (cell death) after treatment with a combination of the chemotherapy drug cisplatin and a mitochondrial division inhibitor drug called mdivi-1. Actin in red; mitochondria in green; nuclei in blue. Understanding how drugs work at the molecular level contrib-utes to better cancer treatments. Image courtesy of Wei Qian and the National Cancer Institute/University of Pittsburgh Cancer Center.

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must consider individual, personal patient preferences. The availability of an increasing amount of genomic information is contributing to a move away from population-based breast cancer screening and toward personalized screening approaches. Personalized screen-ing regimens should be built on validated risk factors such as age and family history; new risk models based on genetic research then are added as they become accept-ed. New risk models are likely to refine personalized decision-making for clinicians and their patients.11

Experience with women who test positive for BRCA variants provides some insight into the effects of genetic testing on breast imaging. Larouche et al found that women who had positive test results for BRCA1 and BRCA2 mutations and women who had inconclusive results on BRCA tests increased their use of mammog-raphy screening following testing.75 Those whose test results showed they were not carrying the mutation did not increase screening frequency.75 Still, some women continue to have mammograms or MR scans at the fre-quency associated with high risk for breast cancer even after a negative result for the BRCA mutation.75

Genome-wide association studies have identified genetic variants that can be added to abnormality pre-diction. Burnside et al estimated risk in women referred for breast biopsy by comparing the predictive nature of demographic risk factors, germline genetic variants, vs Breast Imaging Reporting and Data System (BI-RADS) density categories and features of mammography abnormalities.19 The investigators used 10 identified genetic variants that predict breast cancer and matched biopsy results from participants with a diagnostic mam-mogram acquired within 12 months before biopsy. The authors reported that mammography features such as spiculated margins better predicted malignancy than did genetic variants. However, demographic and genetic information, as well as breast density, were better for predicting the long-term risk of malignancy.19

Studies have shown that MR images have higher sensitivity for malignancy than mammograms or sono-grams, particularly for younger women, and that MR is better than ultrasound imaging as an adjunct to mam-mography.5,76 Detecting recurrence in breast cancer survivors is critical to reducing mortality, and mam-mography can assist with surveillance. The addition

apply to men with breast cancer as well, but the bulk of research has been conducted on women.65

Although progress has been made, clinicians con-tinue to research more precise approaches to treating breast cancer based on molecular subtype.61 As new discoveries about the genomic characteristics of breast cancer gain widespread acceptance, stratification and treatment by molecular subtype is likely to lead the way toward personalized treatment.7

The Future of Targeted TreatmentProfound changes to current breast cancer treatment

are needed, and the framework is in place to conduct large clinical trials and develop consistent approaches to information gathered from genetic profiling.8 Targeted treatment for breast cancer already is available. The U.S. Food and Drug Administration approved trastu-zumab as a targeted therapy in 1998 to treat patients with metastatic breast cancer and overexpression of the ERBB2 protein.3,45 In addition, PARP inhibitors are used to treat ovarian cancer associated with BRCA mutations. Still, although BRCA mutations increase risk, they do not guarantee that a woman will develop breast cancer. Further refining risk assessment can help prevent unnecessary preventive measures such as pro-phylactic mastectomy.13,45

Profiling of somatic mutations is essential to per-sonalizing breast cancer treatment. New methods to evaluate advanced breast cancer include liquid biopsy when it is not possible to diagnose tumor tissue. The new method can examine circulating tumor DNA in a patient’s blood.40 In addition, numerous biomarkers related to growth factors or tumor suppression offer opportunity for new targeted modalities. The progress depends on efforts to standardize and improve report-ing or information sharing about molecular features of breast cancer and on improved translation of research technology into standard clinical practice.7

Role of Imaging in Precision MedicineBreast cancer screening is intended to detect cancer

early and reduce mortality. Guidelines for screen-ing are based largely on individuals at average risk for breast cancer. Decisions based on screening results are made according to scientific evidence of risk but also

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Analyzing metabolite, protein, and gene expression data can be combined with positron emission tomography (PET) to identify metabolic clusters of activity within some breast tumors.6 For example, glutamate is enriched in some breast cancer patients and a ratio of glutamate to glutamine is associated with ER status. Use of metabolo-mics in some imaging modalities such, as nuclear medicine and MR scanning, can quantify the biological activities of specific lesions.6,31 PET-CT is particularly helpful to assess metastases. Increased tumor marker levels in survivors with no symptoms are correlated with higher sensitivity of PET and PET-CT compared with other imaging modali-ties. Drawbacks to its use include cost and the biological cost of radiation associated with PET-CT.5

of sonography or MR imaging in surveillance imaging could improve diagnostic reliability by reducing false-negative and false-positive results.

MR also is more sensitive than radiography in assess-ing bone marrow for signs of breast cancer metastasis. The use of MR surveillance to monitor survivors for local-regional recurrence is an example of an inten-sive follow-up program based on genetic information (positive for BRCA variations and young age).5 The American Cancer Society recommends that women at high risk for breast cancer are screened with MR and mammography; this group includes women with genet-ic variations related to increased breast cancer risk.76 Guidelines from the National Comprehensive Cancer Network already recommend breast MR screening for patients identified as carriers of BRCA1, BRCA2, TP53, CDH1, STK11, PTEN, CHEK2, ATM, and PALB2 mutations.45

Structural and targeted func-tional data from medical imaging should continue to have a role in precision medicine that incor-porates genomic information (see Figure 5).76 Biomarkers also could be used in imaging to evalu-ate treatment response for cancer patients. A study presented at the 2016 Radiological Society of North America meeting showed that MR biomarkers could predict breast cancer treatment response sooner than existing methods. Typically, physicians look at met-rics such as volume or surface area that relate to tumor morphology. MR biomarkers that incorporated 57 metrics into computer-aided detection technology and radi-ologist interpretation detected changes in tumors following treatment sooner than standard diameter or volume measure-ments.77

Figure 5. Precision medicine is the future of cancer therapy. Structural and functional infor-mation from imaging is combined with immunohistochemical and genomic information to make personalized treatment decisions. A. Breast cancer (arrow) is largely obscured on mam-mogram. B. Variable uptake of gadolinium contrast agent on a breast magnetic resonance image (arrow) indicates heterogeneity of intratumoral blood flow. C. Variable uptake of fluo-rodeoxyglucose (FDG) radiotracer (blue arrow) shows the heterogeneity of glucose metabo-lism in primary breast cancer. Extra-axillary nodal disease also is demonstrated (black arrow). D. This information is combined with immunohistochemical assays and mRNA expression (E) to determine a full tumor profile for treatment planning. The image originally was published in JNM. McDonald ES, Clark AS, Tchou J, Zhang P, Freedman GM. Clinical diagnosis and management of breast cancer. J Nucl Med. 2016;57(suppl 1):14S; © by the Society of Nuclear Medicine and Molecular Imaging, Inc.

A B D

Personalized treatment decisions

C

E

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combination of honest results, information, and genetic counseling can help support difficult decisions about prevention and treatment.55 In 2016, cancer patients filed a complaint against Myriad Genetics for failing to give patients access to their own genomic data. The data are considered a portion of medical records, which means patients should have access to full reports and be able to make decisions about how to manage or store genetic information.14,78 The company contended that benign data was not worth releasing, but the American Civil Liberties Union stated that this position violated patient rights under the Health Insurance Portability and Accountability Act (HIPAA). Cancer patients argued that they were entitled to the full test results and many expressed their desire to share their information to con-tribute to the growing body of genetic data on cancer.78

Finally, the success of personalized, or precision, med-icine lies in the ability of clinicians and their patients to understand and act upon genetic data. Gene panel results should offer information to support decision-making.75 Informed consent for genetic sequencing introduces challenges in both clinical and research settings. This includes how to communicate with patients about find-ings that have no clear pathogenicity, and uncertainty about whether or how the variants contribute to disease. The sequencing also introduces ethical considerations regarding notifying family members about germline mutations.28 The role of imaging modalities will depend largely on data showing improved accuracy and relative harms. In a precision medicine approach, potential risks can vary from 1 individual to another.11

Initiatives such as Healthy People 2020, which pro-motes the use of genomic-based tools to improve health, can make genetic information a more natural tool in cancer care (see Box). Healthy People 2020 has a goal specifically devoted to increasing the number of women with a family history of breast or ovarian cancer who receive genetic testing.14

ConclusionAs technology and the infrastructure for precision

medicine continue to advance, the role of genomics in breast cancer care should expand and offer new opportunities for detecting, diagnosing, and treat-ing the disease.14,40 Institutions already have started

ChallengesThe process of integrating genetic data with existing

methods of cancer prevention, diagnosis, and treat-ment presents a major challenge. Issues related to use of genomics in practice include limited knowledge of genomics and precision medicine among clinicians and patients, inconsistency in test development and acceptance, privacy and data security, cost and reim-bursement, and the need to change routine medical practices to incorporate genomic information.14

Incorporating research findings into clinical prac-tice takes an average of 17 years to include only 14% of original research.14 Genomic and DNA data require extensive review before the information can be used in breast cancer treatment.40 Clinical inertia is the relative stability and reluctance of clinicians to change standard practice. This inertia can be beneficial if clinicians adopt new practices only when evidence-based research proves effectiveness vs harm. However, once practice guidelines and other leading or authoritative statements support new technology, the technology typically becomes more standardized and broadly accepted. Many clinicians cite time constraints as a barrier to learning about and implementing new precision medi-cine technologies and processes. Sharing findings and engaging clinicians through short courses, fact sheets, or assistance from genetic counselors can help integrate genomics into precision medicine practice.14

Cost effectiveness and the availability of molecular diagnostics such as multigene assays are ongoing chal-lenges as technology and adoption of expanded reliance on genetic data increase. All tests are not available in all clinical settings, particularly outside the United States and similarly developed countries.61 With an inconsis-tent regulatory environment, few biomarker tests on the market have undergone the type of analytical and clinical validity studies needed to prove their effective-ness. Once a test gains clinical acceptance, insurance reimbursement supports its expanded use. However, payment for these tests also is inconsistent.12

Sharing genetic profiling results and similar data presents logistical and ethical challenges.78 For example, women who receive a positive genetic test result can experience distress and other psychosocial effects relat-ed to breast cancer risk and decision-making. Still, the

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decision making and precision medicine. Biomark Insights. 2016;11:105-111. doi:10.4137/BMI.S33372.

5. Puglisi F, Fontanella C, Numico G, et al. Follow-up of patients with early breast cancer: is it time to rewrite the story? Crit Rev Oncol Hematol. 2014;91(2):130-141. doi:10.1016/j.critrevonc.2014.03.001.

6. Haukaas TH, Euceda LR, Giskeødegård GF, et al; Oslo Breast Cancer Consortium (OSBREAC). Metabolic clusters of breast cancer in relation to gene- and protein expression subtypes. Cancer Metab. 2016;4(1):12. doi:10.1186/s40170 -016-0152-x.

7. Masood S. Breast cancer subtypes: morphologic and biolog-ic characterization. Womens Health (Lond). 2016;12(1):103-119. doi:10.2217/whe.15.99.

8. Ellsworth RE, Blackburn HL, Shriver CD, Soon-Shiong P, Ellsworth DL. Molecular heterogeneity in breast cancer: state of the science and implications for patient care [pub-lished online ahead of print August 26, 2016]. Semin Cell Dev Biol. doi:10.1016/j.semcdb.2016.08.025.

9. Zhang J, Abrams Z, Parvin JD, Huang K. Integrative analysis of somatic mutations and transcriptomic data to functionally stratify breast cancer patients. BMC Genomics. 2016;17(suppl 7):513. doi:10.1186/s12864-016-2902-0

10. The genetics of cancer. National Cancer Institute website. https://www.cancer.gov/about-cancer/causes-prevention/gen etics. Published April 22, 2015. Accessed November 3, 2016.

11. Onega T, Beaber EF, Sprague BL, et al. Breast cancer screen-ing in an era of personalized regimens: a conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer. 2014;120(19):2955-2964. doi:10.1002/cncr.28771.

12. Hayes DF. Considerations for implementation of cancer molecular diagnostics into clinical care. Am Soc Clin Oncol Educ Book. 2016;35:292-296. doi:10.14694/EDBK_160236.

13. Silverstein A, Sood R, Costas-Chavarri A. Breast cancer in Africa: limitations and opportunities for applica-tion of genomic medicine [published online ahead of print]. Int J Breast Cancer. 2016;2016:4792865. doi:10.1155/2016/4792865.

14. Addie S, Olson S, Beachy SH. Applying an Implementation Science Approach to Genomic Medicine: Workshop Summary. Washington, DC: National Academies Press; 2016. https://www.nap.edu/catalog/23403/applying-an-implementation -science-approach-to-genomic-medicine-workshop-summary. Accessed January 26, 2017.

15. National Human Genome Research Institute. A guide to your genome. https://www.genome.gov/pages/education/all aboutthehumangenomeproject/guidetoyourgenome07_vs2 .pdf. Published October 2007. Accessed November 1, 2016.

molecular tumor boards to discuss results from next-genome sequencing and other genomic data.40 Imaging continues to play a critical role in screening, diagnosis, and management as breast cancer care transitions to a personalized approach.73,76 The use of advanced imaging in breast cancer care will depend largely on a modality’s effectiveness and economic value.14 Additional clinical trials are needed to advance the knowledge of genomics and translation of findings into precision medicine.40

Teresa Odle, BA, ELS, has authored numerous Directed Readings for the American Society of Radiologic Technologists. She is a professional editor and writer living in Ruidoso Downs, New Mexico.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department, at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to publications@asrt.org.

© 2017 American Society of Radiologic Technologists

References1. Mukherjee S. A distorted version of our normal selves. The

Emperor of All Maladies. New York, NY: Scribner; 2010:340-355.

2. Zhou F, Li M, Wei Y, et al. Activation of HERV-K Env pro-tein is essential for tumorigenesis and metastasis of breast cancer cells [published online ahead of print]. Oncotarget. 2016. doi:10.18632/oncotarget.11455.

3. Committee on Policy Issues in the Clinical Development and Use of Biomarkers for Molecularly Targeted Therapies. Craig LA, Phillips JK, Moses HL, eds. Biomarker Tests for Molecularly Targeted Therapies: Key to Unlocking Precision Medicine. Washington, DC: National Academies Press; 2016.

4. Gouri A, Dekaken A, El Bairi K, et al. Plasminogen acti-vator system and breast cancer: potential role in therapy

Box

Genomics and Precision Medicine Resources

Precision Medicine Initiative – nih.gov/research-training /allofus-research-program

Healthy People 2020 – healthypeople.govCancer Genome Atlas – cancergenome.nih.govHuman Genome Project – genome.gov/10001772Genomic Data Commons – gdc.cancer.gov

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28. Cancer genetics overview (PDQ) – health professional ver-sion. National Cancer Institute website. https://www.can cer.gov/about-cancer/causes-prevention/genetics/overview -pdq#section/_2594. Accessed January 2, 2017.

29. Matsumoto A, Jinno H, Ando T, et al. Biological markers of invasive breast cancer. Jpn J Clin Oncol. 2016;46(2):99-105. doi:10.1093/jjco/hyv153.

30. Romanowicz H, Pyziak Ł, Jabłoński F, Bryś M, Forma E, Smolarz B. Analysis of DNA repair genes polymorphisms in breast cancer [published online ahead of print]. Pathol Oncol Res. 2016. doi:10.1007/s12253-016-0110-5.

31. Huang S, Chong N, Lewis NE, Jia W, Xie G, Garmire LX. Novel personalized pathway-based metabolomics models reveal key metabolic pathways for breast cancer diagnosis. Genome Med. 2016;8(1):34. doi:10.1186/s13073-016-0289-9.

32. Smithsonian Museum of Natural History and National Human Genome Research Institute. Microbiome. Unlocking Life’s Code website. https://unlockinglifescode .org/explore/genomic-medicine/microbiome. Accessed November 17, 2016.

33. Talking glossary of genetic terms: epigenome. National Human Genome Research Institute website. https://www.genome.gov/glossary/index.cfm?id5529. Accessed November 17, 2016.

34. Biomarkers to guide treatment for early-stage breast cancer. American Society of Clinical Oncology website. http://www.cancer.net/research-and-advocacy/asco-care-and -treatment-recommendations-patients/biomarkers-guide -treatment-early-stage-breast-cancer. Updated February 8, 2016. Accessed November 15, 2016.

35. Van Poznak C, Somerfield MR, Bast RC, et al. Use of bio-markers to guide decisions on systemic therapy for women with metastatic breast cancer: American Society of Clinical Oncology Clinical Practice Guidelines. J Clin Oncol. 2015; 33(24):2695-2704. doi:10.1200/JCO.2015.61.1459

36. An overview of the Human Genome Project: a brief history of the Human Genome Project. National Human Genome Research Institute website. https://www.genome.gov/12011 239/. Reviewed November 8, 2012. Accessed November 19, 2016.

37. 2003: Human Genome Project completed. National Human Genome Research Institute website. https://www.genome .gov/25520492/online-education-kit-2003-human-genome -project-completed/. Updated November 24, 2014. Accessed November 15, 2016.

38. Collins FS, McKusick VA, Jegalian K. National Human Genome Research Institute website. Implications of the genome project for medical science. https://www.genome .gov/25019925/online-education-kit-implications-of-the

16. Human Genome Project. National Institutes of Health web-site. https://report.nih.gov/NIHfactsheets/ViewFactSheet .aspx?csid545&key5H#H. Updated March 29, 2013. Accessed November 6, 2016.

17. Genomics vs genetics: what’s the difference? Center for Genomics and Public Health website. http://depts.washing ton.edu/cgph/GenomicsGenetics.htm. Accessed November 14, 2016.

18. Human genomics in global health: WHO definitions of genetics and genomics. World Health Organization website. http://www.who.int/genomics/geneticsVSgenomics/en/. Accessed November 14, 2016.

19. Burnside ES, Liu J, Wu Y, et al. Comparing mammography abnormality features to genetic variants in the prediction of breast cancer in women recommended for breast biopsy. Acad Radiol. 2016;23(1):62-69. doi:10.1016/j.acra.2015.09.007.

20. Genetic Alliance. Beyond the DNA: your informative guide to epigenetics and health. http://www.geneticalliance.org /sites/default/files/publications/BeyondtheDNA.pdf. Published 2015. Accessed November 17, 2016.

21. Genetics home reference: what is DNA? U.S. National Library of Medicine website. https://ghr.nlm.nih.gov/primer /basics/dna. Published November 15, 2016. Accessed November 16, 2016.

22. Hou JP, Emad A, Puleo GJ, Ma J, Milenkovic O. A new correlation clustering method for cancer mutation analysis [published online ahead of print]. Bioinformatics. 2016; 32(24):3717-3728. doi:10.1093/bioinformatics/btw546.

23. Internet-based tools for teaching transcription and transla-tion. National Human Genome Research Institute website. https://www.genome.gov/27552603/transcription-and -translation/. Updated February 13, 2014. Accessed November 18, 2016.

24. Stork CT, Bocek M, Crossley MP, et al. Co-transcriptional R-loops are the main cause of estrogen-induced DNA dam-age [published online ahead of print]. eLife. 2016;5:e17548. doi:10.7554/eLife.17548.

25. NCI dictionary of cancer terms: gene expression profile. National Cancer Institute website. https://www.cancer .gov/publications/dictionaries/cancer-terms?cdrid5386201. Accessed November 15, 2016.

26. Piletič K, Kunej T. MicroRNA epigenetic signatures in human disease. Arch Toxicol. 2016;90(10):2405-2419. doi:10.1007/s00204-016-1815-7.

27. Baran-Gale J, Purvis JE, Sethupathy P. An integrative transcriptomics approach identifies miR-503 as a candi-date master regulator of the estrogen response in MCF-7 breast cancer cells [published online ahead of print]. RNA. 2016;22(10):1592-1603. doi:10.1261/rna.056895.116.

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Precision Medicine in Breast Cancer

49. Chen X, Liu L, Wang Y, et al. Identification of breast cancer recurrence risk factors based on functional pathways in tumor and normal tissues [published online ahead of print August 23, 2016]. Oncotarget. doi:10.18632/oncotarget.11557.

50. Knudsen ES, Witkiewicz AK. Defining the transcriptional and biological response to CDK4/6 inhibition in relation to ER/HER2- breast cancer [published online ahead of print]. Oncotarget. 2016; 7(43):69111-69123. doi:10.18632/onco target.11588.

51. Kennecke H, Yerushalmi R, Woods R, et al. Metastatic behavior of breast cancer subtypes. J Clin Oncol. 2010;28(20):3271-3277. doi:10.1200/JCO.2009.25.9820.

52. Kadhel P, Schuster C, Grossat N, Janky E, Ghassani A. Causal attribution of breast cancer by survivors in French West Indies [published online ahead of print August 27, 2016]. J Cancer Educ. doi:10.1007/s13187 -016-1096-0.

53. Marcotte R, Sayad A, Brown KR, et al. Functional genomic landscape of human breast cancer drivers, vulnerabilities, and resistance. Cell. 2016;164(1-2):293-309. doi:10.1016/j .cell.2015.11.062.

54. Meiser B, Quinn VF, Gleeson M, et al. When knowledge of a heritable gene mutation comes out of the blue: treatment-focused genetic testing in women newly diagnosed with breast cancer. Eur J Hum Genet. 2016;24(11):1517-1523. doi:10.1038/ejhg.2016.69.

55. Metcalfe KA, Dennis CL, Poll A, et al. Effect of decision aid for breast cancer prevention on decisional conflict in women with a BRCA1 or BRCA2 mutation: a multisite, randomized, controlled trial [published online ahead of print September 1, 2016]. Genet Med. doi:10.1038/gim.2016.108.

56. The genetics of cancer. American Society of Clinical Oncology website. http://www.cancer.net/navigating-can cer-care/cancer-basics/genetics/genetics-cancer. Updated August 2015. Accessed November 12, 2016.

57. Rashid MU, Muhammad N, Bajwa S, et al. High preva-lence and predominance of BRCA1 germline mutations in Pakistani triple-negative breast cancer patients. BMC Cancer. 2016;16(1):673. doi:10.1186/s12885-016-2698-y.

58. BRCA1 and BRCA2: cancer risk and genetic testing. National Cancer Institute website. https://www.cancer.gov/about-can cer/causes-prevention/genetics/brca-fact-sheet#q1. Reviewed April 1, 2015. Accessed November 19, 2016.

59. Oros Klein K, Oualkacha K, Lafond MH, Bhatnagar S, Tonin PN, Greenwood CM. Bhatnagar, Tonin PN, Greenwood CM. Gene coexpression analyses differenti-ate networks associated with diverse cancers harboring TP53 missense or null mutations. Front Genet. 2016;7:137. doi:10.3389/fgene.2016.00137.

-genome-project-for-medical-science/. Updated March 29, 2012. Accessed November 1, 2016.

39. The Cancer Genome Atlas: program overview. National Human Genome Research Institute website. https://cancer genome.nih.gov/abouttcga/overview. Accessed October 30, 2016.

40. Niravath P, Cakar B, Ellis M. The role of genetic testing in the selection of therapy for breast cancer: a review [pub-lished online ahead of print August 25, 2016]. JAMA Oncol. doi:10.1001/jamaoncol.2016.2719.

41. Suter R, Marcum JA. The molecular genetics of breast cancer and targeted therapy. Biologics. 2007;1(3):241-258. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721311.

42. Evans DG, Astley S, Stavrinos P, et al. Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study. Southampton, UK: National Institute for Health Research. https://www.ncbi.nlm.nih .gov/books/NBK379488/. Published August 2016. Accessed November 4, 2016.

43. What are the risk factors for breast cancer? Centers for Disease Control and Prevention website. http://www.cdc .gov/cancer/breast/basic_info/risk_factors.htm. Updated April 4, 2016. Accessed November 3, 2016.

44. Enyedi MZ, Jaksa G, Pintér L, et al. Simultaneous detec-tion of BRCA mutations and large genomic rearrangements in germline DNA and FFPE tumor samples [published online ahead of print]. Oncotarget. 2016;7(38):61845-61859. doi:10.18632/oncotarget.11259.

45. Pinto P, Paulo P, Santos C, et al. Implementation of next-generation sequencing for molecular diagnosis of hereditary breast and ovarian cancer highlights its genetic hetero-geneity. Breast Cancer Res Treat. 2016;159(2):245-256. doi:10.1007/s10549-016-3948-z.

46. Guo Y, Warren Andersen S, Shu XO, et al. Genetically predicted body mass index and breast cancer risk: mende-lian randomization analyses of data from 145 000 women of European descent. PLoS Med. 2016;13(8):e1002105. doi:10.1371/journal.pmed.1002105.

47. Azim HA Jr, Nguyen B, Brohée S, Zoppoli G, Sotiriou C. Genomic aberrations in young and elderly breast cancer patients. BMC Med. 2015;13:266. doi:10.1186/s12916-015 -0504-3.

48. Al-Saran N, Subash-Babu P, Al-Nouri DM, Alfawaz HA, Alshatwi AA. Zinc enhances CDKN2A, pRb1 expression and regulates functional apoptosis via upregulation of p53 and p21 expression in human breast cancer MCF-7 cell. Environ Toxicol Pharmacol. 2016;47:19-27. doi:10.1016 /j.etap.2016.08.002.

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Odle

70. Mayor S. Some breast cancer patients with low genetic risk may not need chemotherapy, trial shows. BMJ. 2016;354:i4635. doi:10.1136/bmj.i4635.

71. McGinley L. Biden unveils launch of major, open-access database to advance cancer research. Washington Post website. https://www.washingtonpost.com/national /health-science/biden-to-unveil-launch-of-major -open-access-database-to-advance-cancer-research /2016/06/05/8918c442-2b30-11e6-9de3-6e6e7 a14000c_story.html. Published June 6, 2016. Accessed November 1, 2016.

72. Friedenreich CM, Neilson HK, Farris MS, Courneya KS. Physical activity and cancer outcomes: a precision medi-cine approach. Clin Cancer Res. 2016;22(19):4766-4775. doi:10.1158/1078-0432.CCR-16-0067.

73. Krishnan K, Baglietto L, Apicella C, et al. Mammographic density and risk of breast cancer by mode of detection and tumor size: a case-control study. Breast Cancer Res. 2016;18(1):63. doi:10.1186/s13058-016-0722-4.

74. Terrazzino S, Deantonio L, Cargnin S, et al. DNA methyl-transferase gene polymorphisms for prediction of radiation-induced skin fibrosis after treatment of breast cancer: a mul-tifactorial genetic approach [published online ahead of print August 23, 2016]. Cancer Res Treat. doi:10.4143/crt.2016.256.

75. Larouche G, Chiquette J, Pelletier S, Simard J, Dorval M. Do women change their breast cancer mammogram screening behaviour after BRCA1/2 testing? [published online ahead of print August 23, 2016]. Fam Cancer. doi:10.1007/s10689 -016-9920-6.

76. McDonald ES, Clark AS, Tchou J, Zhang P, Freedman GM. Clinical diagnosis and management of breast cancer. J Nucl Med. 2016;57(suppl 1):9S-16S. doi:10.2967/jnumed.115 .157834.

77. Forrest W. Study links MRI biomarkers with breast cancer prognosis. AuntMinnie website. http://www.auntminnie .com/index.aspx?Sec5road&sub5wom_2016&pag5dis&itemId5115672. Published November 9, 2016. Accessed November 9, 2016.

78. Hayden EC. Myriad Genetics caught in data fight. Scientific American website. https://www.scientificamerican.com/art icle/myriad-genetics-embroiled-in-breast-cancer-data-fight -again. Published May 24, 2016. Accessed November 1, 2016.

79. Dai X, Xiang L, Li T, Bai Z. Cancer hallmarks, biomark-ers and breast cancer molecular subtypes. J Cancer. 2016;7(10):1281-1294. doi:10.7150/jca.13141.

60. Jiang G, Zhang S, Yazdanparast A, et al. Comprehensive comparison of molecular portraits between cell lines and tumors in breast cancer. BMC Genomics. 2016;17(suppl 7):525. doi:10.1186/s12864-016-2911-z.

61. Goldhirsch A, Winer EP, Coates AS, et al; panel members. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol. 2013;24(9):2206-2223. doi:10.1093/ann onc/mdt303.

62. Zanardi E, Bregni G, de Braud F, Di Cosimo S. Better together: targeted combination therapies in breast cancer. Semin Oncol. 2015;42(6):887-895. doi:10.1053/j.seminon col.2015.09.029.

63. Liu NQ , De Marchi T, Timmermans A, et al. Prognostic significance of nuclear expression of UMP-CMP kinase in triple negative breast cancer patients. Sci Rep. 2016;6:32027. doi:10.1038/srep32027.

64. Bedognetti D, Hendrickx W, Marincola FM, Miller LD. Prognostic and predictive immune gene signatures in breast cancer. Curr Opin Oncol. 2015;27(6):433-444. doi:10.1097 /CCO.0000000000000234.

65. National Institute for Health and Care Excellence. Gene expression profiling and expanded immunohistochemistry tests for guiding adjuvant chemotherapy decisions in early breast cancer management: MammaPrint, Oncotype DX, IHC4 and Mammostrat. https://www.nice.org.uk/guidance /dg10. Published September 25, 2013. Accessed November 19, 2016.

66. Swain SM, Nunes R, Yoshizawa C, Rothney M, Sing AP. Quantitative gene expression by recurrence score in ER-positive breast cancer, by age. Adv Ther. 2015;32(12):1222-1236. doi:10.1007/s12325-015-0268-3.

67. Cancer genetics overview (PDQ) – health professional version. Methods of genetic analysis and gene discovery. National Cancer Institute website. https://www.cancer .gov/about-cancer/causes-prevention/genetics/overview -pdq#section/_146. Updated November 18, 2016. Accessed November 18, 2016.

68. Addie S, Gee Am, Olson S, Beachy SH Roundtable on Genomics and Precision Health. Deriving drug discovery value from large-scale genetic bioresources: proceed-ings of a workshop [prepublication]. National Academies Press. https://www.nap.edu/download/23601. Accessed November 15, 2016.

69. Cardoso F, van’t Veer LJ, Bogaerts J, et al; MINDACT Investigators. 70-gene signature as an aid to treatment decisions in early-stage breast cancer. N Engl J Med. 2016;375(8):717-729. doi:10.1056/NEJMoa1602253.

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Directed Reading Quiz

continued on next page

Read the preceding Directed Reading and choose the answer that is most correct based on the article.

QUIZ ID: 17802-03

2 Category A+ credits2.5 MDCB creditsExpires April 30, 2020*

To earn continuing education credit: Take this Directed Reading quiz online at asrt.org/drquiz. Or, transfer your responses to the answer sheet on Page 426M and mail to ASRT, PO Box 51870,

Albuquerque, NM 87181-1870.

* Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.

Precision Medicine in Breast Cancer

1. Heterogeneity of breast cancer can relate to differences:

1. among tumors in populations.2. within a tumor.3. temporal variability of growth.

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

2. Variations that cause diseases such as breast cancer make up ______ % of the genome.a. 99b. 50c. 10d. 1

3. A characteristic that can be measured and evaluated as an indicator of normal biological or pathogenic processes is a(n):a. allele.b. microRNA.c. biomarker.d. microbiome.

4. Azim et al showed that compared with younger patients, older women’s breast tumors had:

1. more genetic mutations.2. more copy number variations.3. fewer variations of any kind.

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

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Directed Reading Quiz

continued on next page

10. Ductal carcinoma in situ tumors often are of the ______ molecular type and associated with a poor prognosis.a. basal-likeb. ERBB2-positivec. luminal Ad. luminal B

11. The molecular subtype of breast cancer associated with the worst prognosis typically is ______ breast cancer.a. luminal Ab. luminal Bc. ERBB2-positived. basal-like/triple negative

12. Which protein is gaining acceptance as a breast cancer biomarker for cell proliferation?a. Ki-67b. hypotaurinec. PIK3CAd. hPA

13. Which tests measure a tumor sample’s protein ex-pression levels?a. biomarkerb. genome-wide associationc. germlined. immunohistochemistry

14. As of February 2016, the American Society of Clinical Oncology recommended testing for:

1. estrogen receptors.2. progesterone receptors.3. ERBB2 biomarkers.

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

5. Research has shown that genomic profiles of cells from a primary cancer and metastatic cancer cells of the primary cancer are markedly different.a. trueb. false

6. The high penetrance gene ______ has been associated with more human cancer than any other somatic alteration.a. BRCAb. TP53c. PTENd. ERBB2

7. A rare mutation on the CHEK2 gene causes:a. Cowden syndrome.b. truncated protein.c. DNA repair.d. gastric cancer.

8. Which of the following are molecular subtypes of breast cancer?

1. luminal A2. basal-like3. triple-negative

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

9. Luminal A subtype tumors tend to be:a. high grade and associated with poor prognosis.b. estrogen receptor negative and difficult to treat.c. low grade and associated with favorable

prognosis.d. prone to recurrence.

424M RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Directed Reading Quiz

15. The potential genetic link to tissue complications following breast radiation therapy is most likely from:a. DNA methyltransferase enzymes.b. estrogen receptors.c. CDK4 inhibitors.d. endocrine therapy effectiveness.

16. Which of the following modalities is more sensitive than radiography for assessing metastasis in bone marrow?a. computed tomographyb. ultrasonographyc. magnetic resonance imagingd. positron emission tomography

mailto:elipman@asrt.org

✁

Carefully cut or tear here.

427RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Research & Technology

Implantable Infusion Pumps in the MR Environment: Safety Concerns

In January 2017, the U.S. Food and Drug Administration (FDA) communicated that they have received reports of serious adverse events asso-ciated with the use of implantable infusion pumps in

the magnetic resonance (MR) environment. Adverse events included patient injury and death as a result of medication dosing inaccuracies and other mechanical problems with the pump.

The FDA stressed that only implantable infusion pumps labeled as MR Conditional can be used safely within an MR environment, and only under speci-fied conditions of safe use: the make and model of the pump determines these conditions. To help reduce the likelihood of serious adverse events, the FDA put forth recommendations for patients and MR technologists to follow before, during, and after an MR examina-tion for a patient with an implantable infusion pump (see Boxes 1 and 2).

Box 1

Recommendations for Patients With Implantable Infusion Pumps Needing MR ExaminationsMake sure the MR technician knows you have an implantable

infusion pump.Know the make and model of your implantable infusion pump.You might need to have your infusion pump checked or

reprogrammed after an MR examination, even if your pump is labeled as MR Conditional.

Only implantable infusion pumps labeled as MR Conditional can be scanned safely, and only under the specified conditions of safe use.

The before, during, and after instructions following an MR examination differ depending on the make and model of the implantable infusion pump.

To read the full FDA safety communication visit asrt.org/as.rt?dQLrrZ.

Box 2

MR Technologist Recommendations for Scanning Patients With Implantable Infusion Pumps.Follow all institutional patient-screening policies.Do not scan a patient if you do not have the pump’s

instructions for safe MR exposure.Only implantable infusion pumps labeled as MR Conditional

can be scanned safely, and only under the specified conditions of safe use.

The before, during, and after instructions following an MR examination differ depending on the make and model of the implantable infusion pump.

Ensure that the implantable pump model can be safely imaged on the MR system at your site.

428 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Bookshelf

The Madame Curie Complex: The Hidden History of Women in Science. Des Jardins J. 2010. 352 pgs. Feminist Press. feministpress.org. $17.95.

The lives, careers, and chal-lenges of female scientists have not been well-recorded in the history books. The Madame Curie Complex: The Hidden History of Women in Science

attempts to remedy that, describing the accomplish-ments of some of history’s top female scientists as well as little-known facts about them. Equally important is the book’s attempt to address gender bias and underrep-resentation of women within the science profession.

In a chronological narrative arranged by era, the author details some of the many women who dedi-cated their lives to various scientific fields and pursuits but whose contributions were left out of the historic records. The first section includes individuals such as Marie Curie, Lillian Gilbreth, and the “Women of the Harvard Observatory.” Another section, “Cult of Masculinity in the Age of Heroic Science,” includes information about Rosalind Franklin, who was part of the team that discovered the double helix structure of DNA, and other women who were involved in the Manhattan Project. The contributions of scientists such as Barbara McClintock, Evelyn Fox Keller, Jane

Goodall, and Dian Fossey are featured in the section called “American Women and Science in Transition.”

As the book progresses through time and discipline, it touches on topics outside the work realm that affected the women’s lives, such as love, motherhood, family, fame, and obscurity, and shaped who they were. Each biogra-phy builds on the previous one, allowing the reader to compare and contrast them and to recognize patterns. They also provide a lessons-learned aspect about the importance of gender equality in science, suggesting that future generations should work to ensure that the achieve-ments of talented women in scientific and engineering professions are recognized and not overlooked or under-appreciated.

The Madame Curie Complex is a well-organized book about some of the most prevalent women in science and the inequality they suffered as they pursued the world’s most important scientific discoveries. Despite the book’s text-heavy structure, its organization makes it an easy read, and the photographs, though few, provide a welcome glimpse into the lives of the scientists. Overall, it is an interesting book for any reader who wishes to learn about history’s life-changing work and discoveries from the per-spective of those not often noted in history books.

Tricia Leggett, DHEd, R.T.(R)(QM)Associate ProfessorZane State CollegeZanesville, Ohio

Historical Significance

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imaging findings, along with pearls of wisdom gained from years of relevant experience. Finally, the book includes a discussion of disease spectrum and dif-ferential diagnoses along with instructional radiology images. Further reading references are listed at the end of each case. The medical terminology used is precise to illustrate differential diagnoses and the full spectrum of the diagnosis. Although the terms are beyond what is required for a radiologic technologist, they are pre-sented alongside images for clarification.

Radiologic technologists, particularly those employed in computed tomography and magnetic reso-nance imaging, can benefit from this book by viewing the images and learning and reviewing the proper medi-cal terms for clinical histories, which will widen and deepen the scope of their knowledge within diagnoses.

Carol A Reisenbuckler, MA, R.T.(R)(M)Retired Radiologic Technologist and MammographerElmhurst, Illinois

Introduction to Sonography and Patient Care. Penny SM. 2016. 392 pgs. Wolters Kluwer. LWW.com. $73.99.

Each chapter in this intro-ductory sonography textbook includes objectives students should meet, vocabulary with definitions, critical think-ing exercises, and review questions. The “sound off ”

sections are intended to encourage students to be more involved with peers, the profession, and academic con-cepts that promote leadership, critical thinking, and lifelong learning. Multiple drawings and screenshots of actual sonograms help reinforce the content and software applications that likely are being covered in the sonography program. Extra resources are avail-able to students and instructors via Wolters Kluwer’s website, The Point, such as slideshow presentations, videos, laboratory exercises, and case notes; additional resources for instructors include a test generator and lesson plans.

Emergency Radiology COFFEE Case Book: Case-Oriented Fast Focused Effective Education. Khurana B, Mandell J, Sarma A, Ledbetter S. 2016. 672 pgs. Cambridge University Press. cam-bridge.org. $155.

The purpose of the Emergency Radiology COFFEE Case Book is to aid in the development of the essential competency of reli-able, timely, and accurate interpretation of radiology images necessary for the clinical practice of emergency radiology. The acronym COFFEE, which stands for Case-Oriented Fast Focused Effective Education, was first used in the early 2000s in emergency radiology continuing medical education courses and has proved to be a quick and effective learning method. This book is a go-to reference for radiologists and clinicians in emergency medicine and trauma surgery to develop, throughout their clinical duties, their confidence and performance as it relates to imaging.

The book’s organization is by clinical presentation so as to demonstrate actual clinical radiology practices within an emergency department setting. The cases presented in the book are divided into 2 main parts: nontraumatic conditions and traumatic conditions. Part 1, nontraumatic conditions, is further divided into 5 anatomic sections: abdomen, thorax, otolaryngol-ogy, neurology, and musculoskeletal. Part 2, traumatic conditions, includes neurology, thorax, abdomen, and musculoskeletal areas.

Each chapter presents a case with relevant clinical history, presentation symptoms, and 1 to 3 diagnostic images. This format continues with a diagnosis deter-mined from those images, highlighted with colored arrows on image close-ups, and a discussion of the dis-ease, appropriate imaging modality, relevant medical knowledge, and examination of the preferred imaging modalities. A clinical synopsis briefly describes the patient’s treatment.

A self-assessment section is provided for additional learning about the importance of specific clinical and

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reference for its intended audience: the student sonog-rapher. Medical imaging program educators might find this a good resource for the ethics, career exploration, leadership, student success, and communication sec-tions. Practicing sonographers might find it a useful quick reference for keeping their skills current.

Jo Gramley, MAHR, R.T.(R)(M)(CT), RDMSRadiography Program Coordinator/Assistant ProfessorHeartland Community CollegeNormal, Illinois

The textbook is separated into 2 sections; the first is an introduction to sonography and the second covers patient care. The content is basic information that any sonogra-phy student should be learning. However, the focus on student success strategies, time management, leadership, peer support and learning, and self-reflection is more in-depth than seen in other introductory medical imaging books. Section 2 also includes a helpful table on cultural competence and communication styles, which the begin-ning sonographer will benefit from reading.

Other topics include medical terminology, translation resources for English-to-Spanish phrases, patient care procedure details, common lab tests, and electrocardio-gram dysrhythmias. Essentials of professionalism in the clinic are stressed, and strategies to survive the first clini-cal experience are shared, including common stressors, modeling professionalism, work ethic, and self-reflection. Questions, case studies, and critical thinking sections encourage the growth of the student as a professional. The section on differentiation of touch into 2 types used dur-ing patient interactions—a concept not often explained well in other texts—is explained in a way that will help new students understand the reasoning behind each type.

The book touches on Myers-Briggs typing as a way for students to discover their personality types, strengths, weaknesses, and learning and communica-tion traits based on the idea that this knowledge will help them to better understand how to help others. In addition, best practices of sonography, including proper posture and positioning to decrease work injury, are covered in depth.

The last chapter covers basic sonography examina-tions, guidelines, and quality assurance standards. The explanations help students to understand their role and how it affects image quality. Also included is a basic overview of required elements for scanning and how variations and adaptations occur because of patient condition and performing examinations in the mobile environment.

Introduction to Sonography and Patient Care is a comprehensive, well-written book that covers basic information needed by student sonographers and includes topics not included by similar textbooks. Each chapter f lows into the next logically, making it easy to read and to locate information quickly. It is a good

431RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Management Toolbox

Mary Ann McDonough, R.T.(R)(M)George YangJennifer M Palmieri, MS, R.T.(R)(M)

Dyan DeYoung, BS, R.T.(R)(M)Christine M Zwart, PhDVictor Pizzitola, MD

Tracking to Excellence: Automating Breast Imaging Wait-time Monitoring

efficiency, a patient-centered online model, with mam-mogram readings done in real time, is essential to a patient satisfaction-focused approach in a mammogra-phy clinic.6

Workflow

The breast-imaging department at the Mayo Clinic in Arizona adopted a real-time reading workflow in which patients are invited to wait ( 30 minutes) to receive their results in person. This practice, called the rapid-read program, began in 2014 and has evolved to accommodate changes to staff, facilities, and technology. One of the Mayo Clinic’s founding values—the needs of the patient come first—creates an administrative environment where costs of such a program are tolerated willingly. It also is thought that this type of program allows for a superior mammography experience and acts as an advertisement to attract and retain patients.

The Original Clipboard ApproachThe original Mayo Clinic workflow relied on pen

and paper. Technologists offered patients the option of waiting for their results. For patients requesting this service, technologists informed the physician that the patient would wait and marked the time and the name of the patient on a clipboard in the technologists’ control area. The technologist periodically asked the physician to determine when they could dismiss the patient or whether additional imaging was needed.

Providing patients with a low-anxiety and quick experience is an important aspect of quality health care. For the past decade, a screening mammogram has been recommended for most

women older than 40 years.1 Although mammogram examinations take minimal time to finish, many hospi-tals do not return results for patients or schedule addi-tional diagnostic mammograms quickly. Most institu-tions take approximately 1 week to deliver mammo-gram results to the patient; wait times can be longer for patients with abnormal results.2 Legally, the Mammography Quality Standards Act (MQSA) allows up to 30 days after an examination for delivery of mam-mographic findings (in layman’s language) and follow-up recommendations. Many patients report this waiting period as the most stressful part of their procedure.3

Some patients prefer a rapid results workflow that reduces wait time, allows patients to receive results promptly, and offers immediate completion of further diagnostic imaging. Some authors have proposed allow-ing patients to buy a rapid result, hand-delivered by a physician. However, the cost of accomodating rapid results, including overhead incurred by the imaging facility, could outpace what patients would be willing to pay for the option.4,5

Balancing patient preferences with the effect rapid result workflows might have on a facility represents a clear struggle in the competitive space of screening mammography. Despite conflicts with operational

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new approach. With the new workflow, the monitor-ing application is available at every clinical computer workstation within the department, online, and via iPad. Technologists, radiologists, and scheduling staff all inter-act with the program to communicate a patient’s status seamlessly throughout the department. The Figure shows a screen shot of the application’s user interface.

At the beginning of a workday, all patients sched-uled are imported automatically into the application. In addition to software-based monitoring, a printed schedule is provided for reference on a single sheet of legal-sized paper. When a mammogram examination concludes, technologists give the patient the option of receiving their results within 30 minutes. Patients who want this free service are instructed to return to the scheduling desk and request a pager. The technolo-gist presses the Patient Waiting button, which moves

The pen-and-paper process had noticeable deficiencies. First, auditing the workflow required significant rework to migrate the paper record to a Microsoft Excel spreadsheet. Because of the challenges associated with converting the data into a digital format and the variability in data accuracy, there was no record of average turnaround time, percentage of patients choosing to wait, and instances of failure to achieve a 30-minute wait time for the patient. This lack of long-term feedback prevented the department from optimizing its efficiency and maintaining the integ-rity of the rapid-read program. Second, the immediate feedback available to staff was isolated to the clipboard’s physical location, and start time notation did not commu-nicate delayed cases with any particular urgency. Finally, the pen-and-paper process was relegated entirely to the technologists, requiring them to float in and out of the reading room between patients in an attempt to receive word from the radiologist when a patient could be dis-missed or regarding the need for additional images.

The Monitoring ToolTo improve workflow deficiences, the Mayo Clinic

replaced the clipboard with an electronic tablet equi-ped with scheduling software. An Apple iPad with a FileMaker application (FileMaker Inc) replaced the clipboard and records the in-and-out times of rapid-read patients. Technologists can identify patients who opt to wait for results by pressing a button. When a patient is dismissed, the technologist marks them as such. Because in-and-out times can be recorded, this resolves the issue of converting data into a digital format and allows for analytics. In addition, the iPad application includes a timer for each patient. This informs staff of how long a patient waits and includes color-changing features to alert staff to delays. The data collected can be analyzed to determine average wait times and outli-ers. The addition of a second iPad slightly improved issues with physical restrictions of the process; however, the workflow remained technologist directed.

Team-based WorkflowIn collaboration with physicians and scheduling

staff, the technologists overhauled the communication and workflow surrounding the rapid-read program. The monitoring tool was expanded to support this

Figure. The monitoring application interface has the same layout for the Web, iPad, and desktop (shown). Image courtesy of the authors.

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Management ToolboxMcDonough, Yang, Palmieri, DeYoung, Zwart, Pizzitola

technologists.4,10,11 A quick turnaround time decreases patient worry thus improving the work environment for technologists. When patients are less stressed, technolo-gists can take accurate mammograms with ease.4 In addition, technologists originally were responsible for mediating between radiologists and patients, but now radiologists also use the monitoring tool. Technologists no longer act as intermediaries and seem less anxious throughout their workday.

If used in other hospitals, this efficient workflow could help lower radiologist stress as well. Many radi-ologists do not want to read mammograms because mammography has the greatest legal liability.12 However, many claims of malpractice begin with delays in diagnosing breast cancer. So, quickly performing follow-up procedures could ease the physician’s burden.

Finally, this tool allows everyone to track the effectiveness of the rapid-read program. The digital application provides the team with real-time feedback on how long the patient has been waiting and long-term feedback on how efficient their service has been.

Mary Ann McDonough, R.T.(R)(M), is the team lead for the Mayo Clinic in Phoenix, Arizona.

George Yang is a former radiology student intern for the Mayo Clinic in Phoenix, Arizona, and currently is studying nursing and health care administration at the University of Pennsylvania in Philadelphia.

Jennifer M Palmieri, MS, R.T.(R)(M), is the breast imaging supervisor for the Mayo Clinic in Phoenix, Arizona.

Dyan DeYoung, BS, R.T.(R)(M), is the radiology manager overseeing breast imaging for the Mayo Clinic in Phoenix, Arizona.

Christine M Zwart, PhD, is a scientist and programmer in the radiology department for the Mayo Clinic in Phoenix, Arizona, and an assistant professor of health care systems engineering for Arizona’s Mayo Clinic School of Medicine.

Victor Pizzitola, MD, is a radiologist and the breast imaging division chair as well as an assistant professor of radiology for Arizona’s Mayo Clinic School of Medicine.

References1. U.S. Department of Health and Human Services. Health,

United States, 2015: with special feature on racial and ethnic

that patient from the Scheduled list to the Waiting list. Patients on the waiting list immediately are visible to the radiologists, who reprioritize their reading to address waiting patients as soon as possible.

Comparable to the device common in restaurants, the pager given to waiting patients allows them to wait outside the traditional waiting room. Most patients choose to wait in the coffee shop or the lobby, which has a piano for visitors to enjoy. The opportunity to wait in a larger, more welcoming space presumably helps reduce patient anxiety.

When the radiologist has finished reading the mam-mograms, patients who can be dismissed are moved to the Ready for Dismissal category. The scheduling staff receives notification that the patient may leave. Patients are paged and provided with their results—the same results they otherwise would receive up to 30 days later. If the patient needs further imaging, the technologists are alerted and a decision is made as to whether they can accommodate additional diagnostic procedures immedi-ately. The technologists then call the scheduling staff, who page the patient. The scheduling staff informs the patient of their options: to return immediately to the imaging dressing rooms for additional imaging or to schedule an appointment for a later date.

By digitizing the workflow, the patient’s status can appear in many places at once. This balances the pro-cess. Technologists no longer act as go-betweens; they can focus on performing patient examinations. It also allows patients to receive their mammogram results within approximately 30 minutes and schedule further diagnostic examinations on the same day when needed.

DiscussionThis workflow has improved patient, radiologist, and

technologist satisfaction. Because mammography often is a stressful procedure, many women do not schedule recall appointments.7 About 20% of women with a his-tory of breast cancer do not adhere to guidelines for follow-up mammography.2,8,9 Accordingly, the rapid-read program allows the hospital to follow up immediately, preventing patients from falling through the cracks.

Furthermore, this process has helped technologists in many ways. Despite technologists being trained to help worried patients, patient stress often is imparted on

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health disparities. https://www.cdc.gov/nchs/data/hus/hus 15.pdf. Accessed December 13, 2016.

2. Elkin EB, Snow JG, Leoce NM, Atoria CL, Schrag D. Mammography capacity and appointment wait times: bar-riers to breast cancer screening. Cancer Causes Control. 2012;23(1):45-50. doi:10.1007/s10552-011-9853-1.

3. Sharp PC, Michielutte R, Freimanis R, Cunningham L, Spangler J, Burnette V. Reported pain following mammog-raphy screening. Arch Intern Med. 2003;163(7):833-836. doi:10.1001/archinte.163.7.833.

4. Parikh JR. Breast imaging flow models. J Am Coll Radiol. 2004;1(4):265-269. doi:10.1016/j.jacr.2003.12.048.

5. Raza S, Rosen MP, Chorny K, Mehta TS, Hulka CA, Baum JK. Patient expectations and costs of immediate report-ing of screening mammography: talk isn’t cheap. AJR Am J Roentgenol. 2001;177(3):579-583. doi:10.2214/ajr.177.3. 1770579.

6. Chhor CM, Mercado CL. Integrating customer intimacy into radiology to improve the patient perspective: the case of breast cancer screening. AJR Am J Roentgenol. 2016;206(2):265-269. doi:10.2214/AJR.15.15459.

7. Lindfors KK, O’Connor J, Parker RA. False-positive screening mammograms: effect of immediate versus later work-up on patient stress. Radiology. 2001;218(1):247-253. doi:10.1148/radiology.218.1.r01ja35247.

8. Geller BM, Kerlikowske K, Carney PA, et al. Mammography surveillance following breast cancer. Breast Cancer Res Treat. 2003;81(2):107-115. doi:10.1023/A:1025794629878.

9. Keating NL, Landrum MB, Guadagnoli E, Winer EP, Ayanian JZ. Factors related to underuse of surveillance mammography among breast cancer survivors. J Clin Oncol. 2006;24(1):85-94. doi:10.1200/JCO.2005.02.4174.

10. Barton MB, Moore S, Polk S, Shtatland E, Elmore JG, Fletcher SW. Increased patient concern after false-positive mammograms: clinician documentation and subsequent ambulatory visits. J Gen Intern Med. 2001;16(3):150-156. doi:10.1111/j.1525-1497.2001.00329.x.

11. Rimer BK, Bluman LG. The psychosocial conse-quences of mammography. J Natl Cancer Inst Monogr. 1997;(22):131-138.

12. Yousem DM, Beauchamp NJ. Medicolegal Issues. In: Radiology Business Practice: How to Succeed. Philadelphia, PA: Saunders/Elsevier; 2008:463-485.

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Professional Review

Approximately 50% of magnetic resonance (MR) imaging studies worldwide are ordered with contrast.1 Gadolinium is the element of choice for contrast MR imaging, and evidence

shows that multiple doses of gadolinium contrast cause gadolinium retention in certain regions of the brain. All gadolinium–based contrast agents used for MR studies are chelates of gadolinium because gadolinium on its own is highly toxic.1 When bound with a ligand mole-cule, the toxicity of these agents is reduced dramatical-ly.1 Several types of gadolinium contrast agents have been approved by the U.S. Food and Drug Administration.2

To understand gadolinium contrast deposition, it is important to know how gadolinium agents are structured. They can have a linear or a macrocyclic structure. Linear agents have an elongated organic molecular ligand that wraps around the ion.2 The linear agent’s structure is “open chain,” whereas in the macrocyclic structure, the gadolinium is “caged” in the ligand.3 Linear and macro-cyclic agents can be either ionic or nonionic.2 Ionicity is closely related to osmolality (the number of dissolved particles per kilogram of water).2 Typically, ionic agents have a higher osmolality.2 An exception is gadobutrol (Gadavist), which is nonionic but has a high osmolality.2 With nonionic agents, the number of carboxyl groups is reduced to 3, which neutralizes the 3 positive charges of Gd3. With ionic agents, the remaining carboxyl groups are salified with sodium or meglumine.3 The main

difference between nonionic and ionic contrast media is that an ionic compound dissociates into charged particles when it enters a solution such as blood. Nonionic contrast media do not dissolve when they enter a solution, and they have a lower viscosity.3 Although ionic and nonionic gadolinium agents have higher osmolarity than blood, the osmolality of nonionic gadolinium agents is closer to blood; therefore, extravasation of a nonionic gadolinium agent into soft tissues during intravenous administration is less likely to result in serious complications.3

Gadolinium SafetyGadolinium safety became a major concern in 2007,

when the U.S. Department of Agriculture mandated that all gadolinium contrast manufacturers add a black box warning regarding the risk of nephrogenic systemic fibrosis (NSF) for patients with acute or chronic renal insufficiency.4 Until that time, gadolinium–based con-trast agents had been assumed to be non-nephrotoxic.5 Several studies have since determined the toxicity of gadolinium in patients with renal insufficiency and those with normal renal function.5 These studies also have shown that deterioration in renal function can occur in the majority of cases after intra-arterial administration of gadolinium–based contrast agents used at doses higher than 0.2 mmol/kg for diagnostic procedures in patients with renal insufficiency. According to the guidelines of the Contrast Media Safety Committee of the European Society of Urogenital Radiology, contrast-induced

Jennifer Franco, BSRS, R.T.(R)(MR)

Intracranial Deposition of IntravenousGadolinium Contrast: A Literature Review

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Professional ReviewIntracranial Deposition of Intravenous Gadolinium Contrast: A Literature Review

sequence of the entire brain; a gadolinium-enhanced sequence also was performed, using gadodiamide. All studies involved the same MR technique parameters. Unenhanced T1-weighted signal intensities were ana-lyzed from set anatomic regions of the brain. These areas of interest included the dentate nucleus, pons, glo-bus pallidus, and pulvinar of the thalamus. Inductively coupled plasma mass spectrometry also was performed to measure tissue gadolinium concentration.8

McDonald et al found that none of the members of the control group had detectable levels of gadolinium, but all patients who had been exposed to multiple doses of gadolinium contrast had elevated levels of gadolinium deposition in the 4 neuroanatomical regions examined.8 The dentate nucleus contained the highest concentra-tions of gadolinium, and some of the highest tissue concentrations of gadolinium were present in patients who had normal renal function.8 The authors concluded that intracranial gadolinium deposition is likely to occur in all patients who are exposed to as few as 4 lifetime doses of intravenous gadolinium contrast, regardless of renal function.8

A similar study by Kanda et al evaluated the correla-tion between the number of previous gadolinium–based contrast doses and high MR signal intensity, specifi-cally in the dentate nucleus and globus pallidus. The researchers compared MR images of 19 patients who had undergone at least 6 gadolinium-enhanced MR studies and 16 patients who had undergone at least 6 noncontrasted MR studies. T1-weighted MR images of the entire brain were acquired on a GE 1.5 Tesla scan-ner, all using the same MR technique parameters and all without contrast enhancement. Two radiologists ana-lyzed the images and measured mean signal intensity in the regions of interest. The authors noted a distinct cor-relation between multiple doses of gadolinium–based contrast administration and higher signal intensity in the dentate nucleus and, to a lesser extent, in the globus pallidus, which is independent of renal function.9

Functions of the Dentate Nucleus and Globus Pallidus

The anatomic locations of the brain that seem to retain the greatest amount of gadolinium contrast are the dentate nucleus and the globus pallidus.8,9 The

nephropathy is defined as acute renal failure after admin-istration of contrast media when alternative causes of renal damage have been excluded. Contrast-induced nephropathy is the third leading cause of acute renal injury necessitating hospitalization.5 It typically is caused by iodinated contrast, but some gadolinium–based contrast agents are associated with contrast-induced nephropathyas well, especially in patients with advanced renal disease.5 Because of this, most facilities now use the recommended dose guideline of 0.1 mmol/kg for non-vascular MR imaging studies, and this dose appears to be safe for most patients.5

Gadolinium Structure and NSFOther studies have revealed that the chemical struc-

ture of gadolinium–based contrast agents matters in the development of NSF, and the risk is much higher with nonionic linear chelates such as gadodiamide (Omniscan) and gadoversetamide (Optimark) because of the rapid release of gadolinium (dechelation) in these agents.6 Macrocyclic gadolinium–based contrast agents such as gadobenate dimeglumine (Multihance) are more resis-tant to dechelation and are considered to be more stable.6 However, it still is recommended that all gadolinium agents be given at the recommended dose level and only to patients with normal renal function. The incidence of NSF has decreased dramatically with the development of clinical protocols that restrict the use of gadolinium con-trast in patients with impaired renal function.7

Intracranial DepositionAlthough NSF is becoming less of a concern, recent

research suggests that intracranial gadolinium depo-sition can occur in patients with otherwise normal renal function.8 McDonald et al conducted a study on deceased patients to evaluate any correlation between deposition of gadolinium in neuronal tissues and repeated use of gadolinium–based contrast media.8 The study included a control group of 10 deceased adult patients who had received a noncontrasted MR imaging scan between 2000 and 2014 and a group of 13 deceased adult patients who had undergone at least 4 gadolinium-contrasted MR imaging studies during the same period. All patients received MR imaging of the brain, including an unenhanced T1-weighted axial

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6 doses of macrocyclic gadolinium–based contrast agents. T1-weighted axial images were acquired using standardized MR technique parameters, and the areas of interest were analyzed by a radiologist. The signal intensity in the dentate nucleus and globus pallidus was compared with the intensity in the pons, cerebrospinal f luid, and cerebellum. The study showed increased sig-nal intensity in the dentate nucleus and globus pallidus on unenhanced T1-weighted images in patients who had received several doses of the linear gadolinium–based contrast agent gadopentetate dimeglumine. However, no significant increase in signal intensity was shown on images of patients who had received the mac-rocyclic gadolinium–based contrast agent gadoterate meglumine.13 This was 1 of the first research studies to show that intracranial deposition is dependent on the type of gadolinium agent used and that some agents are safer than others.

An animal study published in 2015 by Robert et al14 also compared linear and macrocyclic gadolinium agents, with results similar to those found by Radbruch et al.13 Over a 5-week span, Robert et al injected mul-tiple doses of the linear agent gadodiamide into 1 group of rats and multiple doses of the macrocyclic agent gadoterate meglumine into another group.14 T1-weighted MR imaging was performed once a week during this time. Gadolinium concentrations were measured using spectroscopy, and the authors found increased T1 signal intensity in the deep cerebellar nuclei, including the dentate nucleus, only in the group of rats exposed to the linear agent gadodiamide.12 These findings suggest that linearly structured gadolinium agents result in more intracranial deposition than do macrocyclic-structured agents, which is in line with the findings of McDonald et al.8

Similarly, Ramalho et al also examined the signal intensity differences between types of contrast.15 They compared gadodiamide with gadobenate dimeglumine. These agents are linear in structure, but gadodiamide is nonionic and gadobenate dimeglumine is ionic.3 Group 1 included 23 patients who underwent gadodiamide-enhanced MR imaging and group 2 included 46 patients who underwent gadobenate dimeglumine–enhanced MR imaging. Two radiologists conducted a quantita-tive analysis of unenhanced T1-weighted images using

dentate nucleus is located in the cerebellum, which is responsible for balance and coordination.10 The cerebel-lum consists of 2 cerebellar hemispheres comprising deep gray matter folds in the shape of a caulif lower. Within the center of each cerebellar hemisphere is a collection of cerebellar nuclei, the largest of which is the dentate nucleus.10 Fibers of the dentate nucleus project to the thalamus through the superior cerebellar pedun-cles. From there, the fibers travel to the motor areas of the cerebral cortex, thus influencing motor control.10

The globus pallidus is part of the basal nuclei, which permits unconscious movements such as swinging the arms with the legs during ambulation.10 The globus pallidus consists of a group of output neurons, and the motor cortex transmits information to these nuclei at the center of the brain and to the cerebellum at the brain’s base. The nuclei also send information back through the thalamus, which is located nearby.11

Chemical Structure and Intracranial Deposition

The observed T1 hyperintensity might be a conse-quence of the dissociation of gadolinium from its ligand molecule.12 Because agents with macrocyclic structure cage the element in the molecule, the rates of dissocia-tion of gadolinium from macrocyclic ligands are lower than dissociation from linear ligands and therefore are considered more stable.3 Several studies have suggested that the chemical structure of the gadolinium–based contrast agents is related to intracranial retention.13-15

A study by Radbruch et al compared changes in signal intensity ratios of the dentate nucleus and the glo-bus pallidus on unenhanced T1-weighted MR images between linear and macrocyclic gadolinium–based contrast agents to determine whether intracranial depo-sition was related to the type of contrast agent used.13 Examples of linear gadolinium–based contrast agents include gadopentetate dimeglumine (Magnevist), gadobenate dimeglumine, and gadoxetate disodium (Eovist).3 Examples of macrocyclic gadolinium agents include gadoterate meglumine (Dotarem), gadobutrol, and gadoteridol (ProHance).3 The researchers exam-ined MR images of 50 patients who had been given at least 6 doses of linear gadolinium–based contrast agents and 50 patients who had been given at least

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gadolinium agents, such as gadodiamide and gadoben-ate dimeglumine, tend to have a much higher incidence of retained gadolinium than do macrocyclic-structured gadolinium agents, such as gadoterate meglumine, which showed no evidence of retained gadolinium.13 In addition, nonionic agents had a higher incidence of retained gadolinium in the brain than did ionic agents.15 On the basis of these studies, it can be concluded that the macrocyclic ionic contrast agent gadoterate meglumine might be the safest in terms of retained gadolinium.

Jennifer Franco, BSRS, R.T.(R)(MR), is a magnetic resonance imaging technologist for University of North Carolina Hospitals in Chapel Hill. She can be reached at jenfranco919@gmail.com.

References1. Bellin MF, Van Der Molen AJ. Extracellular gadolinium

–based contrast media: an overview. Eur J Radiol. 2008 ;66(2):160-167. http://dx.doi.org/10.1016/j.ejrad.2008 .01.023.

2. Extracellular Gd agents. MRIquestions.com website. http://mri-q.com/so-many-gd-agents.html. Published 2016. Accessed January 31, 2016.

3. Weinreb J, Amirbekian S. Understanding gadolinium-based contrast agents: from the molecule up. Medscape.org web-site. http://www.medscape.org/viewarticle/780675_4. Published March 15, 2013. Accessed December 1, 2015.

4. Forrest W. FDA readies new safety probe into gadolinium contrast. auntminnie.com website. http://www.auntminnie .com/index.aspx?sec=sup&sub=mri&pag=dis&itemId= 111707. Published August 25 2015. Accessed October 11, 2015.

5. Ledneva E. Renal safety of gadolinium–based contrast media in patients with chronic renal insufficiency. Radiology. 2009;250(3):618-628. doi:10.1148/radiol.2503080253.

6. Karabulut N. Gadolinium deposition in the brain: another concern regarding gadolinium–based contrast agents. Diagn Interv Radiol. 2015;21(4):269-270. http://dx.doi.org/10 .5152/dir.2015.001.

7. Forrest W. Gadolinium contrast retention raises new safety questions. auntminnie.com. http://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=110885. Published May 5, 2015. Accessed October 11, 2015.

8. McDonald RJ, McDonald JS, Kallmes DF, et al. Intra-cranial gadolinium deposition after contrast-enhanced MR imag-

region-of-interest measurements. The globus pallidus to thalamus signal intensity ratio, dentate nucleus to mid-dle cerebellar peduncle signal intensity ratio, and relative change between the first and last examinations for each patient were calculated. The relationship between the signal intensity ratios and the number of enhanced MR imaging examinations also was analyzed. The study showed a significant increase in signal intensities associ-ated with multiple doses of gadodiamide, the nonionic linear agent, but not with gadobenate dimeglumine, the ionic linear agent.15 This finding shows the differences in stability and elimination between the 2 contrast agents. Rate-of-change data indirectly also suggested that gado-linium deposition occurred in the dentate nucleus with gadobenate dimeglumine use, although considerably less than with gadodiamide.15 These results are useful to MR facilities because they show that ionic contrast agents can affect the amount of gadolinium deposition that remains in the brain and that although gadobenate dimeglumine might be safer than gadodiamide, it still might have gadolinium deposition associated with it. These results correlate with the findings of the studies by Radbruch et al15 and Robert et al14—that linearly structured gadolinium–based contrast agents might have a higher incidence of intracranial deposition than macrocyclic-structured agents, suggesting that the mac-rocyclic ionic gadolinium agent gadoterate meglumine might be the safest agent.

LimitationsGaps in the literature exist. Further research is

needed to determine whether gadolinium retention is harmful to the body. Patients who have some level of deposition should be evaluated to determine the exis-tence of balance and coordination issues as a result of gadolinium contrast retention. If so, the frequency and severity of these problems should be analyzed as well.

ConclusionSeveral research studies show that intravenous

gadolinium contrast administration causes intracra-nial deposition, particularly in the dentate nucleus and globus pallidus, with as few as 4 doses of gadolinium contrast, and that this occurs regardless of renal func-tion.8 It also has been shown that linearly structured

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ing. Radiology. 2015;275(3):772-782. http://dx.doi.org /10.1148/radiol.15150025.

9. Kanda T, Fukusato T, Matsuda M, et al. Gadolinium–based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: evaluation of autopsy brain specimens with inductively coupled plasma mass spec-troscopy. Radiology. 2015;276(1):228-232. http://dx.doi.org /10.1148/radiol.2015142690.

10. Kelley LL, Petersen CM. Sectional Anatomy for Imaging Professionals. 2nd ed. St Louis, MO: Mosby; 2007.

11. Healthline Editorial Team. Medial globus pallidus. Healthline website: http://www.healthline.com/human-body-maps/medial-globus-pallidus. March 4, 2015. Accessed February 1, 2016.

12. Kanal E, Tweedle MF. Residual or retained gadolinium: practical implications for radiologists and our patients. Radiology. 2015;275(3):630-634. doi:10.1148/radiol .2015150805.

13. Radbruch A, Weberling LD, Kieslich PJ, et al. Gadolinium retention in the dentate nucleus and globus pallidus is dependent on the class of contrast agent. Radiology. 2015;275(3):783-791. doi:10.1148/radiol.2015150337.

14. Robert P, Lehericy S, Grand S, et al. T1-weighted hypersignal in the deep cerebellar nuclei after repeated administrations of gadolinium–based contrast agents in healthy rats: difference between linear and macrocyclic agents. Invest Radiol. 2015;50(8):473-480. doi:10.1097 /RLI.0000000000000181.

15. Ramalho J, Castillo M, AlObaidy M, et al. High signal inten-sity in globus pallidus and dentate nucleus on unenhanced T1-weighted MR images: evaluation of two linear gadolini-um–based contrast agents. Radiology. 2015;276(3):836-844. doi:10.1148/radiol.2015150872.

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Focus on Safety

An article published in September 2016 cap-tured national attention when the authors sug-gested that first trimester in utero ultrasound exposure was correlated with severity of

autism spectrum disorder symptoms in genetically vul-nerable children.1 That article was not the first to attempt to link in utero ultrasound exposure to autism spectrum disorders, but in this case, the evidence pre-sented was based on uncertain methodology and not on rigorous testing.2-5 At least 2 other research studies indi-cate no causative association with autism spectrum dis-orders and in utero ultrasound exposure, and a compre-hensive review of the evidence-based literature demon-strates no causal links between in utero ultrasound exposures and adverse fetal, neonatal, and childhood outcomes.6-9 Research widely indicates that the medical use of ultrasound during pregnancy is safe; however, because sensational headlines are likely to alarm the public, and because safety remains uncertain, profes-sionals who perform sonography should renew their commitment to ultrasound safety.

The absence of a negative biological effect does not prove safety, and simply having a record of safety does not justify ignoring the known and theoretical risks of ultrasound, which include the ultrasound-induced biological effects of heat and cavitation. Heat has been demonstrated to have teratological effects on the fetus.10 Cavitation occurs in the presence of natural gas bodies, or more likely in gas body contrast agents introduced

into the bloodstream during sonography examinations. Although cavitation is lethal in animal models and can induce cell apoptosis, its effects largely are negligible in fetal imaging.11 Therefore, heat remains the primary concern with fetal imaging.

Materials from the American Institute of Ultrasound in Medicine (AIUM) support no established cause and effect relationship between diagnostic sonography and adverse effects in humans.12-15 Because no research indicates a cause-and-effect relationship between in utero exposure and an adverse outcome, the AIUM recognizes the medical benefit of using ultrasound dur-ing pregnancy.13 However, it also recognizes that most epidemiology studies were performed using intensities before 1992, and thus we currently do not have much knowledge of the effects of current output.14 The lack of a demonstrated effect provides assurance that sonog-raphy is safe when performed for medical benefit by qualified and educated individuals.

Although the research is encouraging, sonogra-phers must not lose focus with regard to ultrasound safety for 2 reasons. First, no literature studying the biological effects of sonography has safety as its hypothesis, nor does it report the results of clinical trials that address the cause-and-effect relationship between ultrasound exposure and adverse effects. Second, in 1992 the ultrasound community moved from examination-specific intensity limits to 1 global limit for all exposures. In the case of fetal imaging,

Jennifer Bagley, MPH, RDMS, RVT

Ultrasound Safety: Can We Do Better?

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Focus on SafetyBagley

To simplify thermal index monitoring for sonog-raphers, AIUM has proposed updated guidelines that indicate that obstetric sonography—when medically indicated—can be performed for an extended time safely if mechanical and thermal indices are kept below 0.7.22 Doing so enhances safety, regardless of total exam-ination time, and clarifies how to interpret the indices during an examination.

The mechanical and thermal indices are not intended to replace operator judgment. Instead, they are to guide the sonographer in taking action and to limit exposure so that a quality diagnostic sonogram is obtained while mitigating potential risks to the patient. In addition to monitoring the safety indices, the sonog-rapher should:¡Decrease output power at the beginning of each

examination and increase only as needed.¡Use M-mode (ie, motion mode; measures motion

over time, uses less power than spectral Doppler, and does not provide audio output) to take fetal heart rate.

¡Avoid using Doppler imaging during the first tri-mester, except when refining for trisomy risk.

¡Never use spectral Doppler to “listen to” the fetal heart beat during an obstetrical examination.

¡Limit use of Doppler in the second and third tri-mesters to what is necessary for medical benefit to the fetus and then for as little time as possible.

¡Move the transducer frequently so as not to dwell too long on fetal bone.

¡Avoid dwelling on the fetal head to observe or docu-ment fetal profiles for parental keepsake images.

In addition, anyone who performs diagnostic sonogra-phy should earn the proper credentials in the specialty areas in which they work.

Patients should be discouraged from visiting fetal keepsake imaging centers because they expose the fetus to excess ultrasound energy for no medical benefit. Keepsake imaging centers might prolong ultrasound exposures unnecessarily, and they do not have to ensure that the operator is qualified to operate the equipment or to identify abnormalities. For these reasons, the U.S. Food and Drug Administration, the Society of Diagnostic Medical Sonography, and the AIUM dis-courage the practice of keepsake imaging.23-25

intensities were raised from 94 mW/cm2 to an overall limit of 720 mW/cm2, a potential 8-fold increase in the intensity that could be used for obstetric imaging.16 These new limits were not tested for safety, and no large-scale epidemiological studies have evaluated the potential biological effects of these increased intensities.

The maximum allowable intensity was increased because of the lack of reported biological effects and to improve the diagnostic capabilities of sonography. The benefits of the technological advances made as a result should not be understated. When the maximum allow-able output intensity was increased to improve diagnostic confidence, the U.S. Food and Drug Administration shifted the responsibility for safety monitoring into the hands of the operator. Sonographers and interpreting physicans are expected to use the output display standard, which includes the mechanical index and thermal index, to monitor for potential risks of biological effects during a sonography examination.16,17

Both mechanical and thermal indices are unitless numbers displayed on the monitor or on the ultrasound system during an examination. A mechanical index of 1.0 or greater indicates that scanning conditions are such that mechanical effects such as cavitation could occur.18 The thermal index is displayed similarly to the mechanical index but indicates that heat-related biological effects might occur. A thermal index of 1.0 indicates that conditions exist in which the temperature in tissues could be raised 1°C.18 The thermal index is further divided into 3 subcategories in soft tissue, which is appropriate to display in examinations that scan adult soft tissue as well as first-trimester fetuses of up to 10 weeks.15 The thermal index at bone should be displayed whenever bone is at focus and during fetal sonography performed at 10 weeks or more.15,16 The thermal index of cranial bone at surface is most appropriately dis-played during a neonatal head examination.16

Evidence suggests that those who perform sonog-raphy are not monitoring the mechanical or thermal indices for safety nor do they possess a basic under-standing of them, including how to monitor them and where they are located on the systems.19-21 The lack of observable biological effects might give a false assurance of safety to operators and patients, which is concerning.

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Focus on SafetyUltrasound Safety: Can We Do Better?

7. Stoch YK, Williams CJ, Granich J, et al. Are prenatal ultra-sound scans associated with the autism phenotype? Follow-up of a randomised controlled trial. J Autism Dev Disord. 2012;42(12):2693-2701. http://dx.doi.org/10.1007/s10803 -012-1526-8.

8. Abramowicz JS. Ultrasound and autism: association, link, or coincidence? J Ultrasound Med. 2012;31(8):1261-1269. http://dx.doi.org/10.7863/jum.2012.31.8.1261.

9. Torloni MR, Vedmedovska N, Merialdi M, et al; ISUOG-WHO Fetal Growth Study Group. Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis. Ultrasound Obstet Gynecol. 2009;33(5):599-608. http://dx.doi.org/10.1002/uog.6328.

10. Shaw GM, Todoroff K, Velie EM, Lammer EJ. Maternal ill-ness, including fever and medication use as risk factors for neural tube defects. Teratology. 1998;57(1):1-7. http://dx.doi .org/10.1002/(SICI)1096-9926(199801)57:1<1::AID -TERA1>3.0.CO;2-6.

11. Child SZ, Carstensen EL. Effects of ultrasound on Drosophila--IV. Pulsed exposures of eggs. Ultrasound Med Biol. 1982;8(3):311-312. http://dx.doi.org/10.1016/0301 -5629(82)90037-0.

12. Statement on mammalian biological effects of heat. American Institute of Ultrasound in Medicine website. http://www.aium.org/officialStatements/17. Approved March 25, 2015. Accessed November 2, 2016.

13. Prudent use and clinical safety. American Institute of Ultrasound in Medicine website. http://www.aium.org/officialStatements/34. Approved April 1, 2012. Accessed November 2, 2016.

14. Conclusions regarding epidemiology for obstetric ultra-sound. American Institute of Ultrasound in Medicine web-site. http://www.aium.org/officialStatements/16. Approved March 27, 2010. Accessed November 2, 2016.

15. Abramowicz JS, Barnett SB, Duck FA, Edmonds PD, Hynynen KH, Ziskin MC. Fetal thermal effects of diag-nostic ultrasound. J Ultrasound Med. 2008;27(4):541-559. http://dx.doi.org/10.7863/jum.2008.27.4.541.

16. American Institute of Ultrasound in Medicine. Medical Ultrasound Safety. 3rd ed. https://www.aace.com/ecnu _resources/AIUM_RESOURCES/NEED_AIUM _SAFETY_BROCHURE_HERE/AIUM_Medical _Ultrasound_Safety-ThirdEdition.pdf. Published 2014. Accessed December 13, 2016.

17. Lee W, Garra B; American Institute of Ultrasound in Medicine. AIUM Technical Bulletin. How to interpret the ultrasound output display standard for higher acoustic out-put diagnostic ultrasound devices: version 2. J Ultrasound Med. 2004;23(5):723-726. http://dx.doi.org/10.7863/jum .2004.23.5.723.

Every sonographer should be familiar with the AIUM’s biological effects and safety statements, which are updated as new scientific evidence develops. In addition, although educating oneself about the poten-tial biological effects of sonography is a good first step, education must be reflected in practice. By monitoring the mechanical and thermal indices and following the recommended guidelines, sonographers can ensure they are performing the safest diagnostic medical examination for their patients while meeting the high-est professional standards for safety.

Jennifer Bagley, MPH, RDMS, RVT, is associate professor in the department of medical imaging and radiation sciences for the University of Oklahoma Health Sciences Center, College of Allied Health, in Oklahoma City.

References1. Webb SJ, Garrison MM, Bernier R, McClintic AM, King

BH, Mourad PD. Severity of ASD symptoms and their correlation with the presence of copy number variations and exposure to first trimester ultrasound. Autism Res. [Published online ahead of print September 1, 2016]. http://dx.doi.org/10.1002/aur.1690.

2. Williams EL, Casanova MF. Potential teratogenic effects of ultrasound on corticogenesis: implications for autism. Med Hypotheses. 2010;75(1):53-58. http://dx.doi.org/10.1016/j .mehy.2010.01.027.

3. Rodgers C. Questions about prenatal ultrasound and the alarming increase in autism. Midwifery Today. 2006;win-ter(80). https://www.midwiferytoday.com/articles/ultra soundrodgers.asp. Accessed November 2, 2016.

4. AIUM responds to autism study: AIUM bioeffects commit-tee statement on paper. American Institute of Ultrasound in Medicine website. http://www.aium.org/soundWaves /article.aspx?aId=965&iId=20160907. Published September 7, 2016. Accessed November 2, 2016.

5. Stafford K. Autism and sonography - should you be con-cerned? Society of Diagnostic Medical Sonography web site. http://www.sdms.org/news/2016/09/08/autism-and -sonography---should-you-be-concerned. Accessed November 2, 2016.

6. Grether JK, Li SX, Yoshida CK, Croen LA. Antenatal ultra sound and risk of autism spectrum disorders. J Autism Dev Disord. 2010;40(2):238-245. http://dx.doi.org/10.1007 /s10803-009-0859-4.

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Focus on SafetyBagley

18. Abbott JG. Rationale and derivation of MI and TI--a review. Ultrasound Med Biol. 1999;25(3):431-441. http://dx.doi.org /10.1016/S0301-5629(98)00172-0.

19. Marsál K. The output display standard: has it missed its tar-get? Ultrasound Obstet Gynecol. 2005;25(3):211-214. http://dx.doi.org/10.1002/uog.1864.

20. Sheiner E, Shoham-Vardi I, Abramowicz JS. What do clini-cal users know regarding safety of ultrasound during preg-nancy? J Ultrasound Med. 2007;26(3):319-325. http://dx.doi .org/10.7863/jum.2007.26.3.319.

21. Bagley JE, Thomas KE, DiGiacinto D. Safety practices of sonographers and their knowledge of the biologic effects of sonography. J Diagn Med Sonogr. 2011;27(6):252-261. http://dx.doi.org/10.1177/8756479311424431.

22. Harris GR, Church CC, Dalecki D, Ziskin MC, Bagley JE; American Institute of Ultrasound in Medicine; Health Canada; British Medical Ultrasound Society. Comparison of thermal safety guidelines for diagnostic ultrasound expo-sures. Ultrasound Med Biol. 2016;42(2):345-357. http://dx.doi.org/10.1016/j.ultrasmedbio.2015.09.016.

23. Avoid fetal “keepsake” images, heartbeat monitors. U.S. Food and Drug Administration website. http://www.fda .gov/ForConsumers/ConsumerUpdates/ucm095508.htm. Updated December 16, 2014. Accessed January 12, 2017.

24. Keepsake fetal imaging. American Institute of Ultrasound in Medicine website. http://www.aium.org/officialState ments/31. Approved April 1, 2012. Accessed January 12, 2017.

25. What to expect during your sonogram. Society of Diagnostic Medical Sonography website. http://www.sdms.org/docs/default-source/thing-link/what-to-expect-during -your-sonogram.pdf. Published 2016. Accessed January 12, 2017.

444 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Practice Fundamentals

Prompt diagnosis of a scaphoid fracture is essen-tial to maintaining long-term bone health and preventing disability. If neglected or misdiag-nosed, a displaced scaphoid fracture can pro-

mote avascular necrosis or early onset osteoarthritis and lead to chronic pain and disability. The scaphoid view, a posteroanterior projection of the wrist posi-tioned in ulnar deviation, often is requested for exami-nations of wrist trauma to identify possible scaphoid fractures.

The scaphoid bone, 1 of the 8 carpal bones in the wrist, articulates with the distal radius and 4 carpal bones (lunate, trapezium, trapezoid, and capitate). Its primary function is to transfer compression loads between the forearm and the hand.1 The scaphoid is the most commonly fractured carpal bone, in part because of its location among the carpals. It is situated in the proximal carpal row on the thumb side of the wrist and adjoins the distal carpal row.1,2 As a link between the 2 rows, the scaphoid helps maintain carpal stability.1,2 When a hyperextension injury occurs, such as a fall on an outstretched hand, this places stress on the scaphoid and can lead to an acute fracture.2

Identifying the location and severity of a scaphoid fracture is vital to providing appropriate treatment (see Figure). Three areas of the scaphoid can be frac-tured: the waist (70% of fractures), the distal end (20%), and the proximal end (10%).1 Fractures are classified according to location and degree of displacement. A

fracture is considered unstable if displacement is more than 1 mm on a radiograph, if the scapholunate angle is greater than 60°, or if the lunocapitate angle is greater than 15°.1

Elizabeth A Paterson, BS, R.T.(R)(CT)(M)Jonathan B Havrda, MPH, CRA, R.T.(R)(CT)(BD)

Scaphoid Imaging and Its Challenges

Figure. Posteroanterior projection with ulnar deviation of the wrist. The radiograph reveals a fracture in the left scaphoid waist (arrow). Reprinted with permission under the Creative Commons Attribution-ShareAlike 4.0 International license. Courtesy of James Heilman, MD. https://commons.wikimedia.org/w/index .php?curid=49147251.

445RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Practice FundamentalsPaterson, Havrda

Elizabeth A Paterson, BS, R.T.(R)(CT)(M), is radiology floor supervisor, lead mammographer, and associate PACS administrator for Cottage Hospital in Woodsville, New Hampshire.

Jonathan B Havrda, MPH, CRA, R.T.(R)(CT)(BD), is director of radiology and PACS administrator for Cottage Hospital in Woodsville, New Hampshire. He is a member of the Radiologic Technology Editorial Review Board and the American Registry of Radiologic Technologists Bone Densitometry Practice Analysis Committee.

References1. Krasin E, Goldwirth M, Gold A, Goodwin DR. Review

of the current methods in the diagnosis and treatment of scaphoid fractures. Postgrad Med J. 2001;77(906):235-237.

2. Martensen KM. Upper Extremity. In: Radiographic Image Analysis. 3rd ed. St Louis, MO: Saunders; 2013:205-208.

3. Bontrager KL, Lampignano J. Upper Limb. In: Textbook of Radiographic Positioning and Related Anatomy. 8th ed. St Louis, MO: Mosby; 2013:157-158.

4. Frank ED, Long BW, Smith BJ. Upper Limb. In: Merrill’s Atlas of Radiographic Positioning and Procedures: Volume 1. 12th ed. St Louis, MO: Mosby; 2011:138.

Precise positioning and central ray angulation are important for optimal demonstration of the scaphoid.2 A proper scaphoid view should demonstrate the bone without superimposition. In addition, adjacent carpal interspaces should be open.3 The bone should not be foreshortened, and ulnar deviation (ie, bending of the patient’s wrist toward the little finger side) should present the angle of the long axis of the metacarpals in alignment with the radius and ulna.3 To visualize the scaphoid borders, scaphoid fat stripe, and bony trabecu-lar markings, the exposure should produce adequate density and contrast with no motion.3

To achieve an optimal image, position the patient’s wrist on the image receptor with the palm down and the shoulder, elbow, and wrist on the same horizontal plane.3 Without lifting or rotating the distal forearm, gently move the patient’s hand as far toward the ulnar side as the patient can tolerate.3 The patient can use his or her other hand to assist in achieving optimal ulnar wrist deviation and minimize discomfort. Angle the central ray 10° to 15° proximally toward the patient’s elbow.3 The central ray should be directed toward the scaphoid, approximately 2 cm distal and medial to the radial styloid process.3 Collimate to the carpal region approximately 6 cm proximal and distal to the wrist joint and 2.5 cm on the sides.4

Many patients with suspected scaphoid fractures have limited range of motion and cannot attain maxi-mum ulnar wrist deviation. When this occurs, the angle of the scaphoid remains more anterior and can obscure the distal portion of the bone.2 To compen-sate for unwanted anterior tilt, increase the central ray angulation to approximately 20° to place the central ray perpendicular to the long axis of the scaphoid.2 Obscure scaphoid fractures might require several projections with different central ray angles or further evaluation with computed tomography or magnetic resonance imaging.

The scaphoid view can be challenging in the pres-ence of wrist trauma and associated pain. However, precise positioning can ensure an accurate diagnosis and a better prognosis.

446 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Patient Care

No doubt about it, as imaging technology has improved, so has patient care.1 As a result, the use of medical imaging, especially computed tomography (CT), has increased during the

past several decades, particularly with pediatric patients, and for good reason: CT provides information to help providers quickly and accurately diagnose inju-ries. It saves lives and often prevents the need for more invasive procedures.1 However, inappropriate use of CT—or any imaging tool that uses ionizing radiation—can result in unnecessary risks to patients, particularly children.1

In 2001, several scientific articles claimed that pedi-atric patients who underwent CT procedures received estimated radiation doses as much as 3 times higher than those given to adults.2 Similar articles about the risks of overreliance on CT soon followed, spurring the need to implement a balanced approach to scanning the pediatric population that weighed the health benefits of CT with the known risks.2 In 2008, the Alliance for Radiation Safety in Pediatric Imaging, a coali-tion founded by the American Society of Radiologic Technologists, the Society for Pediatric Radiology, the the American College of Radiology, and the American Association of Physicists in Medicine, made a notable effort to strike that balance with the launch of the Image Gently campaign.

The campaign includes information about pedi-atric imaging examinations directed to radiologic

technologists, medical physicists, radiologists, pediatri-cians, and parents. It also offers protocols for reducing pediatric radiation dose during CT examinations.3 In 2014, Image Gently introduced new protocols to address the additional innovative features installed in CT scanners since 2008, such as automatic tube cur-rent modulation, reduced tube voltage techniques, and iterative reconstructions.4 The 2014 protocols provided guidance for setting up techniques for newborns, chil-dren, and adults and for acquiring diagnostic-quality images using well-managed radiation dose levels regardless of CT scanner manufacturer and model.4 Thousands of individuals and facilities have joined the effort and taken the pledge to image gently when per-forming pediatric radiologic examinations.3

Building on the success of the Image Gently campaign, the Alliance launched the Think A-Head campaign in November 2016.4 The key drivers of the campaign’s devel-opment include the frequency of head trauma in children, the prevalence of CT use (it is the most common exami-nation performed in children), and the wide variability in levels of radiation dose used in pediatric scans across the United States. The initial goal of the campaign was to offer information that would help providers determine whether a CT scan was the best option for diagnosing children with minor head injuries. It quickly expanded to include eliminating low-value procedures as well as estab-lishing and following age-appropriate protocols for when scans are necessary.4

Emilee Palmer, BS, R.T.(R)(CT)

Image Gently Think A-Head Campaign Focuses on Pediatric Head CT Protocols

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Patient CarePalmer

The campaign’s tools and resources help providers ensure that they are complying with the latest evidence-based medical guidelines regarding performing CT scans on children with minor head injuries. The materi-al also is useful in helping the patient care team—from providers to parents—communicate in an informed manner about why the scan is or is not necessary and how to make the best-informed decision possible (see Box).4

The importance of optimizing dose has long been a guiding principle in the imaging profession, signified by technologists’ staunch commitment to the as low as reasonably achievable (ALARA) principle. Regardless how technology evolves, what must never change is the focus on patient care—something diagnostic imaging professionals are passionate about. Although it is chal-lenging to be the technologist asked to perform a CT scan on a pediatric patient when it is unclear what is best for that patient, information from campaigns such as Think A-Head offer additional tools to open a dialog with physicians and others to help ensure the best care for their patients.

Emilee Palmer, BS, R.T.(R)(CT), is imaging supervisor for OhioHealth Westerville Medical Campus. She also is a member of and ASRT representative to the Think A-Head campaign committee.

References1. World Health Organization. Communicating radiation risks

in paediatric imaging. http://www.who.int/ionizing_radia-tion/pub_meet/radiation-risks-paediatric-imaging/en/. Published 2016. Accessed December 14, 2016.

2. Image Gently development of pediatric CT protocols 2014. Image Gently website. http://www.imagegently.org/Portals/6/Procedures/IG%20CT%20Protocols%20111714.pdf. Published 2014. Accessed December 14, 2016.

3. Image Gently. American Society of Radiologic Technologists website. https://www.asrt.org/patients /image-gently. Accessed December 14, 2016.

4. Physician groups join forces to improve use of head CT scans in children [press release]. http://www.imagegently .org/Portals/6/Think-Ahead/IG%20Think%20Ahead%20Launch%20PR%20UPDATED_Final.pdf?ver=2016-11-02 -101302-000. Published November 2, 2016. Accessed December 14, 2016.

Box

Suggestions for Making an Informed Decision⁴

Providers should: Know when an imaging test is necessary. Explain why a head CT scan is or is not the right choice. Discuss the benefits and risks of CT scans. Discuss possible alternative ways to assess a child’s injury. Child-size the radiation dose.

Parents can ask questions such as: How will this examination improve my child’s care? What are the benefits and risks of the CT scan? What will my child experience before, during, and after the

scan? Are there alternative tests that do not use radiation? Will the radiation dose be child-sized?

In the event a CT scan is appropriate, imaging providers (ie, technologists) can: Optimize, or child-size, the protocol. Scan only when necessary, only the indicated region, and

only once (no multiphase scans). Involve the physicist and other technologists to review

pediatric protocols and optimize scanning.

To learn more about Image Gently initiatives, visit imagegently.org.

448 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Advances in Technology

The global medical device company EOS imaging offers a full-body, low-dose stereoradiographic imaging system that is transforming diagnosis, surgery, and treatment for the most common

osteoarticular conditions (ie, hip, knee, and spine). It is the only technology of its kind on the market. Tailored for orthopedic imaging, the EOS imaging system produc-es 2-D radiographs of the body in an upright position.1,2 From the 2-D images, supplementary EOS software gen-erates patient-specific 3-D measurements and models of the skeletal system that can inform all facets of clinical care.3,4 The first EOS imaging systems were installed in North America and Europe in 2008, and today they are available in 51 countries, including the United States, China, and Japan.1

The EOS imaging system is based on the scientific research of French physicist Georges Charpak, who received the Nobel Prize in Physics in 1992 for his invention of a gaseous particle detector with a multiwire proportional chamber.1,4 His chamber increased the detection of particle collision events by the millions per second, vs the detection of 1 to 2 per second with ear-lier detectors.5 Physicists, engineers, radiologists, and surgeons built upon Charpak’s research in radiation detection, leading to the development of the EOS imag-ing system.1 The system uses a multiwire proportional chamber detector to detect x-rays, thus serving as a measurement of ionization that helps minimize radia-tion exposure to patients.3,4

As with conventional radiography, the EOS imaging system primarily is an imaging tool for the skeleton. However, unlike a standard, single-source x-ray beam, the biplanar EOS system uses 2 perpendicular fan beams that vertically scan the body, producing 2 simultaneous frontal and lateral images of the entire skeleton.3,4,6 Radiographs are taken while the patient is standing to visualize the skeletal system under normal weight-bearing conditions.4 The EOS imaging sys-tem is equipped with the sterEOS workstation.6 This workstation uses statistical modeling and bone-shape recognition software to produce 3-D measurements of frontal and lateral images and 3-D reconstructions of the spine and lower limbs.4,6 For that reason, the system is like computed tomography (CT) imaging but does not provide information on soft tissues such as muscles, spinal cord, nerves, and viscera.4

The EOS imaging system uses a standard low-dose protocol.4 In a study comparing EOS imaging to computed radiography (CR) imaging of the spine, Deschênes et al found that the entrance skin dose was 3 times lower for the nape of the neck and 6 to 9 times lower for the thoracolumbar region when using the EOS system.4,7 In addition, the researchers found that overall image quality was enhanced compared to CR, but that the latter demonstrated the lumbar spinous processes better than did the EOS system.7 Further, Delin et al found that using CT for 3-D reconstruction of femoral and tibial torsion measurements resulted in 4.1 times

Annette Ortiz, MA, R.T.(R)(CT)

The EOS Imaging System: Promising Technology in Skeletal Imaging

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Advances in TechnologyOrtiz

¡ Wavy image results if the patient is unable to stand or sit with steadiness.

¡ Reduced contrast in 2-D images compared to the contrast in conventional radiographs.

¡ 3-D reconstruction is semiautomatic, thus increasing the risk of error.

¡ Available software cannot perform 3-D recon-struction when imaging children younger than 6 years because the software was designed for adult bones.

¡ 3-D reconstruction of the patella, rib cage, and congenital anomalies of the spine is not possible.

¡ Biased measurements can result when imag-ing severe deformities of the limbs with the 3-D angular measurement because it uses a statistical model based on “normal” bones.

¡ Unlike CT imaging, in which many acquisitions are performed to generate the axial view, EOS 3-D reconstruction encompasses only the outer bone surface and not the inner structure of the bone.

Despite its limitations, EOS imaging is a valuable research tool and gradually is replacing conventional digital radiography in some clinical settings because of its low-dose technology and precise 3-D imaging capa-bilities.4 Given its diagnostic benefits and usefulness in follow-up treatments, the popularity of EOS imag-ing likely will increase as research teams continue to improve the technology.

Annette Ortiz, MA, R.T.(R)(CT), is assistant professor in the Radiologic Technology Program for the Bronx Community College in New York.

References1. About us. EOS imaging website. www.eos-imaging.com/us

/about/history. Accessed December 17, 2016.2. Mahboub-Ahari A, Hajebrahimi S, Yusefi M, Velayati

A. EOS imaging versus current radiography: A health technology assessment study. Med J Islam Repub Iran. 2016;30(1):331.

3. Illés T, Somoskeöy S. The EOS™ imaging system and its uses in daily orthopaedic practice. Int Orthop. 2012;36(7):1325-1331. http://dx.doi.org/10.1007/s00264-012-1512-y.

4. Melhem E, Assi A, El Rachkidi R, Ghanem I. EOS(®) bipla-nar X-ray imaging: concept, developments, benefits, and

higher ionizing radiation dose to the ovaries, 24 times higher dose to the testicles, and 13 to 30 times higher dose to the knees and ankles compared to dose expo-sure when using the EOS system.4,8

In 2015, EOS introduced a microdose protocol option to further minimize radiation dose to pediatric patients and others who require repeat radiography examinations.4,9 In the radiological follow-ups of 32 ado-lescent patients with idiopathic scoliosis, Ilharreborde et al found that the microdose protocol resulted in 5.5 times lower radiation exposure than did the standard EOS low-dose protocol, equating to a 45-fold reduction in radiation compared to conventional radiography.10 The researchers also concluded that the microdose pro-tocol did not alter the quality of images.10

EOS imaging might be most useful for evaluating and monitoring scoliosis and sagittal balance because it performs simultaneous orthogonal imaging while the patient is standing, and it also can demonstrate rela-tionships with the adjacent cervical spine, pelvis, and lower limbs.4 Using the EOS imaging system, Vidal et al assessed the reliability of radiographic measurements for global sagittal balance and sagittal spine curves.11 The researchers evaluated full-spine EOS radiographs of 50 patients with adolescent idiopathic scoliosis (AIS) and 25 normal controls.11 The patients with AIS were divid-ed into 2 groups: 25 had not had surgical correction and 25 had undergone posterior arthrodesis surgery. Each patient was scanned with the EOS imaging system while standing in a standardized position defined by looking straight ahead with his or her fists on the clavicles. Vidal et al concluded that cervical lordosis and global sagittal spine balance in AIS could be measured using a simple and widespread tool such as the EOS imaging system.11 In addition, they concluded that the EOS imaging system can obtain large, full-spine radiographs while delivering significantly reduced levels of radiation expo-sure. They found no issues with image quality among the 75 patients.11 Their findings are particularly mean-ingful for patients who have AIS and require repeated radiographic follow-up. Studies using the EOS imaging system to assess cervical spine changes in patients who have AIS after corrective surgery are needed.11

EOS imaging technology offers medical institutions many advantages, but it also has limitations4:

450 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Advances in TechnologyThe EOS Imaging System: Promising Technology in Skeletal Imaging

limitations. J Child Orthop. 2016;10(1):1-14. http://dx.doi .org/10.1007/s11832-016-0713-0.

5. Georges Charpak, Particle Detectors, and Multiwire Chambers. U.S. Department of Energy Office of Scientific and Technical Information website. www.osti.gov/accom plishments/charpak.html. Accessed December 17, 2016.

6. EOS. EOS imaging website. www.eos-imaging.com/us/pro fessionals/eos/eos. Accessed December 17, 2016.

7. Deschênes S, Charron G, Beaudoin G, et al. Diagnostic imaging of spinal deformities: reducing patients radia-tion dose with a new slot-scanning X-ray imager. Spine. 2010;35(9):989-994. http://dx.doi.org/10.1097/BRS .0b013e3181bdcaa4.

8. Delin C, Silvera S, Bassinet C, et al. Ionizing radiation doses during lower limb torsion and anteversion measurements by EOS stereoradiography and computed tomography. Eur J Radiol. 2014;83(2):371-377. http://dx.doi.org/10.1016/j .ejrad.2013.10.026.

9. EOS imaging’s micro dose feature highlighted at EPOS 2015. BusinessWire website. www.businesswire.com/news /home/20150415006368/en/EOS-imaging%E2%80%99s -Micro-Dose-feature-highlighted-EPOS. Accessed December 17, 2016.

10. Ilharreborde B, Ferrero E, Alison M, Mazda K. EOS micro-dose protocol for the radiological follow-up of adolescent idiopathic scoliosis. Eur Spine J. 2016;25(2):526-531. http://dx.doi.org/10.1007/s00586-015-3960-8.

11. Vidal C, Ilharreborde B, Azoulay R, Sebag G, Mazda K. Reliability of cervical lordosis and global sagittal spinal bal-ance measurements in adolescent idiopathic scoliosis. Eur Spine J. 2013;22(6):1362-1367. http://dx.doi.org/10.1007 /s00586-013-2752-2.

451RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Teaching Techniques

A Protégé’s Guide to Working With the Perfect MentorChristopher Bullister, AAS, R.T.(R)

Used responsibly, mentoring is a tool that can take the weakest of mankind to the ends of the earth. Everyone is influenced by the culture, people, and experiences encountered through-

out his or her lifetime. Inexperienced protégés can seek advice and guidance from those who are more experi-enced. However, simply finding a mentor is not the only key to success. It is important to understand the qualities of a good mentor, the necessary willingness of a protégé, and the ultimate end goal of the relationship.

Finding a mentor on whom you can rely can help open the doors for emotional support, career advice, and technical and procedural knowledge related to your field.1 According to Ensher and Murphy2:

Mentors can help you clarify your work expectations, give you an opportunity to do your best, enable you to receive recognition and praise, make you feel cared about, encourage your development, make you feel like your opinions matter, provide you with a friendship at work, talk to you about your progress, and provide opportunities for you to learn and grow.

Protégé–mentor relationships are delicate, but when a successful pairing is made, the benefits can be lifelong.

Finding a MentorWhether you are a student, a technologist, or an educa-

tor, there are a few things to consider if you are looking for

a mentor. First, take the initiative to find a mentor rather than waiting to be chosen. You can search for the best minds in your profession, whether they reside locally or worldwide, through periodicals, conferences, or over the Internet. Local options might include educators, program directors, and staff at clinical rotation sites. Leaders of your state affiliate society, senior technologists, depart-ment managers, and those certified in a modality you are considering pursuing also might be good mentors. Once you identify a person from whom you would like to learn, explore his or her accomplishments, business profiles, and publications. You might even look someone up on social media. After connecting with a potential mentor, ask yourself whether he or she:

� Makes you feel important. � Makes you feel as though your opinions matter. � Takes the time to listen to you.

If the person makes you feel as though your develop-ment and quality of work is not a priority, you might want to look elsewhere.

Adding a Personal TouchI was fortunate enough to be assigned a men-

tor over the past year for the American Society of Radiologic Technologist (ASRT) Student Development Leadership Program. The organiza-tion seemed to choose their mentors wisely, which is important when trying to lead the next generation in the field of radiologic technology. It is important that a

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Teaching TechniquesA Protégé’s Guide to Working With the Perfect Mentor

Giving back is the last step in any successful mentor-ship.1 Former protégés can share their enthusiasm with newcomers who enter the workforce after them. Being passionate and having a desire to spread your knowl-edge allows you to begin leaving your own legacy that will carry on.

Leaving a LegacyAs a recent graduate from a radiologic technology

program, I continue to work in an environment with students. I have proudly taken on the informal role of mentor with students and have begun developing relationships with those who are eager to learn. Many people do not realize that1:

[M]entors and protégés exchange valuable, albeit different, benefits with each other. Although the exchange might be very different, the exchange has to be seen as equally valuable and reciprocal for both parties involved.

This statement speaks to me, and now I can look at every learning experience as beneficial not only for the student but also the teacher.

Those who are passionate and possess a desire to spread knowledge have the greatest influence. These peo-ple also know the crucial roles both mentors and protégés have in the partnership’s success. It is, in a sense, a 2-way street between teacher and student, sensei and grasshop-per, leader and follower. The question to ask now is: How much will you take out of your next experience?

Christopher Bullister, AAS, R.T.(R), is a radiologic technologist for Coastal Carolina Hospital in Hardeeville, South Carolina, and Memorial Health University Medical Center in Savannah, Georgia. He can be reached at cmbthe2@aol.com.

References1. Portner H. Being Mentored: A Guide for Protégés.

Thousand Oaks, CA: Skyhorse Publishing; 2015.2. Ensher E, Murphy S. Power Mentoring: How Successful

Mentors and Protégés Get the Most Out of Their Relationships. San Francisco, CA: Jossey-Bass; 2005.

mentor sparks a protégé’s learning and development in work and in life.

In my experience, asking questions was extremely helpful because it established open communication. As a protégé, you have the right to ask; however, it is important to limit questions and requests to what you really want or need answered in an effort to respect your mentor’s time and commitments.1

Building a RapportBuilding a rapport and a sense of comfort with a

mentor usually results in increased willingness to listen and learn. However, developing a relationship takes time, and it is important to gain trust on both sides. In the beginning, you should gauge whether your poten-tial mentor truly has a passion for his or her role. If mentors show no enthusiasm for their work or appear to be disengaged, it is a red f lag to how well they will encourage you.

Being a Good StudentLearning how to become a good protégé is another

step you must take to have a successful mentorship. Are you ready and able to be mentored? You should “[k]now what you want, know how to get what you want, know how to build and deepen the relationship.”1 As a pro-tégé, I wanted to learn because the ones who ultimately would benefit from the knowledge I gained were my future colleagues and, most importantly, the patients.

The 9 steps to becoming a protégé are1: � Participate. � Take responsibility. � Observe. � Ask. � Chart your course. � Network. � Take informed risks. � Reflect. � Give back.

One key step is to reflect. One of the best ways to learn is to take the time to step back and evaluate what, why, and how you learned. I find this step critical for learning and using this knowledge to influence growth in the next step forward. This list also helps mentors set expectations for and with new students.

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Writing & Research

The Pros and Cons of Writing With CoauthorsCheryl DuBose, EdD, R.T.(R)(CT)(MR)(QM)Kelli Welch Haynes, MSRS, R.T.(R)

Sally Mae has an idea for a journal article, and her friend, Mary Jo, needs to publish articles to meet her productivity requirements for work. Both are hesitant to attempt writing alone.

They are not sure of the process, fear rejection, and are concerned about the workload. They decide to write an article together and settle on a topic: mating habits of a particular bird species found mainly in the south. However, trouble in paradise quickly arrives. Sally Mae wants to focus on the mockingbird, and Mary Jo believes the brown pelican is more appropriate. After much gnashing of teeth and some name calling, they decide that the mockingbird has a more universal appeal. The main topic of the article is established.

Because the article idea and subject are Sally Mae’s, they agree that she will take the lead as first author, directing the f low of the article and the writing pro-cess, as well as submitting the final draft. Mary Jo will contribute to the publication as directed by Sally Mae. After some discussion, it is decided that Mary Jo will begin the literature review process, while Sally Mae focuses on obtaining original research data for the body of the article. Mary Jo completes her section in a timely manner, but because Sally Mae is juggling numerous projects with urgent deadlines, her portion remains unfinished. Mary Jo becomes frustrated at the lack of progress. Once again, tempers f lare. Sally Mae, realiz-ing that her procrastination is responsible for Mary Jo’s frustration, tries to make it up to her by diving into her

assigned sections with vigor. The article eventually is finished and is viewed as a publication success.

At the end of the collaborative writing process, the 2 authors (who are still friends) better understand the pros and cons of working with coauthors on an article. They agree to collaborate again in the future.

The Collaborative Writing ProcessApproximately 15% of technologists with doctor-

ate degrees produce most of the scholarly research and writing in the radiologic sciences, but even this well-educated group faces difficulties with the process.1 For many, the publication process is one of the most daunting and time-consuming tasks an individual can attempt, which might explain why so few within the medical imaging and radiation therapy profes-sion attempt to publish. Other reasons include a lack of research skills, lack of writing ideas, lack of time, difficulty with coauthors, or fear and anxiety of fail-ing.1,2 Collaborative writing is seen as 1 solution to overcoming these barriers and to increasing scholarly productivity.2

One of the first questions to address before start-ing a writing project is whether to work alone or with 1 or more coauthors.3 Evidence suggests that a greater proportion of articles today are team-authored rather than written by an individual.4 For most professionals, working in teams improves the quality of research. Not only does it bring together people with complementary

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Writing & ResearchThe Pros and Cons of Writing With Coauthors

obstacles and pitfalls of the writing process, keeping the group focused and motivated. Once the first collabora-tive project is complete, many groups choose to rotate roles, including the role of first author. By convention, the first author shoulders the greater workload and, as a result, receives the greater credit.2

For radiologic science educators and other technolo-gists who feel pressured to publish by their employment institutions, the increased productivity that coauthor-ing offers is a valuable commodity. For example, authors within the writing group might increase their publica-tions as first authors from 1 to 10 publications over a 3-year period.2 This productivity increase is possible when coauthors appropriately distribute the workload, draw from one another’s strengths, and provide one another with the motivation and support needed to fin-ish the project.2,6

Cons of Collaborative WritingBalanced against the benefits are the challenges that

potential coauthors should consider. First, although 2 heads are better than 1, if the heads do not agree, there can be trouble, even stalemates.3 This is espe-cially true for projects that require work over a long period. Second, although many hands can make light work, 1 pair of hands often does more of the heavy lift-ing. Rarely will all hands work with equal diligence or energy all the time. And third, having coauthors almost always requires more cooperation, greater patience, and increased willingness to pick up the slack. If any of the coauthors lack these characteristics, it can lead to ten-sion as well as late manuscript submissions.4

Effective collaborative writing is a gradual process. Rarely do coauthors produce immediately, instead requiring time to “gel” as a group.7 Trust must be built, egos must be subjugated, and free riders must be dumped.7 This building of a cohesive writing group can be described as a professional friendship, one in which reliability, openness, sharing, respect, and support are expected.2 The qualities of a professional friendship are helpful when combating the cons of collaborative writ-ing because even with the best intentions, collaborative writing projects go awry. Differences in writing styles, productivity timelines, and attitudes can create the greatest challenges; other barriers include5:

areas of expertise, but it also can provide greater depth regarding idea generation and refinement and shares the manuscript writing and revision duties among multiple authors. In addition, working with coauthors can be personally rewarding. However, it also can be frustrating.4

Pros of Collaborative WritingOne of the many advantages to working with coau-

thors is that 2 heads are better than 1. Having someone to consult with on a project can result in a better prod-uct. In addition, many hands can make light work. The most daunting writing project seems manageable when divided among 2 or more colleagues.3 Spreading the work among coauthors permits busy people, who might not otherwise find the time for a project, to join in a cooperative effort to produce a product. Coauthors can add missing components to the writing process, as well as provide peer support and feedback on writing.2 Finally, putting together a team of reputable coauthors can lend weight to the project because readers gravi-tate toward articles and books that bear the names of authors with whose work they are familiar.

Coauthors should be chosen strategically based on the knowledge or skill set they bring.1,2,5 For example, if the paper is an original research article with a data set component, then 1 or more authors should be comfort-able with data analysis. By working with coauthors, writers gain new skills as they learn from one another and take on different roles within the writing process.2

Trust is one of the most important factors in success-ful collaborations; it is difficult for a team to succeed without it.4 If coauthors do not trust one another, they can begin to question one another’s motivations and actions in every situation. Essential goals include devel-oping a shared vision and clear expectations, sharing recognition and credit, handling conflict, building a good team, and enjoying the process.3 Open, honest, and respectful communication is critical to achieving those goals, and the most successful collaborations maintain good communication throughout the project.

Mentoring is another valuable component of the writing and research process.1,2 In the most successful situations, at least 1 member has had at least 1 article published and is able to direct the group through the

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Writing & ResearchDuBose, Haynes

the Arkansas Society of Radiologic Technologists. DuBose serves as an American Society of Radiologic Technologists Magnetic Resonance Chapter delegate and on the Radiologic Technology Editorial Review Board.

Kelli Welch Haynes, MSRS, R.T.(R), is associate professor and program director of the Bachelor of Sciences in Radiologic Sciences program for Northwestern State University in Shreveport, Louisiana. She is resident-elect of the Association of Educators in Imaging and Radiologic Sceinces and past president of the Louisiana Society of Radiologic Technologists. Haynes also serves on the Radiologic Technology Editorial Review Board.

References1. Metcalf KL, Adams RD, Qaqish B, Church JA. Survey

of R.T.s with doctorates: barriers to conducting research. Radiol Technol. 2010;81(5):417-427.

2. Ness V, Duffy K, McCallum J, Price L. Getting published: reflections of a collaborative writing group. Nurse Educ Today. 2014;34(1):1-5. http://dx.doi.org/10.1016/j.nedt .2013.03.019.

3. Schlueter DA. The co-author prenup. St Mary’s Law J. 2013;44(2):451-486.

4. Bennett LM, Gadlin H. Collaboration and team science: from theory to practice. J Investig Med. 2012;60(5):768-775. http://dx.doi.org/10.2310/JIM.0b013e318250871d.

5. Nevin AI, Thousand JS, Villa RA. Working with coauthors.In Rocco T, Hatcher T, eds. Teaching and Writing for Scholarly Publication: A Guide for Faculty and Graduate Students. San Francisco, CA: Jossey-Bass Publishers; 2011:272-329.

6. Page C, Edwards S, Wilson J. Writing groups in teacher education: a method to increase scholarly productivity. SRATE J. 2012;22(1):29-35. http://files.eric.ed.gov/fulltext /EJ995171.pdf. Accessed February 15, 2017.

7. Phillips WL, Sweet CA, Blythe HR. Collaborating on writ-ing. Academe. 2009;95(5):31-33.

� Unequal perceived power differentials inherent in team membership (eg, senior-junior faculty, dis-sertation chair and doctoral candidate, published author and unpublished team member).

� Failure to recognize others’ contributions. � Coauthors who fail to do their share. � Writer’s block. � Domineering or feuding coauthors.

Many of these barriers can be overcome with com-munication and greater attention to interpersonal social skills. Trust building, conflict management, and individual accountability are keys to success with any collaborative project.5

ConclusionMany articles about the pros and cons of collabora-

tive writing include a list of mandates coauthors can use to achieve a successful and productive outcome. Brainstorming ideas and eventually agreeing on a chosen topic is of primary importance for any writing project. All selected members of the group should be considered unique and valuable, with equal valuing of member input and respect throughout the activity. Allocation of subtopics and identification of author placement, including identifying first author, should be next on the list. Members should create deadlines for each stage of the writing process and then meet those deadlines, with some understanding that respon-sibilities outside the project might interfere. Finally, communication that occurs at suitable intervals will help keep the project on track and minimize miscom-munication.2,5

Collaborations are valuable to the pursuit of science and usually are personally rewarding. They are a great way to learn new methods, make friends, and have enriching experiences. Potential problems should be diffused before they detract from the value and fun of the science.

Cheryl DuBose, EdD, R.T.(R)(CT)(MR)(QM), is assistant professor and magnetic resonance imaging program director for Arkansas State University in Jonesboro, Arkansas. She is president of the Association of Collegiate Educators in Radiologic Technology and past-president of

456 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

My Perspective

I often hear people talk about advocacy, but many do not understand what being an advocate means. The dictionary defines an advocate as someone who goes above and beyond for something he or she believes

in or is passionate about.In my opinion, radiologic technology is the best

profession in which to work. I have been a registered technologist (R.T.) for almost 40 years, and I have been an advocate for most of those years. Early in my career, I educated others about my profession, letting them know what a great job I had, but that was the extent of my advocacy efforts. I did not realize there was a need for more—but even if I had, I did not have time to par-ticipate. At the time, I did not realize that sharing my passion for the profession was a form of advocacy. I had not considered that my fellow radiologic technologists and I acted as advocates every day simply by practic-ing patient and radiation safety and liaising between patients and radiologists. If I could turn back time, I would join my state affiliate and participate with the American Society of Radiologic Technologists (ASRT) as much as time allowed. Today, I tell everyone who will listen that whether you can give an hour a week or an hour a month, volunteering for the profession is critical because it strengthens our community of radiologic sci-ence professionals.

I also tell them that they do not have to go it alone. The ASRT and state affiliate societies have resources, materials, and advocacy experts to help. Advocacy is

what these organizations are all about, and whether you are a member of ASRT, your state affiliate, both, or nei-ther, it is important to know what they do for you. They are your advocates; they speak on behalf of you and your profession. They not only advocate for you in mat-ters of licensure, but they also create—with input from volunteers throughout the R.T. community—guide-lines that make up the foundation of the profession and help guide and govern R.T.s in their daily work.

Advocacy also helps us assure patients in every state that anyone who provides medical imaging studies is prepared educationally and clinically competent to do so. This is critical when you consider that it seems like every day, another group is trying to encroach on radiologic technology. For example, advanced practice registered nurses recently campaigned that it is within their scope of practice to “order, perform, supervise and interpret” medical imaging studies.1 Advocates in Kentucky and Massachusetts helped defeat this encroachment by having technologists actively involved in radiology legislative affairs in the states.1,2

My state, Missouri, is one of the few without state licensure or regulation of individuals performing imaging procedures.3 Advocacy helps maintain our profession and ensure that our patients are safe. On the national level, ASRT is working to put in place the Medicare Access to Radiology Care Act (MARCA), which would give mid-level radiology providers an equal status with other mid-level providers, such as physician assistants.4 ASRT

Diane Hutton, BA, R.T.(R)

To Serve Is to Advocate

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My PerspectiveHutton

Being a medical imaging professional provides you with a means of being an advocate. We serve our patients each day; I challenge you to serve your profes-sion as passionately as you do your patients. There are many opportunities for you. If not you, who will step up to advocate for your profession. It takes all of us. Join with me and others to serve while we advocate for the profession we love.

Diane Hutton, BA, R.T.(R), is adjunct clinical instructor for Washburn University in Topeka, Kansas. She also is a senior board member of the Missouri Society of Radiologic Technologists and its legislative activities chair. She may be reached at diane.hutton@mosrt.org.

Reference1. Nurse encroachment bill in Kentucky halted. American

Society of Radiologic Technologists website. https://www .asrt.org/main/standards-regulations/regulatory -legislative-news/2016/04/20/nurse-encroachment-bill -halted. Published April 20, 2016. Accessed January 11, 2017.

2. MA Nurse Imaging Bills Blocked. American Society of Radiologic Technologists website. https://www.asrt.org /main/standards-regulations/regulatory-legislative -news/2016/08/15/Massachusetts_Nurse_Imaging _Bills_Blocked. Published August 15, 2016. Accessed January 18, 2017.

3. Individual State Licensure Information. American Society of Radiologic Technologists website. https://www.asrt .org/main/standards-regulations/state-legislative-affairs /individual-state-licensure-info. Accessed January 18, 2017.

4. MARCA Bill. American Society of Radiologic Technologists website. https://www.asrt.org/main /standards-regulations/federal-legislative-affairs /marca-bill. Accessed January 18, 2017.

also provides resources and assistance for state affiliates to maintain their legislative watch, which ensures that state efforts remain on the radar and can be addressed promptly.

Whether on the state or national level, it takes all of us to act. We can maintain our profession and ensure its integrity if we stand together and speak on behalf of what we do, but it takes advocates. Much like the saying, “if you don’t vote, you shouldn’t complain,” advocacy gives you a voice to make a difference in the areas that matter to you. You do not need to be a public speaker, travel extensively, or have a lot of money to advocate. Advocating is a win-win situation, with the biggest win-ners being our patients. The public needs to see our passion for our profession. For my fellow Missourians and me, being an advocate means going back to Jefferson City again and again until we get state licensure passed. For all R.T.s throughout the country, being an advocate means going back to Washington, DC, to get MARCA passed to promote care for patients. Being an advocate means we all go that extra mile, attend that extra lecture, and have that extra conversation to get our point across. I tell everyone that state licensure in Missouri is about the patients who need radiology services. Our patients expect and deserve quality care provided by education-ally prepared and clinically competent individuals. It is the right thing to do, and that is what being an advocate is about: showing our passion and serving patients to the best of our ability.

The best calling in life is to serve, and a great way to serve is through advocacy. If you are ready to serve but are unsure where to start, consider these options: Educate yourself about issues that affect the pro-

fession and your state. Become a member of your state affiliate. Attend state affiliate or national conferences. Contact state lawmakers and let them know that

all health care professionals who perform medi-cal imaging should have specialized education, supervised clinical training in medical imaging procedures, and quantifiable competency assess-ment through examination.

Know what your membership organizations stand for.

Join an ASRT advocacy committee.

458 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Technical Query

Anyone who has played with a hand-held magnet and iron filings has been exposed to the simplest ver-sion of ferromagnetic physics.

Ferrous materials are highly susceptible to magnetization, and the degree of susceptibil-ity depends on the strength of the magnetic field. From such humble physics stemmed magnetic resonance (MR) imaging and, shortly thereafter, the metallic artifact. Years later, metallic artifacts continue to wreak havoc on image quality.

At the Mind Research Network in Albuquerque, New Mexico, imaging is col-lected for nonclinical research purposes. Artifacts that interfere with data quality introduce unwanted outliers into the data pool. For the research to be valid, the imag-ing data collected from all participants must be uniform.

Figure 1 was collected on a Siemens Magnetom Trio 3.0-Tesla MR imaging sys-tem using the 32-channel head coil. The entire facial anatomy was obscured on the sagittal localizer because orthodontic braces caused a signal loss. The axial distortion correction sequence shows similar signal loss until the slices are well past the orthodontic appli-ances and into the midbrain (see Figure 2). Because artifacts like these are outside of the standard imaging

requirements at the Mind Research Network, the imag-ing protocol must be discontinued when they occur. In the clinical setting, where medical imaging aids in diagnosis, the radiologic technologist, radiologist, and requesting physician work together to determine differ-ent imaging sequences or a different imaging modality altogether to mitigate artifacts and produce the best

Cathy Smith, R.T.(R)(CT)

Metal Mayhem in Magnetic Resonance Imaging

Figure 1. Magnetic resonance image showing obscured facial anatomy because of signal loss due to orthodontic braces. Image courtesy of author.

459RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Technical QuerySmith

possible images. Imaging for research purposes does not allow for this type of customization to achieve the desired result.

In the case of orthodontic retainers and other appli-ances that contain less metal, it often is possible to minimize or eliminate the presence of the artifact in the scan field of view by changing the orientation or the sequence parameters. The placement, volume, and ferromagnetic susceptibility of the metal appliance will determine the extent of the artifact. The ability to mitigate the artifact lies in successful application of MR imaging knowledge and technique.

Cathy Smith, R.T.(R)(CT), is a research technologist for the Mind Research Network in Albuquerque, New Mexico.

Figure 2. Axial distortion correction sequence showing signal loss until the slices are past the orthodontic appliances and into the mid brain. Image courtesy of the author.

460 RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Open Forum

Thoughts on Shielding

Compton Scatter ConcernsDear Radiologic Technology Editorial Review Board,I read with great interest the peer-reviewed research

regarding gonadal shielding, radiation dose, and best practice in the November/December 2016 issue of Radiologic Technology (Vol. 88, No. 2).

I would agree with most of the assumptions of the study. However, exposures in the milligray range that result in scatter in the microgray range are at least in the range of thousandths (1000th) of the primary beam dose.

Such low energy Compton scatter is of borderline significance when compared with using proper collima-tion and appropriate kilovoltage peak (kVp) and other exposure factors in the examination of an actual patient.

In addition, a possible limitation not mentioned in the study is the Compton scatter radiation from the table and the image receiver. I feel that the Compton scatter from the image receiver and table construc-tion could be of greater significance than either the leakage, in air kerma dose, or off-focus radiation all originating from the tube side. This radiation already is being reduced significantly by the required alumi-num filtration on the diagnostic x-ray tube required by the National Council on Radiation Protection and Measurements rules.

This unmentioned source of Compton scatter radia-tion caused by Compton scatter from the phantom and remnant Compton interaction of the aforementioned

equipment structures could, in theory, be diminished greatly by simply placing a second f lat lead shield between the phantom and the table top.

This could prove to be more effective and more practical than attempting to fix a cup-type lead shield to a male phantom pelvis in future research. In addition, this second f lat shield placement, in my opinion, should be considered in any best practice scenario regarding f lat lead shielding and patient dose.

In closing, I wish to commend the researchers on a study that required a lot of careful thought and hard work. This sort of dedication will contribute significantly to the on-going quest of the profession to conform to the principles of ALARA as much as is humanly possible.

John A Garner, PhD, R.T.(R)Terre Haute, Indiana

The Author Responds:I appreciate the feedback from Dr. Garner and

agree that gonadal shielding along with collima-tion and appropriate kVp will further minimize the radiation exposure to the testes. I acknowledged the low-level gonadal exposure and compared the microgray exposure to millirads because millirads are a more familiar exposure unit for radiologic technologists. However, consistent with the linear

461RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

Open Forum

the exposure button cord at full length from the unit. I am in no way discouraging the use of lead aprons by medical imaging staff.

2. The same author knowingly exposed their unshielded body part (hand) to ionizing radia-tion as a measurement tool in an experiment. It would have been more appropriate to conduct the experiment in a controlled environment using dosimeters as a means of measurement. Was the study approved by an ethics commit-tee? If not, it contravenes section 3.152 of the International Atomic Energy Agency Safety Standards3 and quite possibly breaches U.S. fed-eral and state Occupational Safety and Health Administration and/or radiation protection laws.

3. The examination in this experiment was per-formed by a student. It is the responsibility of the supervising radiographer to give their undivided attention to the examination being performed by a student radiographer—anything less has the potential to result in an unwarranted repeat expo-sure to a patient in their care.

As stated in the manuscript, “applying principles of ALARA to minimize exposure to patient, self, and oth-ers”4 are within a radiographer’s scope of practice. The methodology that was employed to conduct this study does not minimize exposure to the author. As medical imaging professionals, we need to teach our students valid and ethical research methodology. The experi-ment in this study is one of those instances in which I would have told a student to speak out.

Gary Denham, BMedRadSc, MMedRadScTaree, New South Wales, Australia

The Author Responds:Mr. Denham brings up some great points. The

authors agree that students should be taught valid and ethical research methodology. In the future we will consider controlled experiments as suggested with approval from an ethics committee using the International Atomic Energy Agency Safety Standards as its guidelines.

nonthreshold dose response, reducing even very low radiation exposures could lessen the potential for biologic risk.

Authors Daniels and Furey stated that contact shields, when located outside the primary beam, can only protect from leakage and external scat-ter radiation. Therefore, internal tissue scatter was the focus of this investigation. I acknowledge that backscatter might also be a contributory fac-tor. Further research to investigate the advantage of posterior shielding is warranted. However, the research literature indicated that misplacement of the anterior gonadal shield can be problematic. Therefore, misplacement of a posterior gonadal shield could also be problematic.

Dr. Garner and I both agree that gonadal shield-ing is a best practice and reducing low-level patient radiation exposure is consistent with ALARA.

Terri L Fauber, EdD, R.T.(R)(M)Richmond, Virginia

Encourage Students to Speak UpI write in reference to the manuscript titled “The

Need for Shielding Is Undeniable” in the November/December 2016 issue of Radiologic Technology (Vol. 88, No. 2). As a medical imaging practitioner and as a researcher and author on the topic of radiation safety, I find the authors’ investigation of the topic highly rel-evant, especially the need for radiography students to speak out when they witness unsafe work practices. I do, however, have concerns about the way this study was conducted for the following reasons:

1. One of the authors stood directly behind the x-ray tube at a distance of approximately 12 inches (0.3 m) from the x-ray tube of a mobile digital radiography unit during an anteroposterior chest examination. The most effective form of pro-tection for radiographers is distance. Standing at a distance of 6 ft to 7 ft (2-2.13 m) reduces a radiographer’s radiation exposure to a negligible level.1,2 Distance would be the most appropriate protection method to teach to students in mobile radiography, performing the examination with

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Open ForumThoughts on Shielding

References1. Australian Radiation Protection and Nuclear Safety Agency.

Radiation Protection in Diagnostic and Interventional Radiology. http://www.arpansa.gov.au/pubs/rps/rps14_1.pdf. Approved July 16, 2008. Accessed December 11, 2016.

2. Radiation dose to workers in the emergency department. Health Physics Society website. https://hps.org/publicinfor-mation/ate/q9456.html. Accessed December 11, 2016.

3. International Atomic Energy Agency. Radiation Protection and Safety of Radiation Sources: International Basic Safety Standards. http://www-pub.iaea.org/MTCD/publica-tions/PDF/Pub1578_web-57265295.pdf. Published 2014. Accessed December 11, 2016.

4. American Society of Radiologic Technologists. The prac-tice standards for medical imaging and radiation therapy. https://www.asrt.org/docs/default-source/practice-stan-dards-published/ps_rad.pdf?sfvrsn=2. Effective June 26, 2016. Accessed December 11, 2016.

The authors believe they acted within the American Society of Radiologic Technologists Radiography Practice Standards, specifically the Radiography Clinical Performance standards (4), specific criteria for the radiographer (1 and 2) regard-ing radiation safety and ALARA.

The authors further believe they also were in com-pliance with the American Registry of Radiologic Technologists Standards of Ethics (4 and 7 explicitly).

In response to the 3 specific concerns:1. The original intent was to perform several

experiments from various positions. The place-ment of the author for the exposure was felt to be the most common practiced position of exposure by a technologist with a student. It was decided this one exposure provided enough information from which to base the article.

2. The author conducting the experiment did nothing outside of standard practice other than place a device to measure exposure in a posi-tion to do so. During portable examinations, hands often hold the exposure switch and are not protected by a shield. In this isolated instance, a computed radiography cassette was placed to record the exposure. Though it was not approved by an ethics committee, it was approved by the department director and deemed not outside of standard practice.

3. There was an ARRT registered radiographer supervising the students during the examina-tion.

Finally, the goal of the article was to point out the exposure of scatter to a student and radiographer while they perform portable x-ray examinations at a suboptimal distance when not wearing a lead apron.

Sandi Watts, MSHA, R.T.(R)Carbondale, Illinois

Matthew Cardinal, MEd, R.T.(R)Forsyth, Illinois

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RADIOLOGIC TECHNOLOGY, March/April 2017, Volume 88, Number 4

What’s Inside?

Backscatter

464

What do you do to advocate for your profession?

Share with your Community at asrt.org/myasrt.

The absence of a negative biological effect does not prove safety.Read more on Page 440.

Approximately 50% of MR studies worldwide are ordered with contrast.Read more on Page 435.

The use of CT has increased with pediatric patients in recent years.Read more on Page 446.

15% of technologists with doctorate degrees produce most of the scholarly research and writing in the radiologic sciences. Read more on Page 453.

The scaphoid is the most commonly fractured carpal bone.

Read more on Page 444.

Historically used in mammography, xeroradiography is a type of x-ray imaging in which a picture of the body is recorded on paper rather than on film. Although beneficial in the diagnosis of breast tumors, the process can require higher doses of radiation and, with the advent of digital mammography, is used rarely in current practice. Image courtesy of the ASRT Museum and Archives.

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