BI-RADS MAMMOGRAPHY

V. DATA COLLECTION

American College of Radiology

261

Fourth Edition 2003

DATA COLLECTION
To facilitate the collection of data across systems
and databases, the American College of Radiology (ACR) and the Breast Cancer Surveillance
Consortium (BCSC) have collaboratively developed two data collection forms for use within a
mammography practice. Based on a standard set
of core variables and a standard definition of
screening mammography, data are collected
through the use of two data collection forms at
the time of the mammographic study. The first
data collection form includes information about
a womans personal health history relevant to
breast cancer; the second form includes clinical
and technical information about the imaging performed.
Standardizing data structure permits comparison
with national data that are published by the
BCSC. Using a set of standard questions in a
standard format affords a facility the opportunity
to participate as a site, in states that have a BCSC
Registry. The BCSC effort is creating mammography data that are being used to build databases
that can be linked with each other and with
pathology data on cancer outcomes from population based registries. For more information on
the BCSC go to:
http://breastscreening.cancer.gov/elements.html.

262

The ACR seeks to improve the measurement of

mammography performance through technical
and interpretive practice. Data collection and
analysis, whether for internal audit or participation in registry and national database activities,
is the responsibility of every practice. The ACR
encourages all facilities to participate in quality
databases to assess performance. It is through
standardized reporting and data exchange that
practices can compare their own performance
from year to year, and compare their practice
to aggregated practice data on a regional and
national level. This promises to enhance the
practice of screening mammography for all who
participate.

Please note that these forms are to assist in

data collection for participation in database
and registry activities and do not constitute
a written mammography report.

American College of Radiology

Patient Information Form

BI-RADS MAMMOGRAPHY

1. Todays date: ___ ___ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
2. Date of examination (if different from todays date) ___ ___ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
3. Name __________________________ _____ _________________________________
4. Previous last name that may have been used when having a mammogram? _________________________
5. Address: Street or First
PO Box ________________________________________________
Apt. _________
MI
Last
City _________________________________________ State _______ Zip Code ________ - _____
Day Time Phone _______ - ______ - _________
6. Date of birth: ___ ___ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
7. Health care provider: ___________________________________________________________________________________
Address:

__________________________________________________________________________________________
__________________________________________________________________________________________

8. What health care coverage is paying for your mammogram? (check all that apply)

Medicare
Medicaid (Medi-Cal)
Private Insurance

Managed Care (HMO, Health Plan, PPO)

Not Sure
I have no coverage

Other: ___________________________________

Note: This item could have selections specific to the state where the practice is located.

9. Height _____ feet _____ inches

11. Are you of Hispanic or Latino origin?

10. Weight ______ pounds

Yes

No

12. What is your racial/ethnic identity? (check all that apply)

White
Native Hawaiian or other Pacific Islander
Black/African American
American Indian or Alaska Native
Asian
Other: __________________________________
13. What is the highest level of education you have completed? (check one)
Less than high school graduate
Some college or technical school
High school graduate or GED
College or post-college graduate
14. Breast problems or breast changes in the last 3 months? (check None, or all that apply)
None
Palpable Lump
Both Left Right
Nipple discharge
Both Left Right Describe: ____________________________________________
Pain
Both Left Right
Skin thickening or retraction
Both Left Right
Large axillary lymph node
Both Left Right
Breast implant problem
Both Left Right
Abnormal nipple
Both Left Right
Presence of other cancer
Both Left Right
Difficult clinical examination
Both Left Right
Other
Both Left Right If other, describe: ____________________________________
15. What is the main reason for your mammogram today? (check one box only and fill in below)
Routine screening
Additional evaluation as follow-up for a recent routine screening exam
Evaluation of a symptom or a finding at clinical examination
Follow-up at short interval (less than 9 months) from prior exam
History of breast augmentation (no current complaints)
Prior to breast reduction surgery
Prior to radiation therapy
Additional evaluation as follow-up for a non-screening exam from another facility
Describe in your own words: ____________________________________________________________________________________________

American College of Radiology

Developed collaborativly and Copyright 2003 by the American College of Radiology and the Breast Cancer Surveillance Consortium.

263

Patient Information Form (continued)

16. When was your last mammogram? Date __ __ /__ __ __ __ (mm/yyyy)
(If unknown check one below)
Never had a mammogram before today
More than 1 year ago up to 2 years ago
Within the past 6 months
Longer than 2 years ago
7 months to about 1 year ago
Not sure
17. Where did you have your last mammogram?
At this facility
At another facility: Name and city of facility ______________________________________________________________________________
18. When did a health care provider last examine your breasts? (check one)
Never
More than 1 year ago
Within the past 3 months
Not sure
4 months to 1 year ago
19. Have you ever been diagnosed with breast cancer? (check one)

No
Yes

Both

Left

Right

If Yes: Year of breast cancer diagnosis: right __ __ __ __ (yyyy); left __ __ __ __ (yyyy), or

Age when first diagnosed with breast cancer: right __ __ years old; left __ __ years old.
20. Have you had any of the following breast procedures? (check None, or all that apply)

None
Fine-needle or cyst aspiration
Core-needle biopsy
Surgical biopsy (benign results)
Biopsynot sure what type
Lumpectomy for breast cancer
Mastectomy
Breast reconstruction
Radiation therapy
Breast reduction
Breast implants (still present)
Breast implants (been removed)

Both
Both
Both
Both
Both
Both
Both
Both
Both
Both
Both

Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left

Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right

Date __ __ /__ __ __ __ (mm/yyyy)

Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)
Date __ __ /__ __ __ __ (mm/yyyy)

21. If you have implants currently, what type are they? (check all that apply)
Silicone gel
Both Left Right
Combination
Both Left Right
Saline
Both Left Right
Pre-pectoral
Both Left Right
Retro-pectoral
Both Left Right
22. Have you ever been treated with chemotherapy? (check one)
No
Yes
Not Sure
23. Have any of your close blood relatives been diagnosed with breast cancer?
Family history unknown
Mother:
No
Yes
Not Sure
Sister:
No
One
2 or more
Not Sure
Daughter: No
One
2 or more
Not Sure
If you answered Yes, were any of these relatives diagnosed before age 50?
Mother:
No
Yes
Not Sure
Sister:
No
One
2 or more
Not Sure
Daughter: No
One
2 or more
Not Sure
24. Have you or a blood relative ever been diagnosed with ovarian cancer? (check one)
No
Not Sure
Yes (check all that apply)
self mother, sister, or daughter more distant blood relative
25. Have you ever given birth? (check one)
No
Yes
If Yes, how old were you when your first child was born? ___ ___ years old.
At what age did you have your first menstrual period? __ __ years old
Developed collaborativly and Copyright 2003 by the American College of Radiology and the Breast Cancer Surveillance Consortium.

Patient Information Form (continued)

26. Have your menstrual periods stopped permanently? (check one)

No
Not sure
Yes: age when they stopped: __ __ years old

If you answered No or Not sure, when did your last period begin? __ __ /__ __ /__ __ __ __ (mm/dd/yyyy)
If you answered Yes, what is the reason that your periods stopped? (check one)

Natural menopause
Surgical procedure
Chemotherapy
Other reason

27. Are you currently taking hormone medications? (check None, or all that apply)

None
Contraceptive (birth control)

age first use ____ age last use ____ # years used ____

Hormone replacement

age first use ____ age last use ____ # years used ____

Tamoxifen or raloxifene

age first use ____ age last use ____ # years used ____

Other hormone:

age first use ____ age last use ____ # years used ____

Estrogen only
Progesterone only
Estrogen and progesterone

Describe: ________________________________________________________________________________________________________

Developed collaborativly and Copyright 2003 by the American College of Radiology and the Breast Cancer Surveillance Consortium.

Radiologist/Technologist Data
This form is a continuation of the Patient Information form. A computer or tracking system will automatically link this
data to the Patient Information form. If this data is not to be computerized then the patient identification should be
added to this form.
Date of Examination ___ ___ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
1. Indication for examination: (check one)
Screening: asymptomatic
Diagnostic: additional evaluation of recent abnormal screening exam
Diagnostic: short-interval follow-up (e.g., 6 months)

Diagnostic: evaluation of a breast problem

Other (core biopsy, or other non-imaging)

2. Types of examination performed (check all that apply, if performed on same day)
Both

Right

Left

Standard views (MLO, CC)

Additional views
Ultrasound
MRI
Nuclear medicine
Other breast imaging

CAD

Double Reading

Hard-Copy Digital

Soft-Copy Digital

Note: For this question, if a facility never or always uses CAD, double reading, hard-copy digital, or soft-copy digital mammography, then the additional
checked boxes for these options should be deleted, and this information should be hard-coded into the system at time of installation.

3. Invasive procedures performed (check all that apply, if performed on same day)
Type of Image Guidance
Cyst aspiration
FNA biopsy
Core biopsy
Needle localization
Ductography

Both

Right

Left

Mammo

Stereo

Ultrasound

4. Comparison with previous mammograms

No (first examination)
No (previous films not available)

Yes ___ ___ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
Pending, waiting for outside films

5. Breast density: (check denser breast if left and right differ)

Almost entirely fat (<25% fibroglandular) Scattered fibroglandular densities (approximately 25%-50% fibroglandular)
Extremely dense (>75% fibroglandular)
Heterogeneously dense (approximately 51%-75% fibroglandular)
6. BI-RADS assessment category (check all that apply)
Category
Both Right
0 Need additional imaging evaluation

1 Negative

2 Benign

3 Probably benign

4 Suspicious

Left

Category
(Optional) 4 A Low
(Optional) 4 B Intermediate
(Optional) 4 C Moderate
5 Highly suggestive of malignancy
6 Known malignancy

Both Right

Left

7. Management recommendations (check all that apply)

Both Right
1,2: Routine interval follow-up, next mammogram:
1 year
Return at age 40
Other: ______________________________________
3: Short-interval follow-up
6 months
Other: ______________________________________
0: Additional imaging evaluation
4: Consider biopsy
5: Appropriate action should be taken
6: Appropriate action should be taken

Left

8. Specify immediate management (check all that apply, if any apply)

Both Right Left
Compare with previous mammograms

FNA biopsy
Additional mammographic views

Core biopsy
Ultrasound

Needle localization
MRI

Clinical examination
Nuclear medicine

Surgical consult
Cyst aspiration

Other ______________________________
Reading Radiologist ID __ __ __

Second Reading Radiologist ID __ __ __

Both Right

Technologist ID __ __ ___

(Optional)

Developed collaborativly and Copyright 2003 by the American College of Radiology and the Breast Cancer Surveillance Consortium.

Left