Liverpool Radiologists Slash Biopsy Referrals with New Breast Imaging Pathway

A health system in Liverpool, England, has introduced a new radiology-led pathway that is cutting unnecessary breast biopsies in half, easing pressure on already stretched breast clinics while sparing patients from anxiety and extra hospital visits. The results were detailed in Clinical Radiology.

Incidental breast findings are increasingly common as imaging volumes rise. With no standardized guidelines for how to handle these discoveries, many patients have been referred for biopsies that later prove unnecessary. Recognizing the strain this places on both patients and clinical resources, radiologists at Liverpool University Hospitals NHS Foundation Trust developed a streamlined review process that ensures only suspicious cases are escalated.

“Advantages to patients include saving unnecessary anxiety and trips to the hospital, thereby reducing travel costs and environmental impact,” explained lead author Dr. Rida Fatima and colleagues. “Furthermore, the pathway enabled rapid assessment of incidental breast lesions that were subsequently found to be malignant in nature.”

The system relies on simple but effective coding. When a radiologist identifies an incidental breast lesion, they add a “JBREAS” alert code to the report. This flags the case for automatic review by a breast imaging specialist, who examines the current scan alongside prior images. That specialist then decides whether further investigation is warranted. If so, a second alert code (“CMALERT”) is added to the report to signal urgent or unexpected findings requiring a referral to the breast clinic. If not, the referrer is reassured that no further action is needed.

Fatima’s team reviewed nearly a decade of data from 2015 to 2024. Out of 736 studies flagged with the JBREAS code, most originating from CT exams, about 96% were subsequently reviewed by breast radiologists. Of those, only 48% (344 cases) required further investigation. Among these, 85% (294 cases) were tagged with a CMALERT to ensure timely follow-up.

Timeliness was another focus. Breast radiologists took an average of four days (median two) to review flagged scans. Once further investigation was recommended, the average time from the primary report to the patient attending clinic was 26 days (median 17). While this interval reflects ongoing demand on an already busy breast service, the overall reduction in biopsy referrals outweighed the added workload of reviewing flagged cases.

Importantly, the pathway not only reduced unnecessary procedures but also ensured malignant lesions were not missed. By reserving clinic referrals for cases with genuine concern, the system concentrated resources where they were most needed.

Challenges remain. Some flagged scans were not fully reviewed, and clinic delays persist. However, the authors stress that these issues are manageable with continued refinement. “While there are challenges to address, particularly regarding the oversight of some cases [resulting in the 96% figure], the benefits far outweigh the drawbacks,” Fatima’s group concluded.

Liverpool University Hospitals plans to further optimize the system by examining missed cases, reducing wait times, and strengthening oversight. If adopted more widely, the model could provide a template for reducing overdiagnosis, conserving clinical resources, and improving patient experience in breast imaging across the UK and beyond.