Do mammographic technologists affect radiologists' diagnostic mammography interpretative performance?

OBJECTIVE: The purpose of this study was to determine whether the technologist has an effect on the radiologists' interpretative performance of diagnostic mammography. MATERIALS AND METHODS: Using data from a community-based mammography registry from 1994 to 2009, we identified 162,755 diagnostic mammograms interpreted by 286 radiologists and performed by 303 mammographic technologists. We calculated sensitivity, false-positive rate, and positive predictive value (PPV) of the recommendation for biopsy from mammography for examinations performed (i.e., images acquired) by each mammographic technologist, separately for conventional (film-screen) and digital modalities. We assessed the variability of these performance measures among mammographic technologists, using mixed effects logistic regression and taking into account the clustering of examinations within women, radiologists, and radiology practices. RESULTS: Among the 291 technologists performing conventional examinations, mean sensitivity of the examinations performed was 83.0% (95% CI, 80.8-85.2%), mean false-positive rate was 8.5% (95% CI, 8.0-9.0%), and mean PPV of the recommendation for biopsy from mammography was 27.1% (95% CI, 24.8-29.4%). For the 45 technologists performing digital examinations, mean sensitivity of the examinations they performed was 79.6% (95% CI, 73.1-86.2%), mean false-positive rate was 8.8% (95% CI, 7.5-10.0%), and mean PPV of the recommendation for biopsy from mammography was 23.6% (95% CI, 18.8-28.4%). We found significant variation by technologist in the sensitivity, false-positive rate, and PPV of the recommendation for biopsy from mammography for conventional but not digital mammography (p < 0.0001 for all three interpretive performance measures). CONCLUSION: Our results suggest that the technologist has an influence on radiologists' interpretive performance for diagnostic conventional but not digital mammography. Future studies should examine why this difference between modalities exists and determine if similar patterns are observed for screening mammography.

Effect of radiologists' diagnostic work-up volume on interpretive performance.

PURPOSE: To examine radiologists' screening performance in relation to the number of diagnostic work-ups performed after abnormal findings are discovered at screening mammography by the same radiologist or by different radiologists. MATERIALS AND METHODS: In an institutional review board-approved HIPAA-compliant study, the authors linked 651 671 screening mammograms interpreted from 2002 to 2006 by 96 radiologists in the Breast Cancer Surveillance Consortium to cancer registries (standard of reference) to evaluate the performance of screening mammography (sensitivity, false-positive rate [ FPR false-positive rate ], and cancer detection rate [ CDR cancer detection rate ]). Logistic regression was used to assess the association between the volume of recalled screening mammograms ("own" mammograms, where the radiologist who interpreted the diagnostic image was the same radiologist who had interpreted the screening image, and "any" mammograms, where the radiologist who interpreted the diagnostic image may or may not have been the radiologist who interpreted the screening image) and screening performance and whether the association between total annual volume and performance differed according to the volume of diagnostic work-up. RESULTS: Annually, 38% of radiologists performed the diagnostic work-up for 25 or fewer of their own recalled screening mammograms, 24% performed the work-up for 0-50, and 39% performed the work-up for more than 50. For the work-up of recalled screening mammograms from any radiologist, 24% of radiologists performed the work-up for 0-50 mammograms, 32% performed the work-up for 51-125, and 44% performed the work-up for more than 125. With increasing numbers of radiologist work-ups for their own recalled mammograms, the sensitivity (P = .039), FPR false-positive rate (P = .004), and CDR cancer detection rate (P < .001) of screening mammography increased, yielding a stepped increase in women recalled per cancer detected from 17.4 for 25 or fewer mammograms to 24.6 for more than 50 mammograms. Increases in work-ups for any radiologist yielded significant increases in FPR false-positive rate (P = .011) and CDR cancer detection rate (P = .001) and a nonsignificant increase in sensitivity (P = .15). Radiologists with a lower annual volume of any work-ups had consistently lower FPR false-positive rate , sensitivity, and CDR cancer detection rate at all annual interpretive volumes. CONCLUSION: These findings support the hypothesis that radiologists may improve their screening performance by performing the diagnostic work-up for their own recalled screening mammograms and directly receiving feedback afforded by means of the outcomes associated with their initial decision to recall. Arranging for radiologists to work up a minimum number of their own recalled cases could improve screening performance but would need systems to facilitate this workflow.

Educational interventions to improve screening mammography interpretation: a randomized controlled trial.

OBJECTIVE: The objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation. MATERIALS AND METHODS: We randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance. RESULTS: One hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015). CONCLUSION: In this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

Association between mammographic density and basal-like and luminal A breast cancer subtypes.

INTRODUCTION: Mammographic density is a strong risk factor for breast cancer overall, but few studies have examined the association between mammographic density and specific subtypes of breast cancer, especially aggressive basal-like breast cancers. Because basal-like breast cancers are less frequently screen-detected, it is important to understand how mammographic density relates to risk of basal-like breast cancer. METHODS: We estimated associations between mammographic density and breast cancer risk according to breast cancer subtype. Cases and controls were participants in the Carolina Breast Cancer Study (CBCS) who also had mammograms recorded in the Carolina Mammography Registry (CMR). A total of 491 cases had mammograms within five years prior to and one year after diagnosis and 528 controls had screening or diagnostic mammograms close to the dates of selection into CBCS. Mammographic density was reported to the CMR using Breast Imaging Reporting and Data System categories. The expression of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 1 and 2 (HER1 and HER2), and cytokeratin 5/6 (CK5/6) were assessed by immunohistochemistry and dichotomized as positive or negative, with ER+ and/or PR+, and HER2- tumors classified as luminal A and ER-, PR-, HER2-, HER1+ and/or CK5/6+ tumors classified as basal-like breast cancer. Triple negative tumors were defined as negative for ER, PR and HER2. Of the 491 cases 175 were missing information on subtypes; the remaining cases included 181 luminal A, 17 luminal B, 48 basal-like, 29 ER-/PR-/HER2+, and 41 unclassified subtypes. Odds ratios comparing each subtype to all controls and case-case odds ratios comparing mammographic density distributions in basal-like to luminal A breast cancers were estimated using logistic regression. RESULTS: Mammographic density was associated with increased risk of both luminal A and basal-like breast cancers, although estimates were imprecise. The magnitude of the odds ratio associated with mammographic density was not substantially different between basal-like and luminal A cancers in case­control analyses and case-case analyses (case-case OR = 1.08 (95% confidence interval: 0.30, 3.84)). CONCLUSIONS: These results suggest that risk estimates associated with mammographic density are not distinct for separate breast cancer subtypes (basal-like/triple negative vs. luminal A breast cancers). Studies with a larger number of basal-like breast cancers are needed to confirm our findings.

The association of breast density with breast cancer mortality in African American and white women screened in community practice.

The effect of breast density on survival outcomes for American women who participate in screening remains unknown. We studied the role of breast density on both breast cancer and other cause of mortality in screened women. Data for women with breast cancer, identified from the community-based Carolina Mammography Registry, were linked with the North Carolina cancer registry and NC death tapes for this study. Cause-specific Cox proportional hazards models were developed to analyze the effect of several covariates on breast cancer mortality-namely, age, race (African American/White), cancer stage at diagnosis (in situ, local, regional, and distant), and breast density (BI-RADS( ® ) 1-4). Two stratified Cox models were considered controlling for (1) age and race, and (2) age and cancer stage, respectively, to further study the effect of density. The cumulative incidence function with confidence interval approximation was used to quantify mortality probabilities over time. For this study, 22,597 screened women were identified as having breast cancer. The non-stratified and stratified Cox models showed no significant statistical difference in mortality between dense tissue and fatty tissue, while controlling for other covariate effects (p value = 0.1242, 0.0717, and 0.0619 for the non-stratified, race-stratified, and cancer stage-stratified models, respectively). The cumulative mortality probability estimates showed that women with dense breast tissues did not have significantly different breast cancer mortality than women with fatty breast tissue, regardless of age (e.g., 10-year confidence interval of mortality probabilities for whites aged 60-69 white: 0.056-0.090 vs. 0.054-0.083). Aging, African American race, and advanced cancer stage were found to be significant risk factors for breast cancer mortality (hazard ratio >1.0). After controlling for cancer incidence, there was not a significant association between mammographic breast density and mortality, adjusting for the effects of age, race, and cancer stage.

Reported mammographic density: film-screen versus digital acquisition.

PURPOSE: To test the hypothesis that American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories for breast density reported by radiologists are lower when digital mammography is used than those reported when film-screen (FS) mammography is used. MATERIALS AND METHODS: This study was institutional review board approved and HIPAA compliant. Demographic data, risk factors, and BI-RADS breast density categories were collected from five mammography registries that were part of the Breast Cancer Surveillance Consortium. Active, passive, or waiver of consent was obtained for all participants. Women aged 40 years and older who underwent at least two screening mammographic examinations less than 36 months apart between January 1, 2000, and December 31, 2009, were included. Women with prior breast cancer, augmentation, or use of agents known to affect density were excluded. The main sample included 89 639 women with both FS and digital mammograms. The comparison group included 259 046 women with two FS mammograms and 87 066 women with two digital mammograms. BI-RADS density was cross-tabulated according to the order in which the two types of mammogram were acquired and by the first versus second interpretation. RESULTS: Regardless of acquisition method, the percentage of women with a change in density from one reading to the next was similar. Breast density was lower in 19.8% of the women who underwent FS before digital mammography and 17.1% of those who underwent digital before FS mammography. Similarly, lower density classifications were reported on the basis of the second mammographic examination regardless of acquisition method (15.8%-19.8%). The percentage of agreement between density readings was similar regardless of mammographic types paired (67.3%-71.0%). CONCLUSION: The study results showed no difference in reported BI-RADS breast density categories according to acquisition method. Reported BI-RADS density categories may be useful in the development of breast cancer risk models in which FS, digital, or both acquisition methods are used.

Mammographic density and breast cancer risk in White and African American Women.

Mammographic density is a strong risk factor for breast cancer, but limited data are available in African American (AA) women. We examined the association between mammographic density and breast cancer risk in AA and white women. Cases (n = 491) and controls (n = 528) were from the Carolina Breast Cancer Study (CBCS) who also had mammograms recorded in the Carolina Mammography Registry (CMR). Mammographic density was reported to CMR using Breast Imaging Reporting and Data System (BI-RADS) categories. Increasing mammographic density was associated with increased breast cancer risk among all women. After adjusting for potential confounders, a monotonically increasing risk of breast cancer was observed between the highest versus the lowest BI-RADS density categories [OR = 2.45, (95 % confidence interval: 0.99, 6.09)]. The association was stronger in whites, with ~40 % higher risk among those with extremely dense breasts compared to those with scattered fibroglandular densities [1.39, (0.75, 2.55)]. In AA women, the same comparison suggested lower risk [0.75, (0.30, 1.91)]. Because age, obesity, and exogenous hormones have strong associations with breast cancer risk, mammographic density, and race in the CBCS, effect measure modification by these factors was considered. Consistent with previous literature, density-associated risk was greatest among those with BMI > 30 and current hormone users (P value = 0.02 and 0.01, respectively). In the CBCS, mammographic density is associated with increased breast cancer risk, with some suggestion of effect measure modification by race, although results were not statistically significant. However, exposures such as BMI and hormone therapy may be important modifiers of this association and merit further investigation.

Mammographic interpretive volume and diagnostic mammogram interpretation performance in community practice.

PURPOSE: To investigate the association between radiologist interpretive volume and diagnostic mammography performance in community-based settings. MATERIALS AND METHODS: This study received institutional review board approval and was HIPAA compliant. A total of 117,136 diagnostic mammograms that were interpreted by 107 radiologists between 2002 and 2006 in the Breast Cancer Surveillance Consortium were included. Logistic regression analysis was used to estimate the adjusted effect on sensitivity and the rates of false-positive findings and cancer detection of four volume measures: annual diagnostic volume, screening volume, total volume, and diagnostic focus (percentage of total volume that is diagnostic). Analyses were stratified by the indication for imaging: additional imaging after screening mammography or evaluation of a breast concern or problem. RESULTS: Diagnostic volume was associated with sensitivity; the odds of a true-positive finding rose until a diagnostic volume of 1000 mammograms was reached; thereafter, they either leveled off (P < .001 for additional imaging) or decreased (P = .049 for breast concerns or problems) with further volume increases. Diagnostic focus was associated with false-positive rate; the odds of a false-positive finding increased until a diagnostic focus of 20% was reached and decreased thereafter (P < .024 for additional imaging and P < .001 for breast concerns or problems with no self-reported lump). Neither total volume nor screening volume was consistently associated with diagnostic performance. CONCLUSION: Interpretive volume and diagnostic performance have complex multifaceted relationships. Our results suggest that diagnostic interpretive volume is a key determinant in the development of thresholds for considering a diagnostic mammogram to be abnormal. Current volume regulations do not distinguish between screening and diagnostic mammography, and doing so would likely be challenging.

Association between time spent interpreting, level of confidence, and accuracy of screening mammography.

OBJECTIVE: The objective of this study was to examine the effect of time spent viewing images and level of confidence on a screening mammography test set on interpretive performance. MATERIALS AND METHODS: Radiologists from six mammography registries participated in this study and were randomized to interpret one of four test sets and complete 12 survey questions. Each test set had 109 cases of digitized four-view screening screen-film mammograms with prior comparison screening views. Viewing time for each case was defined as the cumulative time spent viewing all mammographic images before recording which visible feature, if any, was the "most significant finding." Log-linear regression fit via the generalized estimating equation was used to test the effect of viewing time and level of confidence in the interpretation on test set sensitivity and false-positive rate. RESULTS: One hundred nineteen radiologists completed a test set and contributed data on 11,484 interpretations. The radiologists spent more time viewing cases that had significant findings or cases for which they had less confidence in their interpretation. Each additional minute of viewing time increased the probability of a true-positive interpretation among cancer cases by 1.12 (95% CI, 1.06-1.19; p < 0.001) regardless of confidence in the assessment. Among the radiologists who were very confident in their assessment, each additional minute of viewing time increased the adjusted risk of a false-positive interpretation among noncancer cases by 1.42 (95% CI, 1.21-1.68), and this viewing-time effect diminished with decreasing confidence. CONCLUSION: Longer interpretation times and higher levels of confidence in an interpretation are both associated with higher sensitivity and false-positive rates in mammography screening.

Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study.

BACKGROUND: False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis. OBJECTIVE: To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography. DESIGN: Prospective cohort study. SETTING: 7 mammography registries in the National Cancer Institute-funded Breast Cancer Surveillance Consortium. PARTICIPANTS: 169,456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006. MEASUREMENTS: False-positive recalls and biopsy recommendations stage distribution of incident breast cancer. RESULTS: False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non-statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, -1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, -1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer. LIMITATIONS: Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer. CONCLUSION: After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis. PRIMARY FUNDING SOURCE: National Cancer Institute.

Comparative effectiveness of digital versus film-screen mammography in community practice in the United States: a cohort study.

BACKGROUND: Few studies have examined the comparative effectiveness of digital versus film-screen mammography in U.S. community practice. OBJECTIVE: To determine whether the interpretive performance of digital and film-screen mammography differs. DESIGN: Prospective cohort study. SETTING: Mammography facilities in the Breast Cancer Surveillance Consortium. PARTICIPANTS: 329,261 women aged 40 to 79 years underwent 869 286 mammograms (231 034 digital; 638 252 film-screen). MEASUREMENTS: Invasive cancer or ductal carcinoma in situ diagnosed within 12 months of a digital or film-screen examination and calculation of mammography sensitivity, specificity, cancer detection rates, and tumor outcomes. RESULTS: Overall, cancer detection rates and tumor characteristics were similar for digital and film-screen mammography, but the sensitivity and specificity of each modality varied by age, tumor characteristics, breast density, and menopausal status. Compared with film-screen mammography, the sensitivity of digital mammography was significantly higher for women aged 60 to 69 years (89.9% vs. 83.0%; P = 0.014) and those with estrogen receptor-negative cancer (78.5% vs. 65.8%; P = 0.016); borderline significantly higher for women aged 40 to 49 years (82.4% vs. 75.6%; P = 0.071), those with extremely dense breasts (83.6% vs. 68.1%; P = 0.051), and pre- or perimenopausal women (87.1% vs. 81.7%; P = 0.057); and borderline significantly lower for women aged 50 to 59 years (80.5% vs. 85.1%; P = 0.097). The specificity of digital and film-screen mammography was similar by decade of age, except for women aged 40 to 49 years (88.0% vs. 89.7%; P < 0.001). LIMITATION: Statistical power for subgroup analyses was limited. CONCLUSION: Overall, cancer detection with digital or film-screen mammography is similar in U.S. women aged 50 to 79 years undergoing screening mammography. Women aged 40 to 49 years are more likely to have extremely dense breasts and estrogen receptor-negative tumors; if they are offered mammography screening, they may choose to undergo digital mammography to optimize cancer detection. PRIMARY FUNDING SOURCE: National Cancer Institute.

Effect of observing change from comparison mammograms on performance of screening mammography in a large community-based population.

PURPOSE: To evaluate the effect of comparison mammograms on accuracy, sensitivity, specificity, positive predictive value (PPV(1)), and cancer detection rate (CDR) of screening mammography to determine the role played by identification of change on comparison mammograms. MATERIALS AND METHODS: This HIPAA-compliant and institutional review board-approved prospective study was performed with waiver of patient informed consent. A total of 1,157,980 screening mammograms obtained between 1994 and 2008 in 435,183 women aged at least 40 years were included. Radiologists recorded presence of comparison mammograms and change, if seen. Women were followed for 1 year to monitor cancer occurrence. Performance measurements were calculated for screening with comparison mammograms versus screening without comparison mammograms and for screening with comparison mammograms that showed a change versus screening with comparison mammograms that did not show a change while controlling for age, breast density, and data clustering. RESULTS: Comparison mammograms were available in 93% of examinations. For screening with comparison mammograms versus screening without comparison mammograms, CDR per 1000 women was 3.7 versus 7.1; recall rate, 6.9% versus 14.9%; sensitivity, 78.9% versus 87.4%; specificity, 93.5% versus 85.7%; and PPV(1), 5.4% versus 4.8%. For screening with comparison mammograms that showed a change versus screening with comparison mammograms that did not show a change, CDR per 1000 women was 25.4 versus 0.8; recall rate, 41.4% versus 2.0%; sensitivity, 96.6% versus 43.5%; specificity, 60.4% versus 98.1%; and PPV(1), 6.0% versus 3.9%. Detected cancers with change were 21.1% ductal carcinoma in situ and 78.9% invasive carcinoma. Detected cancers with no change were 19.3% ductal carcinoma in situ and 80.7% invasive carcinoma. CONCLUSION: Performance is affected when change from comparison mammograms is noted. Without change, sensitivity is low and specificity is high. With change, sensitivity is high, with a high false-positive rate (low specificity). Further work is needed to appreciate changes that might indicate cancer and to identify changes that are likely not indicative of cancer.

Influence of annual interpretive volume on screening mammography performance in the United States.

PURPOSE: To examine whether U.S. radiologists' interpretive volume affects their screening mammography performance. MATERIALS AND METHODS: Annual interpretive volume measures (total, screening, diagnostic, and screening focus [ratio of screening to diagnostic mammograms]) were collected for 120 radiologists in the Breast Cancer Surveillance Consortium (BCSC) who interpreted 783 965 screening mammograms from 2002 to 2006. Volume measures in 1 year were examined by using multivariate logistic regression relative to screening sensitivity, false-positive rates, and cancer detection rate the next year. BCSC registries and the Statistical Coordinating Center received institutional review board approval for active or passive consenting processes and a Federal Certificate of Confidentiality and other protections for participating women, physicians, and facilities. All procedures were compliant with the terms of the Health Insurance Portability and Accountability Act. RESULTS: Mean sensitivity was 85.2% (95% confidence interval [CI]: 83.7%, 86.6%) and was significantly lower for radiologists with a greater screening focus (P = .023) but did not significantly differ by total (P = .47), screening (P = .33), or diagnostic (P = .23) volume. The mean false-positive rate was 9.1% (95% CI: 8.1%, 10.1%), with rates significantly higher for radiologists who had the lowest total (P = .008) and screening (P = .015) volumes. Radiologists with low diagnostic volume (P = .004 and P = .008) and a greater screening focus (P = .003 and P = .002) had significantly lower false-positive and cancer detection rates, respectively. Median invasive tumor size and proportion of cancers detected at early stages did not vary by volume. CONCLUSION: Increasing minimum interpretive volume requirements in the United States while adding a minimal requirement for diagnostic interpretation could reduce the number of false-positive work-ups without hindering cancer detection. These results provide detailed associations between mammography volumes and performance for policymakers to consider along with workforce, practice organization, and access issues and radiologist experience when reevaluating requirements.

Are mammography recommendations in women younger than 40 related to increased risk?

Our objective was to examine the association between self-reported breast cancer risk factors and reported physician recommendations for mammography among women younger than 40. This study uses the 2005 National Health Interview Survey (NHIS) and includes 2,703 women ages 30-39 who reported having seen a doctor in the past 12 months. The NHIS is a population-based, cross-sectional survey of adult respondents in the United States. Overall, 19.0% of these women reported a recent mammography recommendation. Among women reporting no prior mammogram, women ages 30-34 with risk factors for breast cancer were more likely to report a recent mammogram recommendation than women without risk factors. There was no such association for women ages 35-39. Among women who reported a prior mammogram, risk factors were not associated with a recommendation for mammography; there was an association with age and recent clinical breast examination. Despite a lack of evidence-based guidelines for women under 40 years of age, these data suggest some younger women are being recommended for early mammography without indication. The relative benefits and harms of recommending mammography in this age group need further examination.

Are there racial/ethnic disparities among women younger than 40 undergoing mammography?

While the probability of a woman developing invasive breast cancer at age <40 is low (<1%), mammography use reported among younger women (age <40) is substantial, and varies by race/ethnicity. Little detail is known about mammography use among women aged <40, particularly by race/ethnicity. We describe racial/ethnic differences in: (1) mammography indication after considering underlying risk factors (breast symptoms and family history); (2) follow-up recommendations, and (3) mammography outcomes for first mammograms in women aged <40. These 1996-2005 Breast Cancer Surveillance Consortium data are prospectively pooled from seven U.S. mammography registries. Our community-based sample included 99,615 women aged 18-39 who self-reported race/ethnicity and presented for a first mammogram (screening or diagnostic) with no history of breast cancer. Multivariable analyses controlled for registry site, age, family history of breast cancer, symptoms, and exam year. Overall, 73.6% of the women in our sample were seen for a screening mammogram. Following screening mammography, African American (AA) women were more likely than white women to be recommended for additional workup [relative risk (RR): 1.15 (95% CI: 1.07-1.23)]. Following diagnostic mammography, AA [RR: 1.30 (95% CI: 1.17-1.44)] and Asian [RR: 1.44 (95% CI: 1.26-1.64)] women were more likely to be recommended for biopsy, fine-needle aspiration, or surgical consultation. Depending on race/ethnicity, and considering the rate of true positive to total first screening mammograms of younger women, a women has a likelihood of a true positive of 1 in 363-1,122; she has a likelihood of a false positive of 1 in 7-10. This study of community-based practice found racial/ethnic variability in mammography indication, recommendations, and outcomes among women undergoing first mammography before 40. These findings highlight important areas for future research to understand the motivating factors for these practice patterns and the implications of early mammography use.

Barriers to adherence to screening mammography among women with disabilities.

OBJECTIVES: Given the lack of screening mammography studies specific to women with disabilities, we compared reasons offered by women with and without disabilities for not scheduling routine screening visits. METHODS: We surveyed women in the Carolina Mammography Registry aged 40 to 79 years (n = 2970), who had been screened from 2001 through 2003 and did not return for at least 3 years, to determine reasons for noncompliance. In addition to women without disabilities, women with visual, hearing, physical, and multiple (any combination of visual, hearing, and physical) limitations were included in our analyses. RESULTS: The most common reasons cited by women both with and without disabilities for not returning for screening were lack of a breast problem, pain and expense associated with a mammogram, and lack of a physician recommendation. Women with disabilities were less likely to receive a physician recommendation. CONCLUSIONS: Women with disabilities are less likely than those without disabilities to receive a physician recommendation for screening mammography, and this is particularly the case among older women and those with multiple disabilities. There is a need for equitable preventive health care in this population.

Positive predictive value of mammography: comparison of interpretations of screening and diagnostic images by the same radiologist and by different radiologists.

OBJECTIVE: The purpose of this study was to evaluate whether the positive predictive value (PPV) after a recommendation for biopsy differs when one as opposed to more than one radiologist performs the workup after abnormal findings are discovered at screening mammography. MATERIALS AND METHODS: Using data in a mammography registry for the years 1996-2005, we identified 6,391 diagnostic examinations with a recommendation for biopsy that were performed on a day other than the day of the screening examination. The PPV after a recommendation for biopsy was calculated for two scenarios. In the first scenario, the radiologist interpreting the diagnostic images had interpreted the screening images. In the second scenario, the radiologist read diagnostic images after another radiologist had read the screening images. We used conditional logistic regression analysis to perform within-radiologist comparisons, controlling for covariates known to be associated with PPV after a recommendation for biopsy. RESULTS: Of the screening examinations with positive findings, 2,335 (36.5%) were scenario 1, and 4,056 (63.5%) were scenario 2. We found no difference between the two scenarios with respect to PPV after a recommendation for biopsy when we controlled for age, breast density, family history of breast cancer, history of breast procedures, time since last mammogram, use of ultrasound at any point in the workup after abnormal results of screening mammography, and interval in days between the screening and diagnostic studies. CONCLUSION: Who interprets the follow-up images after screening mammograms show abnormal findings does not appear to be an important factor influencing the wide variability in PPV among radiologists.

Accuracy of self-reported breast cancer among women undergoing mammography.

This study estimated the sensitivity and specificity of self-reported breast cancer and their associations with patient factors and pathologic findings using data from the Breast Cancer Surveillance Consortium. We included 24,631 women with and 463,804 women without a prior diagnosis of breast cancer who completed a questionnaire (including breast cancer history) at participating US mammography facilities between 1996 and 2006. We determined "true" cancer status using cancer registries and pathology databases. Multivariable logistic regression models were used to examine associations with patient factors and pathologic findings. Sensitivity of self-reported breast cancer was higher for women with invasive cancer (96.9%) than for those with ductal carcinoma in situ (DCIS) (90.2%). Specificity was high overall (99.7%) but much lower for women with a history of lobular carcinoma in situ (LCIS) (65.0%). In multivariable models, women reporting older ages, a nonwhite race/ethnicity, or less education had lower sensitivities and specificities. Sensitivity was reduced when there was evidence of prior DCIS, especially when this diagnosis had been made more than 2 years before questionnaire completion. Women reporting a family history of breast cancer had higher sensitivity. Evidence of prior LCIS was associated with lower specificity. The accuracy of self-reported breast cancer depends on the respondent's characteristics and prior diagnoses. Accuracy is lower among nonwhite women and women reporting less education. There appears to be uncertainty surrounding breast findings such as DCIS and LCIS. These results have important implications for research relying on self-report and for patient communication and care.

When radiologists perform best: the learning curve in screening mammogram interpretation.

PURPOSE: To examine changes in screening mammogram interpretation as radiologists with and radiologists without fellowship training in breast imaging gain clinical experience. MATERIALS AND METHODS: In an institutional review board-approved HIPAA-compliant study, the performance of 231 radiologists who interpreted screen-film screening mammograms from 1996 to 2005 at 280 facilities that contribute data to the Breast Cancer Surveillance Consortium was examined. Radiologists' demographic data and clinical experience levels were collected by means of a mailed survey. Mammograms were grouped on the basis of how many years the interpreting radiologist had been practicing mammography, and the influence of increasing experience on performance was examined separately for radiologists with and those without fellowship training in breast imaging, taking into account case-mix and radiologist-level differences. RESULTS: A total of 1 599 610 mammograms were interpreted during the study period. Performance for radiologists without fellowship training improved most during their 1st 3 years of clinical practice, when the odds of a false-positive reading dropped 11%-15% per year (P < .015) with no associated decrease in sensitivity (P > .89). The number of women recalled per breast cancer detected decreased from 33 for radiologists in their 1st year of practice to 24 for radiologists with 3 years of experience to 19 for radiologists with 20 years of experience. Radiologists with fellowship training in breast imaging experienced no learning curve and reached desirable goals during their 1st year of practice. CONCLUSION: Radiologists' interpretations of screening mammograms improve during their first few years of practice and continue to improve throughout much of their careers. Additional residency training and targeted continuing medical education may help reduce the number of work-ups of benign lesions while maintaining high cancer detection rates.

Disclosing harmful mammography errors to patients.

PURPOSE: To assess radiologists' attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient's mammogram, leading to a delayed cancer diagnosis. MATERIALS AND METHODS: We conducted an institutional review board-approved survey of 364 radiologists at seven geographically distinct Breast Cancer Surveillance Consortium sites that interpreted mammograms from 2005 to 2006. Radiologists received a vignette in which comparison screening mammograms were placed in the wrong order, leading a radiologist to conclude calcifications were decreasing in number when they were actually increasing, delaying a cancer diagnosis. Radiologists were asked (a) how likely they would be to disclose this error, (b) what information they would share, and (c) their malpractice attitudes and experiences. RESULTS: Two hundred forty-three (67%) of 364 radiologists responded to the disclosure vignette questions. Radiologists' responses to whether they would disclose the error included "definitely not" (9%), "only if asked by the patient" (51%), "probably" (26%), and "definitely" (14%). Regarding information they would disclose, 24% would "not say anything further to the patient," 31% would tell the patient that "the calcifications are larger and are now suspicious for cancer," 30% would state "the calcifications may have increased on your last mammogram, but their appearance was not as worrisome as it is now," and 15% would tell the patient "an error occurred during the interpretation of your last mammogram, and the calcifications had actually increased in number, not decreased." Radiologists' malpractice experiences were not consistently associated with their disclosure responses. CONCLUSION: Many radiologists report reluctance to disclose a hypothetical mammography error that delayed a cancer diagnosis. Strategies should be developed to increase radiologists' comfort communicating with patients.