possible. Their input must provide the impetus for change, as it has so effectively in the past.

Even with this broad base support, this effort demands strong leadership and coordination. Therefore, for practical reasons, lead responsibility for implementing many of the recommendations is assigned to the National Cancer Institute and to the relevant professional groups, who should, in turn, enlist other groups most able and qualified to assist. Where additional funding or policy changes are required, that responsibility is also designated.

A. IMPROVE CURRENT APPLICATION OF SCREENING MAMMOGRAPHY

Evidence from randomized clinical trials and from community breast cancer screening programs documents the ability of mammographic screening to reduce mortality from breast cancer. However, mammography is not a perfect technology, nor is it always applied perfectly. Wide variations in the quality of mammographic services need to be addressed, as does the serious and growing shortage of qualified mammographers.

The committee identified several key challenges to providing high-quality breast screening services to all women who would benefit: organizing breast screening services to increase their quality and efficiency (Recommendation A1), improving the overall quality of mammography interpretation and encouraging the development and dissemination of adjunct technologies that would further improve mammography (Recommendation A2), and conserving the workforce of breast imagers and support personnel and making optimal use of their skills (Recommendation A3).

A1. Health care providers and payers should consider adopting elements of successful breast cancer screening programs from other countries. Such programs involve centralized expert interpretation in regionalized programs, outcome analysis, and benchmarking.

International differences in breast cancer detection patterns and mortality are influenced by the organization of breast cancer screening programs. Comparative studies of screening programs indicate that programs with high rates of abnormal mammograms tend to have low positive predictive value for biopsies. Although these studies cannot determine the underlying causes of this trend, they highlight several characteristics of successful breast cancer screening programs in other countries that are not fully realized in the United States.

Aspects of foreign screening programs can provide models to guide the improvement of domestic programs, including the incorporation of quality



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