per year, in addition to eliminating the mental anguish and the possible need for a biopsy for thousands of women and also cutting unnecessary waiting time. Though no one knows the actual costs of settling malpractice suits, since so many are settled out of court, these settlements are thought to contribute to the ever-escalating costs of malpractice insurance for radiologists who read mammograms, a trend that discourages physicians from entering the profession.

Given these, and other, factors, the committee sought ways to optimize the productivity of radiologists who interpret mammograms and, at the same time, improve their accuracy. They looked toward the experience of other countries, notably the United Kingdom, and their organization of screening services. Although differences in the number of “excess” biopsies due to false-positive readings were difficult to assess, for even within the United States significant regional variations exist, committee members did identify elements in the programs of some European countries, as well as Canada and Australia, that could be useful in the United States, which has limited national or regional standards or programs for breast cancer screening. For instance, in the United Kingdom radiologic technologists, who are not physicians, are trained to meet national certification standards, and have proven comparable in accuracy and speed to radiologists.

Also, the British National Breast Cancer Screening Program invites every woman for a screening mammogram, which is paid for through the National Health Service—but only at three-year intervals. In the United States, the recommended screening interval is one year, which is likely to detect more cancers, but women do not get screened unless they are referred by health care providers or refer themselves. Many women are never screened because they lack adequate, if any, insurance coverage. That group tends to include underserved women in lower socioeconomic groups in whom breast cancer may not be detected at an early stage when still treatable.

A program that might be adapted by health care providers in the United States is the European Code Against Cancer which stresses that screening should be done within integrated breast care centers that have quality assurance programs. Another model is Britain’s National Health Service Breast Screening Program, which has developed national quality assurance standards and a quality assurance network though which programs are regularly monitored, with results measured against established targets. In the United States no organization collects or monitors data to promote high performance levels and guidelines are only voluntary. (The Mammography Quality Standards Act [MQSA] requires facilities in the United States to collect quality data for internal use, but does not require the facilities to use the data in any specific or documented approach for quality improvement.)

In Sweden and the Netherlands, which both report low rates of false positives, screening takes place in outlying centers and diagnosis and



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