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Improving Breast Cancer Screening Services

The controversy over mammography is often focused on whether or not it should be used as a screening tool. But another equally important issue, given its widespread use, is the optimization of mammography…. Considerable effort should, therefore, be devoted to determining how to make mammography as effective as it can be and to reduce the tremendous variation in interpretation and biopsy rates.38

Laura Esserman and colleagues

This chapter examines critical issues in providing high-quality breast screening services. The fundamental criterion for implementing a screening program for all women in a particular target group is that the screening tests should have an acceptable level of accuracy, cost effectiveness, and a favorable balance of benefits to harms. Although different programs might place relatively greater emphasis on detecting small tumors or on reducing the false-positive rate, there is little disagreement that achieving the highest practical balance between sensitivity and specificity is central to ongoing efforts to improve the quality of mammography services. This chapter reviews alternative approaches to the organization of breast screening services, ways that mammography could be improved, technologies that might augment or replace mammography in breast cancer screening, and the challenges in supporting and developing a well-trained workforce.

SCREENING OUTCOMES VARY BY COUNTRY

Nearly a dozen countries have national or regional screening programs in which personal invitations for regular mammograms are sent to all women over age 40 or 50, depending on the country (Table 3-1).74 There are international differences in breast cancer detection patterns and mortality. Examination of how these patterns are influenced by the organization of breast cancer screening should indicate ways to improve quality.



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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis 3 Improving Breast Cancer Screening Services The controversy over mammography is often focused on whether or not it should be used as a screening tool. But another equally important issue, given its widespread use, is the optimization of mammography…. Considerable effort should, therefore, be devoted to determining how to make mammography as effective as it can be and to reduce the tremendous variation in interpretation and biopsy rates.38 Laura Esserman and colleagues This chapter examines critical issues in providing high-quality breast screening services. The fundamental criterion for implementing a screening program for all women in a particular target group is that the screening tests should have an acceptable level of accuracy, cost effectiveness, and a favorable balance of benefits to harms. Although different programs might place relatively greater emphasis on detecting small tumors or on reducing the false-positive rate, there is little disagreement that achieving the highest practical balance between sensitivity and specificity is central to ongoing efforts to improve the quality of mammography services. This chapter reviews alternative approaches to the organization of breast screening services, ways that mammography could be improved, technologies that might augment or replace mammography in breast cancer screening, and the challenges in supporting and developing a well-trained workforce. SCREENING OUTCOMES VARY BY COUNTRY Nearly a dozen countries have national or regional screening programs in which personal invitations for regular mammograms are sent to all women over age 40 or 50, depending on the country (Table 3-1).74 There are international differences in breast cancer detection patterns and mortality. Examination of how these patterns are influenced by the organization of breast cancer screening should indicate ways to improve quality.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis TABLE 3-1 Breast Screening Programs in Different Countries*   United States Canada Year screening program started 1988 (Medicare) 1988 (British Columbia was the 1st province) Age of women screened (target population) 40 and older, generally until 75 50 to 69 Screening interval (years) 1-2 2ii Percent of target population screened 55-63%iv 54%v Referral type Doctor or self-referral Doctor or self-referral Double readingx Somexi No Number of views 2 2 Quality enforcement National law (MQSA)xiv Voluntary accreditationxv Quality assurance site visits Yes No Level of organization Medicare is national; otherwise based on state and private insurance provider policiesxx Provincexxi *Finland, Luxembourg, and Japan also have national mammography screening programs; Italy, Spain, and Norway have regional programs. iSwedish governments makes guidelines, but standards and practices are organized at the county level. iiThe Canadian Province of British Columbia offers annual mammograms. iiiScreening interval established individually by county. ivBased on year 2000 data from Behavioral Risk Factor Surveillance System Public Use Data Tape (CDC, 2001). Also National Health Interview Survey, 2000 (CDC 2002); women over 40, and mammograms in last year; ACS Breast Cancer Facts and Figures 2003-2004. vBased on 1996 data; Paquette et al. (2000); mammogram in past 2 years. viBased on 2001-2002 data; NHS Breast Screening Programme Annual Review 2003. viiBased on WE trial 1977-1979; attendence after first invitation; Lynge et al. viiiShould be range b/c age policies differ; WE trial data is old (1977) and small sample size, but all studies go back to this same ref. ixBased on 1990-1995 data; Facheboud et al., 1998, Int. J. Cancer. xISBN http://appliedresearch.cancer.gov/ibsn/data/double.html. Accessed February 4, 2004. xiThe United States does not require double reading of mammograms, but the practice is common. However, overall, double reading of screening mammograms is less common in the United States than other countries.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis United Kingdom Swedeni The Netherlands Australia 1988 1986 1989 1994 50 to 70 Beginning at 40; ending at 64 or 74 50 to 75 40 to 79 3 1 1/2-2, depending on ageiii 2 2 76%vi 89%vii, viii 78%16 54 Invite Invite Invite Invite or self-referral No Yes Yes Yes 2xii 2 2xiii 2 Voluntaryxvi National lawxvii National lawxvooo National accreditation requirementsxix Yes Yes Yes Yes National County (Swedish counties are comparable to stated in the U.S.) National National xiiInitial mammogram only; NHS reports as of December 2003 86% of local screening services are doing two-view mammographies. xiiiInitial only. xivThe Mammography Quality Standards Act ensures x-ray technical quality but does not review quality of interpretation. xvCanadian Association of Radiologists. xviRadiographic Quality Control Manual for Mammography. xviiNational Swedish law based on European Guidelines for Quality Assurance in Screening Mammography. xviiiDutch Technical Protocol for Quality Control. xixExternal quality assurance program must be established to receive funding. xxNo national policy. Contains aspects of both national centralized care (Medicare) and decentralized regional care (private). xxiCanadian government sets has national guidelines, but standards and service organization are set at the provincial level.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis Most women who undergo biopsies will not have breast cancer. Although some might describe these biopsies as “needless,” in reality they reflect the lack of precision of current detection methods. Some of the imprecision is likely due to the quality of the mammographic interpretation, and some is due to the inherent limitations of the technology. Some solutions to the problem lie in organizational changes, such as adopting different procedures for interpreting mammograms, different standards, and different ways of organizing mammography services. Other solutions might lie in technological improvements. Screening for breast cancer is organized differently in different countries. A close comparison between the different countries and the results offers some useful insights into strategies for reducing breast cancer mortality in the United States. Mortality is influenced by screening patterns, as well as patterns of care. Screening programs can be compared according to a variety of measures, such as differences in breast cancer survival rates, rates of abnormal mammograms, or rates of false positives. But there are caveats to each of these measures. A 2003 study reported that 5-year survival rates for all breast cancers are higher in the United States (89 percent) than in Europe (79 percent), but this was based on data from a heterogeneous group of countries including those with national or regional screening programs (Italy, Spain, The Netherlands, and the United Kingdom) and those without (Estonia and France).101 The study, which compared the United States Surveillance Epidemiology and End Results (SEER) data set with the comparable EUROCARE data set, revealed that breast cancer survival was higher for women in the United States than in Europe, at least for breast cancers diagnosed between 1990 and 1992.a (During the first decade of a service screening program, most breast cancer deaths will occur in women who were diagnosed before the program started which means that a reduction in breast cancer mortality will only emerge when most of the breast cancers in the target population have been screen detected.74) Five-year survival was 89 percent for women in the United States and 79 percent for women in Europe.101 Most of the difference in survival rates was due to the stage at which women were diagnosed. Forty percent of tumors in the SEER data set were early stage (T1N0M0) compared with only 30 percent in the EUROCARE set.b The authors attribute these differences to the availability a   Analyses of breast cancer survival outcomes do not reflect recent practice changes, either in detection or treatment, because of the need to use a study period that is at least as long as the natural course of the disease, which is about 10 years. b   T1 indicates a tumor less than 2 cm, N0 indicates that the cancer has not spread to the lymph nodes, and M0 indicates the absence of metastasis to other organs.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis of diagnostic and treatment facilities and to the effectiveness of the different health care systems.102 The frequency with which different breast cancer treatments were used, such as the frequency of axillary node dissection, breast-conserving surgery, and the modified radical Halstead mastectomy, varied two- to three-fold among countries.100 Although the relative contributions of earlier detection and state-of-the-art therapy are difficult to quantify, a recent study concluded that early detection through screening had probably contributed more to the reduction of mortality rates than had improvements in therapy.115 The study, which was conducted in Sweden, compared the results of women who participated in screening with those who did not. Cancers detected in the women who participated in screening were detected at an earlier stage and were less likely to have invaded the lymph nodes, which gained them a prognostic advantage over women whose cancer was not screen-detected but was presumably detected through physical exam or development of symptoms. There is substantial variation between countries, as well as within the United States, in the frequency that mammograms are identified as abnormal (Figure 3-1). A review of 32 studies showed that the screening programs with high rates of abnormal mammograms also tended to be those with lower positive predictive values for biopsies, suggesting that many of those biopsies could have been safely avoided.36 The data collected in the screening studies reviewed do not permit determination of the underlying causes of the variation in the percentage of mammograms that are judged to be abnormal and the predictive value of biopsies. Possible sources of variation include: Characteristics of the population that was screened, including the age distribution, and the proportion of women being screened for the first time (prevalence screens) versus those who have been screened before (incidence screens). Features of the mammography examinations (such as screening interval, number of views per breast, use of single versus double readings, and availability of prior films for comparison). Features of physicians interpreting the mammogram (such as experience or comfort with ambiguity). Features of the health care system (such as malpractice concerns, financial incentives, or national policies). Finally, although this review emphasizes international variation, the considerable variation in performance within the United States is also worth noting, suggesting that international differences such as universal access to health care, more centralized health care systems, and high cost of malpractice litigation account for only part of the differences in screening program

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis FIGURE 3-1 Frequency of abnormal mammograms in North America compared to other countries. These data are based on a review of 32 screening mammography studies.36 With the exception of one point that indicates a study from British Columbia, Canada, all points listed for North America are from studies conducted in the United States. performance. Although on average there are fewer “excess” biopsies in European screening programs than in the United States (at least those programs that were reviewed in the study, which was conducted in the late 1980s and 1990s), there are also European programs that appear to be worse, at least by this measure. In 1988, the United Kingdom had the highest breast cancer mortality rate in Europe. That same year, the national breast screening program was established, and it is now one of the most well-established, well-analyzed, and extensive screening programs in the world. Since then, the United Kingdom has had the greatest reduction in breast cancer mortality for Europe.19 There are several important differences in the delivery of breast screening services in the United States and other countries (Table 3-2). The main programmatic differences between the United States and Britain are: All women in Britain receive invitations for screening mammograms

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis at regular intervals, whereas the large majority of women in the United States are referred by a health care provider or by themselves. The British National Health Service pays for all screening mammograms in the United Kingdom, whereas mammograms in the United States are covered through a complex patchwork of medical payment systems that exclude millions of women. The volume of mammographic interpretations required of radiologists to be eligible to read mammograms in the United States is about one-tenth that required in Britain. The recommended interval for screening mammography is 12 months in the United States and 36 months in Britain. Quality assurance standards concerning mammographic interpretation for the National Health Service Breast Screening Program are set nationally and are regularly monitored through a quality assurance network. Although the threat of malpractice is frequently cited as an important reason for the difference in screening practices between the two countries, this is part of the larger context of the health care and can not be regulated through breast cancer screening programs. (Problems of malpractice in the United States are discussed later in this chapter in the section Breast Imagers Needed.) Table 3-2 summarizes the different outcomes of the breast screening programs in the United States and Britain. The results in Table 3-2 are only valid for comparison within the same study which directly compares the two countries because of the similar methodology used in collecting the data; other studies with different methodology may result in different statistics. Overall, women in the United States are called back after screening mammograms about twice as often as women in Britain and significantly more of the surgical biopsies they undergo turn out to be negative. But this does not translate into improved rates of cancer detection, which are not significantly different between the countries. It could be argued that women in the United States are excessively subjected to unnecessary medical procedures. Yet, the fact that breast cancer mortality rates in the United States are lower than they are in Britain must be considered. Although differences in treatment quality cannot be ruled out, there is a more immediate reason to expect higher breast cancer mortality in Britain. Breast cancers are detected at a later stage in Britain, and stage of detection is well established as a factor in survival. The three-fold difference in screening intervals between Britain and the United States is highly likely to be a significant contributor to the differences in mortality between the two countries. Longer screening intervals are associated with more false positives, as well as in increase in

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis TABLE 3-2 Comparison of Screening Mammography Outcomes in the United States and Britain   United States Britain Source Comments Sensitivity 77% (>300/month) 70 % (≤ 300/month) 79% (>300/month) Esserman et al., 2002 JNCIi Used enriched test set; U.S. figures are for high-volume radiologists Specificity 88% (>300/month) 88%   Volume was not significantly correlated with specificity for any of the groups. Mammograms judged to be abnormal at 1st screen 12.0% 7.4% Smith-Bindman, 2003 JAMA U.S. value = median of estimates from two data sets (11.2-13.1) Mammograms judged to be abnormal at later screens 7.4% 3.6%   U.S. value = median of estimates from two data sets (6.8-8.0) Mammograms judged to be abnormal 6.9% 4.9% Elmore et al., 2003 JNCI Values are medians of estimates for three or more studies; included both 1st and subsequent screening mammograms Women with abnormal mammograms later diagnosed with breast cancer 7.6% 12.3%   Values are medians of estimates for three or more studies Negative biopsies 73% 40%   Included all types of biopsy Biopsy rates/100 screening mammograms for later screens 0.33 0.28 Smith-Bindman, 2003 JAMA Differences are not significant

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis Negative open surgical biopsies at 1st screen 82% 36%     % Negative open surgical biopsies at later screen 22% 10%     % Cancers detected 78.6% (>300/month) 70% (≤ 300/month) 83.5% Esserman et al., 2002   # Cancers detected at 1st screen/1,000 6.8 8.4 Smith-Bindman, 2003 JAMA Median of estimates from two data sets (6.3-7.2) # Cancers detected at later screens/1,000 2.6 4.3   U.S. value = Median of estimates from two data sets (2.3-2.8) % Invasive cancers detected at early stage (T1N0M0) 41% 26% Sant, 2003 Int J Cancer; Sant, 2004 Int J Cancer U.S. data from SEER; UK based on median of two counties (18-34%); for cases diagnosed in 1990s Five-year survival rate for invasive breast cancers 89% 78%   U.S. data from SEER; U.K. data based on median of two counties (73-83%) for cases diagnosed in 1990s Mortality rate for all breast cancers/100,000 21.2 26.8 Cancer Facts & Figures 2003, ACS   iThis reference is from a specific study examining a relatively small group of radiologists that interpreted a specific set of mammograms; therefore, these figures are for internal comparison only and cannot be appropriately compared to the sensitivity and specificity of population-based studies.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis the frequency of late-stage cancers. Although there are many aspects of the British national screening program that should be considered for adoption in the United States, the 3-year screening interval is not one of them. Mammography services in both Sweden and several Canadian provinces also have high performance standards, but there are fewer published data and direct comparisons with services in the United States, so they are not reviewed here. The British Health Service monitors and tracks the outcomes of their breast cancer screening programs more thoroughly than do other countries.74 QUALITY ASSURANCE IMPROVES OUTCOMES The National Health Service Breast Screening Programme (NHSBSP) in the United Kingdom has integrated quality assurance into all clinical aspects of its programs (Box 3-1).107 Ranges of acceptable performance for BOX 3-1 Quality Assurance for Breast Screening in the United Kingdom The United Kingdom is divided into 11 National Health Service regions, each of which is supported by a quality assurance reference center that collects and collates data about the performance and outcomes of the breast screening program, organizes quality assurance visits, and provides support for the regional director of quality assurance and the professional coordinators. Each region has a quality assurance director for breast screening and a quality assurance reference center. Each regional quality assurance director is supported by a regional quality assurance team, which includes a professional coordinator from each of the professions that contribute to the breast screening program (radiology, radiography, pathology, surgery, breast care nursing, administration, and medical physics). Each professional coordinator meets regularly with colleagues in the region to review the performance and outcomes of the breast screening program, to share good practice, and to encourage continued improvements in the program. There is also a program of regular quality assurance visits to breast screening units. Regional quality assurance directors and professional coordinators meet regularly in a series of national coordinating committees. The committees produce guidance on good practice and set standards and targets for staff working in the breast screening program and for the technical performance of equipment. National standards and targets for the performance and outcomes of the program are also published. SOURCE: See http://www.cancerscreening.nhs.uk/breastscreen/quality-assurance.html. Accessed March 4, 2004.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis BOX 3-2 PERFORMS: A Self-Assessment Program to Improve Performance PERFORMS (PERsonal perFORmance in Mammographic Screening) is an integral part of quality assurance for breast cancer screening in the United Kingdom. It is a self-assessment program for mammogram interpretation, developed in 1991 and funded by the NHSBSP. As of 2003, it is the only system of its kind in the world.89 The PERFORMS program film set is released early each year. It contains 2 film sets, each with 60 two-view cases (mediolateral oblique and cranio-caudal). Up to 90 percent of U.K. radiologists use the PERFORMS system to assess their mammogram interpretation skills.124 PERFORMS results indicate the number of malignant cases a radiologist missed in the testing film set and whether they showed any patterns in the types of cases they missed, such as dense mammograms or mammograms with many microcalcifications. Pathology information is also provided where appropriate. Particular film sets allow the individual to see a large number of examples of one particular abnormality and have been shown to improve radiologists’ detection of these specific features.124 Additional advanced training sets are also available that concentrate on the types of cases that the radiologists were most likely to misinterpret. Analysis of the PERFORMS data can provide the participating radiologist with insight into how they perform in comparison with their anonymous colleagues. In addition, the program also can provide details concerning the specific cases that a radiologist incorrectly recalled for further assessment (false positives) or incorrectly identified as normal (false negative). Targeted training with the cases producing disagreement may achieve a higher level of consensus and reduce clinically important inconsistencies.10 An individual’s results are anonymous and are made available only to the radiologist who takes the test—although, for quality assurance purposes, the results can also be collated to provide anonymous regional or national results. recall, biopsy, and cancer detections rates have been established and an organized program operates at the local and national levels to monitor and achieve these targets. All screening programs in the United Kingdom receive data that enable a comparison of their recall and cancer detection rates with other programs. Both programs and individual radiologists below a minimum standard are subject to quality assurance. In contrast, the United States has only voluntary guidelines and there is no national organization to collect or monitor data to promote high levels of performance. Finally, an organized program of professional development in the United Kingdom specifically provides instruction related to mammography interpretation (Box 3-2). Although, a self-testing program exists in the United States, it is not widely used.

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis In another study conducted in the United Kingdom, three RTs in a hospital that was otherwise unable to maintain double reading requirements for mammograms were trained to meet national certification standards.122 The trained radiographers performed well and were comparable in both accuracy and speed to that of the four participating radiologists. A 6-week study of 33 experienced RTs conducted in a U.S. hospital found that even without training, the technologists could classify screening mammograms as to their need for additional workup (such as additional views, sonography, or biopsy) with “reasonable” accuracy.111 The technologists assigned each of the more than 3,000 women whose mammograms they reviewed to one of two categories: either she needed additional workup to explore possible abnormalities, or no workup was required. The RTs’ classification of more than 80 percent of these cases matched those of the hospital’s nine radiologists, and the RTs identified most of the cases that later proved to be malignant. Each of the studies described above involved the interpretation of screening mammograms by RTs working under the supervision of a board-certified radiologist, and do not apply to diagnostic mammograms. The Committee does not suggest that RTs should interpret diagnostic mammograms or that screening mammograms should be interpreted solely by an RT; rather, they would work to expand the capacity of radiologists. RTs could also take on other tasks commonly performed by radiologists such as filling out forms, dictating, and hanging and taking down films. Having a physician extender support the work of breast imagers would add the cost of an extra salary, but this could result in overall reduced costs if they could take on other tasks commonly done by radiologists. The most important requirement that would have to be met if nonphysicians were to interpret mammograms would be that the quality of the mammography service was shown to improve, or at least, did not decline. In fact, the use of physician extenders for double-reading has the potential to increase quality. Because double-reading by a second radiologist is not reimbursed by Medicare, few mammography facilities can afford to have two radiologists interpret each mammogram, even though this practice is known to improve sensitivity. Another requirement would be that mammograms interpreted by physician extenders should also be viewed by an interpreting radiologist. Challenges to this proposal include the acceptance of the radiology profession and malpractice coverage. In May 2004 the ACR leadership council recently voted against a proposal to allow the interpretation of any imaging examination by nonphysicians. However, resistance to expanding professional boundaries has been overcome by other medical specialties, for example, the use of nurse practitioners and midwives in obstetrics and gynecology; these professionals have also dealt with similar malpractice

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis issues. Indeed, it is even conceivable that malpractice rates for radiologists could be lowered if they adopted the practice of double-reading made possible by supportive assistance from nonphysicians with specialized training in mammography. The MQSA stipulates that mammograms are to be interpreted only by a physician specifically certified in mammography (Box 3-8). The Act does not, however, preclude other personnel from examining the mammograms that are also interpreted by certified physicians. Although not widely appreciated and rarely practiced, it would in fact be permissible within the provisions of the MQSA to have nonphysician personnel examine mammograms—as long as a certified physician signed the mammogram report indicating that he or she had interpreted it. This suggestion that physician BOX 3-8 Who Does What in Mammography This includes only the initial requirements established by law in the MQSA. Further requirements are set by the FDA in the Code of Federal Regulations for Mammography, 21 CFR 900.12. Interpreting Physician—Interprets mammograms Must have state license to practice medicine Must be certified in an appropriate specialty area by an FDA-approved accreditation body or have 3 months of training in mammographic interpretation Must complete 60 hours of category I medical education in mammography Must interpret a minimum of 240 mammograms every six months Radiologic Technologist—Performs mammograms Must be licensed to perform radiographic procedures by FDA-approved accreditation body (See Box 3-4). Must complete 40 hours of training specific to mammography Must perform 200 mammograms every 2 years Medical Physicist—Surveys mammography equipment and oversees quality assurance practices Must be state licensed to perform physics survey Must have a Master’s degree or higher in physical science Must complete 20 hours of specialized training in conducting surveys of mammography facilities Must conduct surveys of at least 1 mammography facility and a total of 10 mammography units

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis extenders could be enlisted to help read mammograms would thus offer women a more thorough examination than is currently typical of most mammography facilities where mammograms are viewed only by a single breast imager. Physician extenders could potentially improve the overall accuracy of mammographic interpretation through double reading, as well as alleviate the burden on the breast imaging physicians by prescreening the mammograms to allow the interpreting physician to spend more time on the more problematic mammograms. SUMMARY Mammography is not a perfect screening technology, but it can reduce mortality from breast cancer. However, there is wide variation in performance among breast imaging facilities and individual breast imagers. Organizing breast screening services to increase the utilization of services as well as their quality and efficiency should thus be priority for health care payers and providers. Approaches to improving mammography that need to be examined include organizational changes such as those implemented in some European countries including limiting interpretation to more expert and experienced breast imagers, and regionalization and reading at a central location. Although the evidence for how such changes might improve mammography in the United States is mixed, they have led to improvements in some European countries. Certainly, better accuracy and lower rates of callbacks and false positives should result in more cost-effective care. Even without the single-payer, universal access health care system common to all other developed countries, screening services in the United States could adapt many features of those systems to regionally based programs. As pointedly noted by Harmon Eyre and his colleagues at the American Cancer Society:39 Screening under opportunistic condition rather than through a system is inefficient at both the individual level and population level; moreover, without a system, there is no readiness to implement any new early detection technology that could improve disease control. A comprehensive system of early-detection potentially not only leads to high levels of participation but also insures that all the elements of a program of early detection an intervention are highly competent, interrelated, and inter-dependent. A system has the potential not only to increase quality but also to reduce the volume of small errors that contribute to incremental erosions of efficiency…. While there are many practical barriers that must be overcome to establish true population-based screening programs, a system of organized

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Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis screening holds the greatest potential to realize the benefits of reducing the incidence rate of advanced cancers. Harmon J. Eyre, Robert A. Smith, Curtis J. Mettlin Cancer Screening and Early Detection, 2003 State and federal legislators have taken an active role in exploring ways to improve breast cancer detection. The federal Mammography Quality Standards Act represents an unusual governmental intervention aimed at, and successful in, improving the technical quality of mammography. In the future, the MQSA may address the vexing problem of variation in radiologist interpretation of breast images. In spite of the impression left by widespread coverage in the national media,f differences among radiologists are not the largest component of the problem of inconsistency in interpretation. Other factors, notably organizational factors, have received much less attention, and are more difficult to control than individual factors, such as volume or training requirements. New technologies, such as digital mammography, CAD, and MRI are being examined. Although they have advantages in some situations that may justify their use, they can add significant costs, and their value as improvements in sensitivity and specificity over screen-film mammography has not been established. Organizational factors such as double reading by two radiologists improves accuracy; high volume centers on average have higher accuracy, above and beyond the increase attributable to reading volume of individual radiologists; and use of CAD can reduce the variability in mammographic interpretation among different readers. As the U.S. population ages, demand for mammography will rise at a time when supply of personnel and facilities appears to be falling, increasingly threatening access. Among other things, low reimbursement and the unattractiveness of breast imaging as a subspecialty due to stress and malpractice litigation seem to be driving the impending shortages. Other problems include a dearth of radiologist researchers to conduct trials and investigate new approaches to breast cancer detection. To address the shortage of mammographers, expansion of responsibilities by nonphysicians to include preliminary interpretation of images should be considered. A key to improving mammographic interpretation is to reduce known and controllable sources of variability in quality, but at the same time to avoid adding to the burden of an already overextended workforce. f   See, for example, series of articles by Michael Moss in the New York Times (October 24, 2002).

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