In addition to the inconsistent quality of mammographic interpretation, some experts believe the growing shortage of breast imagers might soon create a crisis in access to high-quality mammography services. This shortage, coupled with an imbalance between the closures and openings of screening facilities, has created delays of several months in some parts of the country. One approach to address this shortage would be to train physician assistants, or physician extenders, a practice that has helped to alleviate shortages and reduce the workload for physicians in other medical specialties. The judicious use of physician extenders could raise the productivity of the limited number of radiologists who interpret screening mammograms. The committee does not suggest that physician extenders should interpret diagnostic mammograms or that screening mammograms should be interpreted solely by a physician extender, rather they would work to expand the capacity of radiologists.

The MQSA stipulates that mammograms are to be interpreted only by a physician specifically certified in mammography. 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 extenders could be enlisted to help read mammograms could 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.

The potential for alleviating the shortage prompted the committee to recommend:

To expand the capacity of breast screening programs, mammography facilities should enlist specially trained nonphysician personnel to prescreen mammograms for abnormalities or double-read mammograms to expand the capacity of breast imaging specialists. (Recommendation A3)

INTEGRATE BIOLOGY, TECHNOLOGY, AND RISK MODELS TO DEVELOP NEW SCREENING STRATEGIES

The wide-ranging levels of risk for breast cancer have important implications for screening and detection. Most guidelines in the United States now recommend annual mammograms for every woman over the age of 40, but the ability to better classify women according to their risk levels—whether high, normal, or low—could allow a more individualized approach to screening. For example, most women would gain no medical benefit



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