ing, double reading of mammograms, and the organization of services in centralized high-volume facilities. Such services would include centralized facilities for interpreting mammograms and other screening data, whether it would be ultrasound, magnetic resonance imaging (MRI), or other new technologies once they are developed and validated. Centralization should not, however, involve reducing access to screening services. Consolidation of interpretation facilities does not need to coincide with consolidation of facilities that women attend for mammograms. In cases where traveling long distances might limit attendance at screening facilities, image acquisition and image interpretation could be conducted at separate locations.

Callback rates in mammography screening can be reduced when mammograms are read by breast imaging specialists at a central location, as opposed to having them dispersed among the sites where the mammography is done. By centralizing the reading, the mammography service reduced the overall callback rate by 2 percent, from 11 to 9 percent, which was statistically significant.76

On the other hand, the quality of a breast cancer screening program cannot be measured solely by the recall rate or the cancer detection rate, although these are important considerations. It is the rate of detection of small early stage, node-negative tumors that provides the greatest opportunity to save lives. Larger tumors are less often confused with normal breast structures and are less likely to be missed or to be false positives, and thus fewer women undergo unnecessary follow-up.109

Improving Screening Practices Can Reduce Health Care Costs

Aggregate costs of screening mammography in the United States are more than $3 billion, and cost savings in screening practices could have a significant impact.22 The average cost of a diagnostic workup following a false-positive mammogram is about $500 per case.29 About 40 million women in the United States are screened each year for breast cancer, which means that if the percentage of mammograms judged to be abnormal were reduced from 10 to 5 percent, 200,000 fewer women would be called back for follow-up work every year, which would translate into an annual savings of $100 million.

Equal Access Is a Component of Quality

In addition to considering how mammography should be organized to deliver optimal quality, it is essential to optimize access to services. Because access to health care in the United States is so uneven, it is important to consider not only the internal organization of a screening service, but also



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