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Breast Imaging |
1 From the Department of Radiology, University of California (UCSF) Medical Center, Box 1667, San Francisco, CA 94143-1667. Received September 4, 2001; revision requested October 16; final revision received February 28, 2002; accepted March 20. Supported by Breast Cancer Surveillance Consortium cooperative agreement no. 1U01 CA 63740 from the National Cancer Institute. Address correspondence to E.A.S.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Data (ie, patient age; family history of breast cancer; availability of previous mammograms for comparison; and abnormal interpretation, cancer detection, and stage 0–I cancer detection rates) were derived from review of mammographic studies obtained from January 1997 through August 2001. The breast imaging specialists have substantially more initial training in mammography and at least six times more continuing education in mammography, and they interpret 10 times more mammographic studies per year than the general radiologists. Differences between specialist and general radiologist performances at both screening and diagnostic examinations were assessed for significance by using Student t and 
2 tests.
RESULTS: The study involved 47,798 screening and 13,286 diagnostic mammographic examinations. Abnormal interpretation rates for screening mammography (ie, recall rate) were 4.9% for specialists and 7.1% for generalists (P < .001); and for diagnostic mammography (ie, recommended biopsy rate), 15.8% and 9.9%, respectively (P < .001). Cancer detection rates at screening mammography were 6.0 cancer cases per 1,000 examinations for specialists and 3.4 per 1,000 for generalists (P = .007); and at diagnostic mammography, 59.0 per 1,000 and 36.6 per 1,000, respectively (P < .001). Stage 0–I cancer detection rates at screening mammography were 5.3 cancer cases per 1,000 examinations for specialists and 3.0 per 1,000 for generalists (P = .012); and at diagnostic mammography, 43.9 per 1,000 and 27.0 per 1,000, respectively (P < .001).
CONCLUSION: Specialist radiologists detect more cancers and more early-stage cancers, recommend more biopsies, and have lower recall rates than general radiologists.
© RSNA, 2002
Index terms: Breast neoplasms, diagnosis, 00.11, 00.30 • Breast neoplasms, radiography, 00.11, 00.30 • Breast radiography, quality assurance, 00.11 • Cancer screening, 00.11, 00.30 • Radiology and radiologists, observer performance
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The purpose of our study was to evaluate various performance parameters for radiologists in a practice of breast imaging specialists and general diagnostic radiologists who interpret a large series of consecutive screening and diagnostic mammographic studies, with the aim of extending the scope of previously published observations concerning screening mammography and determining whether similar observations are valid for diagnostic mammography.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Our study was reviewed and approved by our institutional review board. Appropriate informed consent was obtained from all patients (to permit review of medical records) and from all interpreting radiologists (to permit analysis and reporting of radiologist-specific performance).
Interpreting Physicians
All of the interpreting physicians in our practice are American Board of Radiology–certified radiologists, but their levels of mammography experience and expertise vary. Most are general diagnostic radiologists who have been in practice for 3–32 years (mean, 19.6 years). These individuals, who have neither special training nor a special focus in mammography, interpret sufficient numbers of mammographic studies, both within and outside of our practice, to satisfy U.S. federal regulations for continuing experience (ie, 960 examinations per 2-year period) (13). They also acquire a sufficient level of postgraduate education in mammography to satisfy U.S. federal regulations for continuing education (15 hours of category 1 credit per 3-year period) (13).
Our practice also includes three radiologists (including E.A.S. and D.E.W.) who are breast imaging specialists. These individuals interpret more than 5,000 mammographic studies per year both within and outside of our practice, and they acquire at least 30 hours of category 1 continuing education credit in mammography per year. Our senior radiologist has been in full-time breast imaging practice for 25 years; the other two began practicing in this specialty 7 and 8 years ago, each after having completed a 1-year breast imaging fellowship taught by the senior radiologist.
Mammography Facilities
Our practice operates two fixed-site mammography facilities, one of which is an integral part of our institution’s Comprehensive Cancer Center. All of the specialist radiologists and several of the general diagnostic radiologists interpret mammographic studies at this facility, which is called the Breast Imaging Center (BIC). Radiology residents and breast imaging fellows are trained at the BIC on an ongoing basis. At least two residents and one fellow are always on service; these physicians routinely preview each screening and diagnostic mammographic study prior to its interpretation by a staff radiologist so that all BIC interpretations are rendered by using a form of quadruple reading. Another aspect of routine practice at the BIC is a radiologic-pathologic correlation conference, which is attended by all specialist radiologists, fellows, and residents. At this conference, the pathologic diagnosis for every interventional breast procedure is compared with the radiologic findings to formulate recommendations for additional imaging studies, if appropriate.
Our other fixed-site facility is part of the outpatient radiology department in our institution’s Ambulatory Care Center (ACC). Three of the general diagnostic radiologists interpret mammographic studies at this facility by using a single- rather than multiple-reading protocol, insofar as there are neither residents nor fellows on service at the ACC. The radiologic-pathologic correlation performed by each general diagnostic radiologist (ACC and BIC) is limited to a personal review of the pathologic diagnoses for all cases that are recommended for biopsy by that radiologist, as required by U.S. federal regulations (13).
All BIC diagnostic mammographic studies are interpreted at the BIC, and all ACC diagnostic mammographic studies are interpreted at the ACC. However, whereas all BIC screening studies are interpreted at the BIC, ACC screening studies also are interpreted at the BIC whenever it is practical (in almost 85% of cases) and with no purposeful selection of which ACC screening studies are interpreted at either facility. During this study, all radiologists at both facilities recommended routine screening mammography at an annual interval. Therefore, it is highly likely that there are no substantial differences between the actual frequencies of yearly versus longer interval screening at both facilities, although we cannot confirm this with direct measurement.
Our BIC-based technologists almost always perform mammography at the BIC, and our ACC-based technologists almost always perform mammography at the ACC, with only very occasional cross coverage between the two facilities. However, the levels of experience and expertise of BIC and ACC technologists are essentially identical: The two groups have the same amount of initial training, continuing education, and quality-assurance supervision by the same (BIC) mammography specialist radiologists, and they have similar amounts of continuing experience.
During this study, the mammography equipment at the BIC was very similar in quality to that at the ACC. The imaging protocols used at the two facilities were identical. Furthermore, periodic Mammography Quality Standards Act–mandated testing of BIC and ACC mammography equipment for quality assurance has produced identical results.
Data Collection and Analysis
Prior to image interpretation, under the supervision of a mammography technologist, the patient completes a questionnaire in which she provides data on her age, family history of breast cancer, and the reason(s) for undergoing mammography. These data subsequently are transferred into our computer database. At the time of image interpretation, a radiologist reviews the patient questionnaire and enters the following information into the database: the indication for the examination—that is, screening or diagnostic, and if diagnostic, whether the examination is being performed for evaluation of a palpable mass or another indication; whether previous mammograms are available for comparison; a Breast Imaging Reporting and Data System (BI-RADS) assessment category for each breast; and management recommendations.
Screening mammography findings are considered to be abnormal when either breast is assigned to BI-RADS category 0 (incomplete, needs additional imaging), 4 (suspicious), or 5 (highly suggestive of malignancy). Diagnostic mammography findings are considered to be abnormal when either breast is assigned to BI-RADS category 4 or 5. With fewer than one-fourth of diagnostic mammographic examinations, targeted breast ultrasonography (US) is performed concurrently. For such cases, the data collection procedures of this study were set up so that the presence or absence of US findings did not affect the concurrent mammographic assessment.
Subsequent to image interpretation, we record a benign or malignant diagnosis for all cases in which biopsy is performed. When biopsy reveals malignancy (defined as ductal carcinoma in situ or any invasive carcinoma), we also collect data on the histologic diagnosis, tumor size, and axillary nodal status, from which we determine the stage of the cancer on the basis of the American Joint Committee on Cancer staging system (14).
Because it has been shown that screening and diagnostic mammographic examinations are associated with substantial and sometimes significant differences in rates of abnormal interpretation, biopsy, and cancer detection (8,11), the results of these two types of examinations were analyzed separately. In this study, for both screening and diagnostic mammographic examinations, we calculated abnormal interpretation rates by dividing the number of abnormal interpretations by the number of studies interpreted, biopsy rates by dividing the number of abnormal examinations for which biopsy was performed by the number of studies interpreted, and cancer detection rates by dividing the number of abnormal examinations at which cancer was diagnosed by the number of studies interpreted.
Data tabulations and statistical computations were accomplished by using programming software (S-PLUS; Insightful, Seattle, Wash). The Student t test was performed for comparisons of data with approximately normal distributions, and the 2 test was performed for comparisons of proportional data. A P value of less than .05 was considered to indicate statistical significance.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Abnormal Interpretation Rates
The results of mammographic interpretations are shown in Table 4. For screening mammography, the abnormal interpretation rate (ie, recall rate) for specialist radiologists was 4.9%, which is approximately 30% lower than the rate of 7.1% for general radiologists (P < .001). The opposite was observed for diagnostic mammography in that the abnormal interpretation rate (ie, biopsy recommended rate) for specialist radiologists, 15.8%, was approximately 60% higher than that for general radiologists, 9.9% (P < .001). The group of general radiologists who work at the BIC had higher abnormal interpretation rates, for both screening and diagnostic mammography, than the group of general radiologists who work at the ACC. For screening mammography, these rates were 7.8% for BIC radiologists and 6.0% for ACC radiologists (P = .003). For diagnostic mammography, these rates were 11.8% for BIC radiologists and 8.8% for ACC radiologists (P = .010).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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To put the differences in interpretive performance observed among individual radiologists into proper perspective, it is important to determine the extent to which these differences might be due to underlying differences in the studied patient populations. This is pertinent for screening mammography because advancing patient age is directly proportional to cancer detection rate (15–18) and because comparison with previous mammograms is associated with a decreased abnormal interpretation (ie, recall) rate (18–23). Therefore, our finding that there were only small, nonsignificant differences in age, family history of breast cancer, and previous mammogram availability between studies interpreted by specialist versus general radiologists, and between those interpreted by BIC versus ACC general radiologists, strongly suggests that the several, much more substantial significant differences in performance parameters between these radiologist groups truly represented differences in interpretive performance rather than effects of selection bias due to differences in the patient populations studied by specialist versus general radiologists.
In addition, there was no indication of selection bias with regard to the patients examined at the BIC versus at the ACC or with regard to the quality of mammographic examinations performed at the BIC versus at the ACC, which have similarly skilled technologists and mammography equipment of similar quality. These observations further support our conclusion that the substantial statistically significant differences in performance parameters between specialist and general radiologists, and between BIC and ACC general radiologists, truly represented differences in interpretive performance.
The most striking differences in radiologist performance were observed between our three specialist radiologists and the seven general radiologists, who interpret mammograms less frequently. At analysis of all reported parameters of interpretive performance, each of these differences was statistically significant. For screening mammography, the abnormal interpretation (ie, recall) rate for the specialist radiologists was significantly lower than that for the general radiologists. For diagnostic mammography, however, the abnormal interpretation (ie, biopsy recommended) rate for the specialist radiologists was higher than that for the general radiologists.
The results were uniformly consistent for the remaining performance parameters at both screening and diagnostic mammographic examinations. The biopsy performed, cancer detection, and stage 0–I cancer detection rates all were significantly higher for the specialist radiologists. Thus, the specialist radiologists make more true-positive and fewer false-positive interpretations at screening mammography, and this is clearly a preferable level of performance. At diagnostic mammography, the specialist radiologists make more true-positive and more false-positive interpretations, and we believe these results also represent a preferable level of performance because the principal goal of mammography is cancer detection rather than reduction of benign biopsy results.
Several differences in the experience and expertise of these two groups of radiologists may explain the observed differences in their performances. First, the specialist radiologists have considerably more training and education in mammography. The general radiologists received the basic amount of initial training in mammography during their diagnostic radiology residencies and have received close to the minimum amount of continuing education in mammography that is required by federal regulations. On the other hand, two of the three specialist radiologists have completed 1-year breast imaging fellowships, the other has taught breast imaging fellows for more than 10 years, and all of the specialist radiologists earn at least six times more hours of category 1 continuing education credits in mammography than are required by federal regulations.
Our specialist radiologists also have considerably more continuing experience in mammographic interpretation. As breast imaging specialists, they read at least 5,000 studies per year, which is 10 times greater than the basic caseload that is required by federal regulations and handled by most of our general radiologists. However, to the extent that increased experience correlates with improved performance, the important factor appears to be caseload per year rather than number of years of experience, because, on average, the general radiologists have been in practice many more years than the specialist radiologists: 19.6 versus 13.3 years.
For both screening and diagnostic mammographic examinations, the BIC general radiologists have somewhat higher abnormal interpretation, biopsy performed, cancer detection, and stage 0–I cancer detection rates than the ACC general radiologists. Therefore, the BIC radiologists make more positive interpretations, with increases in both true-positive and false-positive cases. As stated previously, such results are considered a preferable level of performance.
We cannot explain these observed differences in performance among the general radiologists on the basis of either experience or expertise, because there are no substantial differences in the amounts of initial or continuing education in mammography received by our ACC versus BIC general radiologists, nor are there substantial differences in the years of practice experience or mammography caseload per year between the two groups. The only difference between these groups of radiologists involves the environment within which they interpret mammograms. ACC radiologists single read mammographic studies because neither residents nor breast imaging fellows have clinical service rotations at the ACC. On the other hand, BIC radiologists perform interpretations by using a multiple-reading system: At least two residents and one breast imaging fellow preview both screening and diagnostic mammographic studies and then present their findings to the staff radiologist. The actual interpretation is then made by the staff radiologist, who must decide whether to accept or reject the assessments proposed by the residents and fellows. This multiple-reading system is much more similar to the second-look type of double reading that is performed by computer-assisted detection software programs than it is to the independent or consensus double reading that is performed by two human observers, because computer-assisted detection second reading also involves a single interpreting radiologist who must decide, in addition to acting on his or her own personal assessments, whether or not to act on the prompts presented by the computer-assisted detection system.
We conclude that the observed differences in performance between BIC and ACC general radiologists in our practice are a result of multiple- versus single-reading interpretation, not only because there are no differences in experience or expertise between these groups of radiologists, but also because prospective computer-assisted detection second reading has been shown to produce similar improvements in performance (ie, an increase in both true-positive and false-positive interpretations) (24).
Finally, further assessment of the outcomes of the described diagnostic mammography cases at subset analysis based on the indications for the examinations revealed that the preferable performances of the specialist (vs general) radiologists and BIC (vs ACC) general radiologists were limited to their performances at examinations performed for indications other than the evaluation of a palpable mass. Because all groups and subgroups of radiologists had equivalent performance in the palpable mass cases, we conclude that for all of the radiologists in our practice, presence of a palpable mass, rather than radiologist experience and expertise, is the principal factor that governs the decision of whether or not to recommend biopsy.
In summary, our study results indicate that at both screening mammography and diagnostic mammography in our practice, specialist radiologists have a significantly more preferable interpretive performance compared with general radiologists, and we suspect that this difference is related to the increased amounts of initial training and continuing education in mammography and the increased continuing experience in mammographic interpretation (regarding caseload per year, not number of years in practice) of the specialist radiologists. In addition, among our general radiologists, we observed a smaller magnitude of but occasionally also significantly more preferable performance by those general radiologists who use the multiple- rather than single-reading system of interpretation.
We believe that the major strengths of our findings are the large number of screening and diagnostic mammograms studied, the statistically significant differences observed, and the fact that each analyzed subgroup consisted of several radiologists (although an even larger number of radiologists in each subgroup would facilitate a more accurate determination of the range of performance among all practicing radiologists). The major limitation of our study is that we reported no data on the performance of general radiologists who have an intermediate level of education and experience—that is, between that of our specialist and general radiologist groups. Throughout the United States and in other countries, there are many general radiologists who have a special interest in mammography and who have acquired much more than the required levels of education and experience in mammography. It will be important to determine the levels of mammographic performance for this subgroup of radiologists.
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FOOTNOTES |
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Abbreviations: BIC = Breast Imaging Center, BI-RADS = Breast Imaging Reporting and Data System, ACC = Ambulatory Care Center
Author contributions: Guarantor of integrity of entire study, E.A.S.; study concepts, E.A.S., D.E.W.; study design, E.A.S.; literature research, E.A.S.; clinical studies, E.A.S., D.E.W., K.E.D.; data acquisition and analysis/interpretation, E.A.S., D.E.W., K.E.D.; statistical analysis, E.A.S., D.E.W., K.E.D.; manuscript preparation, E.A.S.; manuscript definition of intellectual content, editing, revision/review, and final version approval, E.A.S., D.E.W., K.E.D.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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