Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Variability in Mammography Quality Assessment After Implementation of Enhancing Quality Using the Inspection Program (EQUIP)

OBJECTIVE

Analyze mammography quality and deficiencies, including variability in quality assessment among subspecialized breast radiologists, after implementing the Enhancing Quality Using the Inspection Program (EQUIP).

METHODS

After IRB approval, this single institution study retrospectively queried data prospectively entered into our automated reporting software after implementing EQUIP (October 2017-March 2019). Screening and diagnostic combination (digital mammography with tomosynthesis) mammograms were reviewed by seven breast radiologists. Quality was assessed as excellent, good, adequate, or problems found. Of those with problems found, the deficiency and corrective action were evaluated. The interpreting radiologist, EQUIP radiologist, and performing technologist were recorded. P values were calculated using Fisher exact test and chi-square analyses.

RESULTS

Of 17 312 mammograms, 529 (3%) underwent EQUIP review. Of 43 (8%) with problems found, 23 (53%) did not include sufficient tissue, 9 (21%) had motion degradation, 3 (7%) had artifacts, 2 each (4.7% each) had the nipple not in profile or skin folds, and 4 (9%) were categorized as "other." Nine (9/529, 1.7%) required recall for repeat imaging. The lead interpreting physician (LIP) was more likely to categorize mammograms as technically inadequate compared to other radiologists (P < 0.00001), and there were also statistically significant differences in how the remaining radiologists stratified cases (P < 0.00001) even when excluding the LIP.

CONCLUSION

Insufficient tissue was the most common problem identified in the EQUIP-reviewed mammograms with deficiencies. Significant variability was present among radiologist EQUIP designations. Ongoing review of clinical image quality with EQUIP allows for opportunities to provide corrective feedback.

Effect of the EQUIP initiative on additional images performed at screening mammography: a pilot study

PURPOSE

The Enhancing Quality Using the Inspection Program (EQUIP) initiative was launched to improve clinical image quality. The purpose of this study was to determine if the implementation of the EQUIP reporting system resulted in an increased number of extra views performed at the technologists' discretion during screening mammography.

MATERIALS AND METHODS

Following IRB approval at a single comprehensive cancer center, patients who underwent screening mammography with combination full-field digital mammography plus digital breast tomosynthesis during a 6-month period before (January 2017 to June 2017) and after (January 2018 to June 2018) EQUIP implementation were identified. For each patient, both screening mammograms were retrospectively reviewed by 1 of 3 subspecialized breast radiologists (3-10 years of experience). The following data were recorded: demographics, breast density, surgical history, technologist, number and type of extra views, final BI-RADS assessment, radiologist-assigned indication for the view, and radiologist-assigned necessity of the view. McNemar's test for paired data was computed with p value of <0.05 considered statistically significant.

RESULTS

Of 820 patients, 370 (45%) had additional views in 2018 compared to 317 (39%) in 2017. After EQUIP, patients were 38% more likely to have additional views (OR = 1.38, 95% CI = 1.11-1.73). The total number of additional views in 2018 was 636 compared to 530 in 2017 (20% increase). Among patients with extra views in both years, the number of additional views per patient did not significantly increase post EQUIP implementation (OR = 1.18, 95% CI = 0.73-1.92). The most common extra view was exaggerated craniocaudal lateral, and the most common reason cited by the reviewing radiologist was lateral fibroglandular tissue at the edge of the images. Most of the extra views performed in 2018 were not performed in 2017 and over half were deemed unnecessary. Eight of eleven technologists demonstrated an increased frequency of screening mammograms with extra views performed post EQUIP.

CONCLUSION

Following EQUIP implementation, screening mammography patients were significantly more likely to have extra views performed at the technologists' discretion. Our findings emphasize the importance of ongoing technologist education and radiologist feedback.

Understanding the Mammography Audit

Screening mammography aims to identify small, node-negative breast cancers when they are still curable while maintaining an acceptable range of false-positive recalls and biopsies. The mammography audit is a powerful tool to help radiologists understand their performance with respect to that goal. This article defines audit terms and describes how to use collected and derived data to perform a mammography audit. Accepted benchmarks are discussed as well as their applicability to radiologists and breast imaging practices in the United States. Special considerations regarding volumes and radiologist characteristics are explored, because these factors may affect audit results.

Screening Mammography and Digital Breast Tomosynthesis: Controversies

Breast cancer screening with mammography reduces breast cancer mortality; however, diverging recommendations regarding screening have caused controversy. The emerging technology of digital breast tomosynthesis (DBT) may soon become the mainstay of breast cancer screening. We present recommendations for breast cancer screening based on guidelines. A PubMed literature review was performed and the results from five large clinical studies comparing the efficacy of digital mammography alone versus digital mammography with DBT are examined. We emphasize the importance of annual screening to reduce breast cancer mortality. Our review of the literature demonstrates that DBT increases cancer detection rates and reduces callbacks. Additional research is needed to determine whether the increased cancer detection rates are associated with a decrease in mortality.

A case of intraventricular primary central nervous system lymphoma

We report a case of primary central nervous system lymphoma presenting as multiple intraventricular masses in an immunocompetent 68 year old man with severe headache and unsteady gait. The diagnosis was obtained by analysis of the cerebrospinal fluid and subsequent surgical biopsy. This is an unusual appearance for primary central nervous lymphoma, with the majority of the cases presenting as solitary masses.