Rationale and Objectives
To determine whether the mammographic technologist has an effect on the radiologists’ interpretative performance of screening mammography in community practice.
Materials and Methods
In this institutional review board–approved retrospective cohort study, we included Carolina Mammography Registry data from 372 radiologists and 356 mammographic technologists from 1994 to 2009 who performed 1,003,276 screening mammograms. Measures of interpretative performance (recall rate, sensitivity, specificity, positive predictive value [PPV 1 ], and cancer detection rate [CDR]) were ascertained prospectively with cancer outcomes collected from the state cancer registry and pathology reports. To determine if the mammographic technologist influenced the radiologists’ performance, we used mixed effects logistic regression models, including a radiologist-specific random effect and taking into account the clustering of examinations across women, separately for screen-film mammography (SFM) and full-field digital mammography (FFDM).
Results
Of the 356 mammographic technologists included, 343 performed 889,347 SFM examinations, 51 performed 113,929 FFDM examinations, and 38 performed both SFM and FFDM examinations. A total of 4328 cancers were reported for SFM and 564 cancers for FFDM. The technologists had a statistically significant effect on the radiologists’ recall rate, sensitivity, specificity, and CDR for both SFM and FFDM ( P values <.01). For PPV 1 , variability by technologist was observed for SFM ( P value <.0001) but not for FFDM ( P value = .088).
Conclusions
The interpretative performance of radiologists in screening mammography varies substantially by the technologist performing the examination. Additional studies should aim to identify technologist characteristics that may explain this variation.
Breast cancer is the most common cancer in women, excluding cancers of the skin and is expected to account for an estimated 232,670 cases and 40,000 deaths in the United States in 2014 . Routine screening mammography is the primary means of early breast cancer detection with radiologic technologists fulfilling an essential role in the mammography process. Although routine screening mammography has been shown to be effective in reducing breast cancer mortality , many factors lead to variability in interpretative performance by radiologists .
Several studies have found radiologists’ gender, work patterns, postresidency training, years of experience, specialization, and screening versus diagnostic mix influence mammography performance measures . It is also likely that the radiologists’ ability to interpret mammograms is affected by technologists who work with the radiologists. Possible sources of variation in radiologists’ interpretative ability may include the interface between the radiologist and technologist and the ability of the radiologic technologist to obtain a high-quality image in terms of positioning, compression, and sharpness.
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Materials and methods
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Study Population
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Definitions
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Statistical Analysis
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Results
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Table 1
Patient Characteristics for 1,003,276 Screening Mammograms by Modality
Patient Characteristic SFM Examinations ( n = 889,347) FFDM Examinations ( n = 113,929) No Cancer ( n = 885,019) Cancer ( n = 4328) No Cancer ( n = 113,365) Cancer ( n = 564) N (%) N (%) N (%) N (%) Age (years) 18-39 44,850 (5.1) 106 (2.5) 4023 (3.6) 6 (1.1) 40-49 240,640 (27.2) 700 (16.2) 26,443 (23.3) 78 (13.8) 50-59 249,940 (28.2) 1174 (27.1) 31,125 (27.5) 120 (21.3) 60-69 185,846 (21.0) 1140 (26.3) 27,513 (24.3) 167 (29.6) 70-79 125,030 (14.1) 892 (20.6) 18,094 (16.0) 134 (23.8) ≥80 38,713 (4.4) 316 (7.3) 6167 (5.4) 59 (10.5) Race Black 143,750 (16.2) 712 (16.5) 20,155 (17.8) 96 (17.0) White 651,721 (73.6) 3193 (73.8) 84,409 (74.5) 433 (76.8) Other 12,273 (1.4) 55 (1.3) 1507 (1.3) 5 (0.9) Missing 77,275 (8.7) 368 (8.5) 7294 (6.4) 30 (5.3) Breast density Almost entirely fat 48,057 (5.4) 119 (2.8) 6894 (6.1) 24 (4.3) Scattered fibroglandular densities 395,301 (44.7) 1840 (42.5) 44,387 (39.2) 197 (34.9) Heterogenously dense 346,786 (39.2) 1862 (43.0) 46,272 (40.8) 290 (51.4) Extremely dense 67,949 (7.7) 321 (7.4) 5681 (5.0) 26 (4.6) Missing 26,926 (3.0) 186 (4.3) 10,131 (8.9) 27 (4.8) Family history of breast cancer Yes 70,766 (8.0) 467 (10.8) 12,538 (11.1) 81 (14.4) No/missing 814,253 (92.0) 3861 (89.2) 100,827 (88.9) 483 (85.6) History of breast procedure Yes 187,652 (21.2) 1285 (29.7) 27,705 (24.4) 192 (34.0) No/missing 697,367 (78.8) 3043 (70.3) 85,660 (75.6) 372 (66.0) Time since prior mammogram No prior 88,270 (10.0) 549 (12.7) 6856 (6.1) 48 (8.5) <1 year 11,110 (1.3) 66 (1.5) 437 (0.4) 2 (0.4) 1 to <3 years 649,189 (73.4) 2906 (67.1) 81,772 (72.1) 374 (66.3) ≥3 years 79,892 (9.0) 546 (12.6) 8437 (7.4) 79 (14.1) Missing 56,558 (6.4) 261 (6.0) 15,863 (14.0) 61 (10.8) Year of examination 1994 4843 (0.6) 19 (0.4) 0 0 1995 14,616 (1.7) 56 (1.3) 0 0 1996 31,192 (3.5) 167 (3.9) 0 0 1997 45,199 (5.1) 231 (5.3) 0 0 1998 67,056 (7.6) 311 (7.2) 0 0 1999 76,359 (8.6) 389 (9.0) 0 0 2000 84,707 (9.6) 405 (9.4) 0 0 2001 91,532 (10.3) 447 (10.3) 0 0 2002 97,266 (11.0) 474 (11.0) 0 0 2003 83,159 (9.4) 431 (10.0) 5631 (5.0) 28 (5.0) 2004 68,809 (7.8) 320 (7.4) 5877 (5.2) 24 (4.3) 2005 67,451 (7.6) 298 (6.9) 5800 (5.1) 32 (5.7) 2006 59,576 (6.7) 310 (7.2) 7602 (6.7) 44 (7.8) 2007 45,424 (5.1) 224 (5.2) 19,986 (17.6) 107 (19.0) 2008 35,339 (4.0) 171 (4.0) 31,099 (27.4) 150 (26.6) 2009 12, 471 (1.4) 75 (1.7) 37,370 (33.0) 179 (31.7)
FFDM, full-field digital mammography; SFM, screen-film mammography.
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Table 2
Mean (95% Confidence Intervals) and Median (25th–75th Percentile) Interpretative Performance Measures for Screen-Film Mammography and Full-Field Digital Mammography
SFM Examinations FFDM Examinations Mean (95%CI) Median (25th–75th Percentile) Mean (95%CI) Median (25th–75th Percentile) Recall rate (per 100 examinations) 8.1 (7.7–8.6) 7.6 (5.1–10.7) 10.5 (9.6–11.5) 9.9 (8.2–13.1) Sensitivity 78.7 (76.3–81.2) 81.8 (68.8–100) 79.3 (70.0–88.7) 90.9 (80.0–100) Specificity 92.2 (91.8–92.7) 92.7 (89.8–95.2) 89.8 (88.9–90.8) 90.4 (87.5–92.0) Positive predictive value 5.6 (5.1–6.1) 4.6 (2.9–7.4) 4.0 (2.9–5.1) 3.8 (1.9–5.3) Cancer detection rate (per 1000 examinations) 3.8 (3.6–4.1) 3.7 (2.3–4.9) 4.0 (3.1–5.1) 3.6 (1.2–5.8)
CI, confidence interval; FFDM, full-field digital mammography; SFM, screen-film mammography.
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Table 3
Resulting P Values From Mixed-Effects Logistic Regression Models Assessing Variability of Performance Measures by Technologist
Performance Measure SFM Examinations ( n = 889,347) FFDM Examinations ( n = 113,929) Recall Rate <.0001 .001 Sensitivity <.0001 .019 Specificity <.0001 .003 Positive predictive value <.0001 .088 Cancer detection rate <.0001 .0001
FFDM, full-field digital mammography; SFM, screen-film mammography.
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Discussion
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Study Limitations
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Conclusions
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Acknowledgments
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