Downloaded from www.ajronline.org by 109.161.215.63 on 11/20/15 from IP address 109.161.215.63. Copyright ARRS. For personal use only; all rights reserved
55
Commentary .:;H..
H
Low-Cost Mass Screening Mammography Edward
for Breast
with
A. Sickles1
The articles in this issue of the journal by Warren Burhenne et al. [1 ] and Vogel et al. [2] describe large-scale efforts to bring low-cost mammography screening to substantial numbers of women over wide geographic areas. Each of these projects
Cancer
succeeded
admirably
in achieving
its goals.
Readers
interested in initiating or participating in such mass screening activities can learn a great deal from these articles about the complexity of planning that is required to ensure smooth operation. However, there is much more to be learned by contrasting the articles. By examining various differences in design between the two projects (expertise of participating screeners, extent of quality assurance procedures, completeness of data collection methods), one can appreciate how such factors govern the scope, the character, and ultimately the results of a screening program.
The Texas
Breast Screening
Project
teria for mammography facilities, principally limited to the successful completion of a detailed questionnaire. Fewer than S% of facilities were required to submit sample mammograms as an indicator of satisfactory breast positioning and image quality, almost 1 0% of facilities were allowed to participate simply by submitting a written claim that they were able to produce two-view mammography examinations at a dose of less than 1 rad, and for all facilities the radiologists’ and technologists’ required expertise was defined only as having “specific training in the production and interpretation of mammograms.” Furthermore, mammography facilities participating in the TBSP were not required to perform any ongoing quality assurance procedures, and the reporting of results was restricted to a superficial review of clinical outcomes, one much less stringent than recommended for the medical audit of an individual mammography screening practice [3, 4]. The decision to limit the scope of these activities surely was made in part because of the very large number of participating facilities in the
The designers of the Texas Breast Screening Project (TBSP) made the administrative decision to involve as many existing mammography facilities as could be encouraged to participate, at least in part because of their goal of attracting the largest possible number of asymptomatic women to a single screening examination. As a result, TBSP organizers developed well-intentioned but relatively lenient eligibility cri-
This article is a commentary 1 Department of Radiology,
on the preceding articles by Warren Burhenne et at. and Vogel et al. Box 0628, University of Califomia, San Francisco, School of Medicine,
E. A. Sickles. AJR 158:55-57,
January
TBSP;
1992 0361 -803x/92/1
581-0055
© American
Roentgen
more
centralized
control
over
mammography
facilities would have required employment of a larger administrative staff than was deemed practical. Another probable factor prompting this choice was the desire to recruit as many mammography facilities as possible, coupled with the perception that some, perhaps many, facilities would decline to participate if quality control or reporting requirements were difficult to satisfy.
Ray Society
San Francisco,
CA 941 43-0628.
Address
reprint
requests
to
56
SICKLES
Downloaded from www.ajronline.org by 109.161.215.63 on 11/20/15 from IP address 109.161.215.63. Copyright ARRS. For personal use only; all rights reserved
The British
Columbia
Mammography
Screening
Program
Whereas the TBSP was organized to maximize recruitment for one-time screening, the British Columbia Mammography Screening Program (BCMSP) was set up to produce and convincingly demonstrate optimal clinical results for a lowcost high-volume operation, so that provincewide expansion of screening services would be funded. In my opinion, this outcome-oriented goal contributed to the attainment of clinical results that were superior to those achieved in Texas. The overall cancer detection rate in the BCMSP was greater than that in the TBSP (more true-positive interpretations), and this improved performance was accomplished despite a lower rate of abnormal screening interpretations (fewer false-positive interpretations). Even more important, the cancers detected in the BCMSP had very highly favorable prognoses, similar to those reported in other successful screening programs [3-7]. More than one fourth of screening-detected cancers were ductal carcinoma in situ, 60% of cancers were 1 0 mm in size or smaller, only 1 2% were associated with axillary lymph node metastasis, 85% were classified as either stage 0 or stage 1 and 36% satisfied the Martin-Gallager criteria for minimal breast cancer [8]. Parallel data from the ,
TBSP,
as yet unpublished,
indicate
commendable
clinical
results. However, the tumor size, nodal status, and staging data for TBSP cancers are not as favorable as those detected in British Columbia (Vogel VG, personal communication). Basic to the success of the BCMSP were the twin administrative decisions to begin screening at a single site and to establish rigorous centralized control over all screening operations. Also of considerable significance, interpretation of screening examinations was restricted to a small team of skilled radiologists; only five were chosen from almost 30 applicants, a selection based at least in part on training and experience in screening (not diagnostic) mammography. In an effort to maximize ongoing interpretive excellence, each radiologist’s rates of abnormal interpretation and cancer detection were assessed regularly. Furthermore, the performance standards established by these expert screeners are to be required of radiologists recruited to serve at future satellite screening sites. Because the BCMSP was started in a single location, it was relatively easy to develop and monitor effective record-keeping, quality assurance, follow-up, and other administrative activities. However, even more important to the full provincewide program is the plan for a central office to maintain responsibility for and complete control over these activities for all future screening sites. This should ensure consistency in operation and excellence in performance, at the same time achieving economies of scale. Although the BCMSP article describes very few quality assurance procedures, readers should not assume that others have been neglected. Quite the contrary, the BCMSP has an ongoing quality assurance program that equals those of most expert mammography practices in the United States. Indeed, on the basis of personal experience, I can attest to the routine production of high-quality mammographic images and careful review of their interpretation. Some readers may be confused by these statements in view of recent publicity concerning poor mammographic im-
age quality and interpretation
in the Canadian
National
Breast
AJR:158, January
1992
Screening Study (NBSS) [9-12]. BCMSP images are of excellent quality and clinical results are outstanding at least in part because (1) the British Columbia project started much more recently than the Canada-wide NBSS, after conventional screen-film mammographic imaging techniques had improved greatly [1 3], and (2) BCMSP designers learned many important lessons from the deficiencies of the NBSS [14].
Conclusions There are important clinical implications for the administrative choices made in establishing mammography massscreening programs. Recruitment-oriented goals of programs like the TBSP take precedence in a clinical environment where one aims to introduce mammography screening to as many nonparticipating women as possible. However, in maximizing the accessibility of the procedure by recruiting very large numbers of existing mammography facilities, there may be loss of some control over the quality of mammography at individual facilities, as well as the ability to collect and thereby use (by feedback to screeners) the full spectrum of pertinent data on the clinical results of screening. The outcome-oriented goals of programs such as the BCMSP are of greatest importance when one aims to guarantee that high-level performance standards will be met and maintained. Such programs require rigorous centralized control over screening activities, considerably more administrative effort, and to some degree a restriction in the number of screeners in order to achieve clinical excellence. Although there clearly was need for recruitment-oriented programs in 1 987 when the TBSP took place, the mammography climate in the United States has matured considerably in the ensuing 5 years. Currently there is much more emphasis on quality assurance activities [1 5], and appropriately so. We now understand that increased use of mammography screening is beneficial only if very high standards of practice are achieved [9, 1 2]. The future lies with outcome-oriented mass screening, such as that reported by the BCMSP. The current outcome-driven environment produces similar clinical implications for individual mammography practices. Interpretation of mammography examinations by a select few expert screeners is preferable to interpretation by numerous general radiologists. Routine performance of a comprehensive array of quality assurance procedures is necessary to monitor the technical aspects of an imaging operation. And collection and analysis of outcome data are crucial to the demonstration of, and important in the maintenance of, ultimate clinical success. The following statement, which some have applied to mass screening programs [9, 1 2], should have equal validity for individual radiology practices: mammography screening should be done very well indeed, or perhaps it should not be done at all.
REFERENCES 1 . Warren Burhenne U, Hislop TG, Burhenne HJ. The British Columbia Mammography Screening Program: evaluation of the first 1 5 months. AJR 1992:158:45-49 2. Vogel VG, Peters GN, Evans WP, et at. Design and conduct of a low-cost
AJA:158,
January
mammography
3.
Downloaded from www.ajronline.org by 109.161.215.63 on 11/20/15 from IP address 109.161.215.63. Copyright ARRS. For personal use only; all rights reserved
4, 5.
6.
7.
8.
LOW-COST
1992
screening
project:
experience
of the
MASS
American
MAMMOGRAPHY
Cancer
Society, Texas Division. AJR 1992;1 58:51 -54 Sickles EA, Ominsky SH, Sollitto RA, Galvin HB, Monticciolo DL. Medical audit of a rapid-throughput mammography screening practice: methodology and results of 27,1 14 examinations. Radiology 1990;175:323-327 Sickles EA. Quality assurance: how to audit your own mammography practice. Radiol Clin North Am 1992 (in press) Fagerberg G, Baldetorp L, GrOntoft 0, LundstrOm B, M#{227}nson JC, NordenskjOld B. Effects of repeated mammographic screening on breast cancer stage distribution. Acta Radiol 1985;24:465-473 Tab#{227}r L, Duffy SW, Krusemo UB. Detection method, tumour size and node metastases in breast cancers diagnosed during a trial of breast cancer screening. Eur J Cancer Clin Oncol 1987;23:959-962 Tab#{227}r L, Fagerberg G, Duffy SW, Day NE, Gad A, GrOntoft 0. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am 1992 (in press) Martin JE, Gallager HS. Mammographic diagnosis of minimal breast cancer. Cancer 1971:28: 1519-1 526
American Residents’
9. 1 0.
11. 1 2. 1 3.
1 4. 15.
Kopans
SCREENING
DB.
The
Canadian
57
screening
program:
a different
perspective
(commentary). AJR 1990;1 55:748-749 Baines CJ, McFarlane DV, Miller AB. The role of the reference radiologist: estimates of inter-observer agreement and potential delay in cancer detection in the National Breast Screening Study. Invest Radiol 1990:25: 971 -976 Editorial. Breast cancer screening in women under 50. Lancet 1991;337: 1575-1576 Day NE, Dully SW. Breast cancer screening in women under 50 (letter). Lancet 1991;338: 113-114 Baines CJ, Miller AB, Kopans DB, et al. Canadian National Breast Screening Study: assessment of technical quality by extemal review. AJR 1990:155:743-747 Miller AB, Baines CJ, Sickles EA. Canadian National Breast Screening Study (letter). AJR 1990:155:1133-1134 McLelland A, Hendrick RE, Zinninger MD, Wilcox PA. The American College of Radiology Mammography Accreditation Program. AJR 1991:157:473-479
Roentgen Ray Society Award Papers, 1992
The ARRS announces competition for the 1 992 President’s Award papers concerning the clinical application of the radiologic sciences.
and two
Executive
Council
Awards
for the best
Awards The winner of the President’s Award will receive a certificate and a $2000 prize. The winners of the two Executive Council Awards will each be given a certificate and a prize of $1 000. The winners will be announced on March 1 6, 1992. Winning papers will be presented at the ARRS annual meeting at Marriott’s Orlando World Center, Orlando, FL, May 1 0-1 5, 1 992. Winning papers will be submitted for early publication in the American Journal of Roentgenology. All other papers will be returned to the authors.
Regulations Eligibility is limited to residents or fellows in radiology who have not yet completed 4 years of approved training in a radiologic discipline. A letter from the resident’s department chairman attesting to this status must accompany the manuscript. The resident must be the sole or senior author and be responsible for all or most of the project. Submitted manuscripts must not exceed 5000 words and have no more than 1 0 illustrations. Four copies of the manuscript and illustrations are required. Submitted manuscripts should not contain previously presented or published material and should not be under consideration for publication elsewhere. Deadline for submissions is February 1 4, 1992. Send papers to Nancy 0. Whitley, M.D. Chairman, Committee on Education & Research American Roentgen Ray Society Department of Radiology University of Maryland Medical Systems Hospital 22 5. Greene St. Baltimore, MD 21201
55
Commentary .:;H..
H
Low-Cost Mass Screening Mammography Edward
for Breast
with
A. Sickles1
The articles in this issue of the journal by Warren Burhenne et al. [1 ] and Vogel et al. [2] describe large-scale efforts to bring low-cost mammography screening to substantial numbers of women over wide geographic areas. Each of these projects
Cancer
succeeded
admirably
in achieving
its goals.
Readers
interested in initiating or participating in such mass screening activities can learn a great deal from these articles about the complexity of planning that is required to ensure smooth operation. However, there is much more to be learned by contrasting the articles. By examining various differences in design between the two projects (expertise of participating screeners, extent of quality assurance procedures, completeness of data collection methods), one can appreciate how such factors govern the scope, the character, and ultimately the results of a screening program.
The Texas
Breast Screening
Project
teria for mammography facilities, principally limited to the successful completion of a detailed questionnaire. Fewer than S% of facilities were required to submit sample mammograms as an indicator of satisfactory breast positioning and image quality, almost 1 0% of facilities were allowed to participate simply by submitting a written claim that they were able to produce two-view mammography examinations at a dose of less than 1 rad, and for all facilities the radiologists’ and technologists’ required expertise was defined only as having “specific training in the production and interpretation of mammograms.” Furthermore, mammography facilities participating in the TBSP were not required to perform any ongoing quality assurance procedures, and the reporting of results was restricted to a superficial review of clinical outcomes, one much less stringent than recommended for the medical audit of an individual mammography screening practice [3, 4]. The decision to limit the scope of these activities surely was made in part because of the very large number of participating facilities in the
The designers of the Texas Breast Screening Project (TBSP) made the administrative decision to involve as many existing mammography facilities as could be encouraged to participate, at least in part because of their goal of attracting the largest possible number of asymptomatic women to a single screening examination. As a result, TBSP organizers developed well-intentioned but relatively lenient eligibility cri-
This article is a commentary 1 Department of Radiology,
on the preceding articles by Warren Burhenne et at. and Vogel et al. Box 0628, University of Califomia, San Francisco, School of Medicine,
E. A. Sickles. AJR 158:55-57,
January
TBSP;
1992 0361 -803x/92/1
581-0055
© American
Roentgen
more
centralized
control
over
mammography
facilities would have required employment of a larger administrative staff than was deemed practical. Another probable factor prompting this choice was the desire to recruit as many mammography facilities as possible, coupled with the perception that some, perhaps many, facilities would decline to participate if quality control or reporting requirements were difficult to satisfy.
Ray Society
San Francisco,
CA 941 43-0628.
Address
reprint
requests
to
56
SICKLES
Downloaded from www.ajronline.org by 109.161.215.63 on 11/20/15 from IP address 109.161.215.63. Copyright ARRS. For personal use only; all rights reserved
The British
Columbia
Mammography
Screening
Program
Whereas the TBSP was organized to maximize recruitment for one-time screening, the British Columbia Mammography Screening Program (BCMSP) was set up to produce and convincingly demonstrate optimal clinical results for a lowcost high-volume operation, so that provincewide expansion of screening services would be funded. In my opinion, this outcome-oriented goal contributed to the attainment of clinical results that were superior to those achieved in Texas. The overall cancer detection rate in the BCMSP was greater than that in the TBSP (more true-positive interpretations), and this improved performance was accomplished despite a lower rate of abnormal screening interpretations (fewer false-positive interpretations). Even more important, the cancers detected in the BCMSP had very highly favorable prognoses, similar to those reported in other successful screening programs [3-7]. More than one fourth of screening-detected cancers were ductal carcinoma in situ, 60% of cancers were 1 0 mm in size or smaller, only 1 2% were associated with axillary lymph node metastasis, 85% were classified as either stage 0 or stage 1 and 36% satisfied the Martin-Gallager criteria for minimal breast cancer [8]. Parallel data from the ,
TBSP,
as yet unpublished,
indicate
commendable
clinical
results. However, the tumor size, nodal status, and staging data for TBSP cancers are not as favorable as those detected in British Columbia (Vogel VG, personal communication). Basic to the success of the BCMSP were the twin administrative decisions to begin screening at a single site and to establish rigorous centralized control over all screening operations. Also of considerable significance, interpretation of screening examinations was restricted to a small team of skilled radiologists; only five were chosen from almost 30 applicants, a selection based at least in part on training and experience in screening (not diagnostic) mammography. In an effort to maximize ongoing interpretive excellence, each radiologist’s rates of abnormal interpretation and cancer detection were assessed regularly. Furthermore, the performance standards established by these expert screeners are to be required of radiologists recruited to serve at future satellite screening sites. Because the BCMSP was started in a single location, it was relatively easy to develop and monitor effective record-keeping, quality assurance, follow-up, and other administrative activities. However, even more important to the full provincewide program is the plan for a central office to maintain responsibility for and complete control over these activities for all future screening sites. This should ensure consistency in operation and excellence in performance, at the same time achieving economies of scale. Although the BCMSP article describes very few quality assurance procedures, readers should not assume that others have been neglected. Quite the contrary, the BCMSP has an ongoing quality assurance program that equals those of most expert mammography practices in the United States. Indeed, on the basis of personal experience, I can attest to the routine production of high-quality mammographic images and careful review of their interpretation. Some readers may be confused by these statements in view of recent publicity concerning poor mammographic im-
age quality and interpretation
in the Canadian
National
Breast
AJR:158, January
1992
Screening Study (NBSS) [9-12]. BCMSP images are of excellent quality and clinical results are outstanding at least in part because (1) the British Columbia project started much more recently than the Canada-wide NBSS, after conventional screen-film mammographic imaging techniques had improved greatly [1 3], and (2) BCMSP designers learned many important lessons from the deficiencies of the NBSS [14].
Conclusions There are important clinical implications for the administrative choices made in establishing mammography massscreening programs. Recruitment-oriented goals of programs like the TBSP take precedence in a clinical environment where one aims to introduce mammography screening to as many nonparticipating women as possible. However, in maximizing the accessibility of the procedure by recruiting very large numbers of existing mammography facilities, there may be loss of some control over the quality of mammography at individual facilities, as well as the ability to collect and thereby use (by feedback to screeners) the full spectrum of pertinent data on the clinical results of screening. The outcome-oriented goals of programs such as the BCMSP are of greatest importance when one aims to guarantee that high-level performance standards will be met and maintained. Such programs require rigorous centralized control over screening activities, considerably more administrative effort, and to some degree a restriction in the number of screeners in order to achieve clinical excellence. Although there clearly was need for recruitment-oriented programs in 1 987 when the TBSP took place, the mammography climate in the United States has matured considerably in the ensuing 5 years. Currently there is much more emphasis on quality assurance activities [1 5], and appropriately so. We now understand that increased use of mammography screening is beneficial only if very high standards of practice are achieved [9, 1 2]. The future lies with outcome-oriented mass screening, such as that reported by the BCMSP. The current outcome-driven environment produces similar clinical implications for individual mammography practices. Interpretation of mammography examinations by a select few expert screeners is preferable to interpretation by numerous general radiologists. Routine performance of a comprehensive array of quality assurance procedures is necessary to monitor the technical aspects of an imaging operation. And collection and analysis of outcome data are crucial to the demonstration of, and important in the maintenance of, ultimate clinical success. The following statement, which some have applied to mass screening programs [9, 1 2], should have equal validity for individual radiology practices: mammography screening should be done very well indeed, or perhaps it should not be done at all.
REFERENCES 1 . Warren Burhenne U, Hislop TG, Burhenne HJ. The British Columbia Mammography Screening Program: evaluation of the first 1 5 months. AJR 1992:158:45-49 2. Vogel VG, Peters GN, Evans WP, et at. Design and conduct of a low-cost
AJA:158,
January
mammography
3.
Downloaded from www.ajronline.org by 109.161.215.63 on 11/20/15 from IP address 109.161.215.63. Copyright ARRS. For personal use only; all rights reserved
4, 5.
6.
7.
8.
LOW-COST
1992
screening
project:
experience
of the
MASS
American
MAMMOGRAPHY
Cancer
Society, Texas Division. AJR 1992;1 58:51 -54 Sickles EA, Ominsky SH, Sollitto RA, Galvin HB, Monticciolo DL. Medical audit of a rapid-throughput mammography screening practice: methodology and results of 27,1 14 examinations. Radiology 1990;175:323-327 Sickles EA. Quality assurance: how to audit your own mammography practice. Radiol Clin North Am 1992 (in press) Fagerberg G, Baldetorp L, GrOntoft 0, LundstrOm B, M#{227}nson JC, NordenskjOld B. Effects of repeated mammographic screening on breast cancer stage distribution. Acta Radiol 1985;24:465-473 Tab#{227}r L, Duffy SW, Krusemo UB. Detection method, tumour size and node metastases in breast cancers diagnosed during a trial of breast cancer screening. Eur J Cancer Clin Oncol 1987;23:959-962 Tab#{227}r L, Fagerberg G, Duffy SW, Day NE, Gad A, GrOntoft 0. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am 1992 (in press) Martin JE, Gallager HS. Mammographic diagnosis of minimal breast cancer. Cancer 1971:28: 1519-1 526
American Residents’
9. 1 0.
11. 1 2. 1 3.
1 4. 15.
Kopans
SCREENING
DB.
The
Canadian
57
screening
program:
a different
perspective
(commentary). AJR 1990;1 55:748-749 Baines CJ, McFarlane DV, Miller AB. The role of the reference radiologist: estimates of inter-observer agreement and potential delay in cancer detection in the National Breast Screening Study. Invest Radiol 1990:25: 971 -976 Editorial. Breast cancer screening in women under 50. Lancet 1991;337: 1575-1576 Day NE, Dully SW. Breast cancer screening in women under 50 (letter). Lancet 1991;338: 113-114 Baines CJ, Miller AB, Kopans DB, et al. Canadian National Breast Screening Study: assessment of technical quality by extemal review. AJR 1990:155:743-747 Miller AB, Baines CJ, Sickles EA. Canadian National Breast Screening Study (letter). AJR 1990:155:1133-1134 McLelland A, Hendrick RE, Zinninger MD, Wilcox PA. The American College of Radiology Mammography Accreditation Program. AJR 1991:157:473-479
Roentgen Ray Society Award Papers, 1992
The ARRS announces competition for the 1 992 President’s Award papers concerning the clinical application of the radiologic sciences.
and two
Executive
Council
Awards
for the best
Awards The winner of the President’s Award will receive a certificate and a $2000 prize. The winners of the two Executive Council Awards will each be given a certificate and a prize of $1 000. The winners will be announced on March 1 6, 1992. Winning papers will be presented at the ARRS annual meeting at Marriott’s Orlando World Center, Orlando, FL, May 1 0-1 5, 1 992. Winning papers will be submitted for early publication in the American Journal of Roentgenology. All other papers will be returned to the authors.
Regulations Eligibility is limited to residents or fellows in radiology who have not yet completed 4 years of approved training in a radiologic discipline. A letter from the resident’s department chairman attesting to this status must accompany the manuscript. The resident must be the sole or senior author and be responsible for all or most of the project. Submitted manuscripts must not exceed 5000 words and have no more than 1 0 illustrations. Four copies of the manuscript and illustrations are required. Submitted manuscripts should not contain previously presented or published material and should not be under consideration for publication elsewhere. Deadline for submissions is February 1 4, 1992. Send papers to Nancy 0. Whitley, M.D. Chairman, Committee on Education & Research American Roentgen Ray Society Department of Radiology University of Maryland Medical Systems Hospital 22 5. Greene St. Baltimore, MD 21201
