Abstract
Many US radiologists have screening mammography recall rates above the expert-recommended threshold of 12%. The influence of digital breast tomosynthesis (DBT) on the distribution of radiologist recall rates is uncertain. To evaluate radiologists' recall and cancer detection rates before and after beginning interpretation of DBT examinations. This cohort study included 198 radiologists from 104 radiology facilities in the Breast Cancer Surveillance Consortium who interpreted 251 384 DBT and 2 000 681 digital mammography (DM) screening examinations from 2009 to 2017, including 126 radiologists (63.6%) who interpreted DBT examinations during the study period and 72 (36.4%) who exclusively interpreted DM examinations (to adjust for secular trends). Data were analyzed from April 2018 to July 2019. Digital breast tomosynthesis and DM screening examinations. Recall rate and cancer detection rate. A total of 198 radiologists interpreted 2 252 065 DM and DBT examinations (2 000 681 [88.8%] DM examinations; 251 384 [11.2%] DBT examinations; 710 934 patients [31.6%] aged 50-59 years; 1 448 981 [64.3%] non-Hispanic white). Among the 126 radiologists (63.6%) who interpreted DBT examinations, 83 (65.9%) had unadjusted DM recall rates of no more than 12% before using DBT, with a median (interquartile range) recall rate of 10.0% (7.5%-13.0%). On DBT examinations, 96 (76.2%) had an unadjusted recall rate of no more than 12%, with a median (interquartile range) recall rate of 8.8% (6.3%-11.3%). A secular trend in recall rate was observed, with the multivariable-adjusted risk of recall on screening examinations declining by 1.2% (95% CI, 0.9%-1.5%) per year. After adjusting for examination characteristics and secular trends, recall rates were 15% lower on DBT examinations compared with DM examinations interpreted before DBT use (relative risk, 0.85; 95% CI, 0.83-0.87). Adjusted recall rates were significantly lower on DBT examinations compared with DM examinations interpreted before DBT use for 45 radiologists (35.7%) and significantly higher for 18 (14.3%); 63 (50.0%) had no statistically significant change. The unadjusted cancer detection rate on DBT was 5.3 per 1000 examinations (95% CI, 5.0-5.7 per 1000 examinations) compared with 4.7 per 1000 examinations (95% CI, 4.6-4.8 per 1000 examinations) on DM examinations interpreted before DM use (multivariable-adjusted risk ratio, 1.21; 95% CI, 1.11-1.33). In this study, DBT was associated with an overall decrease in recall rate and an increase in cancer detection rate. However, our results indicated that there is wide variability among radiologists, including a subset of radiologists who experienced increased recall rates on DBT examinations. Radiology practices should audit radiologist DBT screening performance and consider additional DBT training for radiologists whose performance does not improve as expected.
Highlights
In the United States, high false-positive rates on mammography have been recognized as a significant harm of breast cancer screening.[1]
After adjusting for examination characteristics and secular trends, recall rates were 15% lower on digital breast tomosynthesis (DBT) examinations compared with digital mammography (DM) examinations interpreted before DBT use
Adjusted recall rates were significantly lower on DBT examinations compared with DM examinations interpreted before DBT use for 45 radiologists (35.7%) and significantly higher for 18 (14.3%); 63 (50.0%) had no statistically significant change
Summary
In the United States, high false-positive rates on mammography have been recognized as a significant harm of breast cancer screening.[1] Only 4% to 5% of positive mammograms recalled for further evaluation lead to a cancer diagnosis.[2] There have long been calls for quality improvement efforts to lower screening recall rates in the United States,[3] but there is little evidence of improvements to date. The American College of Radiology professional guidelines for mammography interpretation issued in 20134 included a recommended upper threshold of 12% for recall rate, citing the findings of a panel of expert breast imaging physicians.[5] In an evaluation of digital mammography (DM) screening performance in the Breast Cancer Surveillance Consortium (BCSC) from 2007 to 2013, only 155 of 249 radiologists (62.2%) had a recall rate below the expertrecommended upper threshold of 12%.2. In an evaluation of digital mammography (DM) screening performance in the Breast Cancer Surveillance Consortium (BCSC) from 2007 to 2013, only 155 of 249 radiologists (62.2%) had a recall rate below the expertrecommended upper threshold of 12%.2 The median recall rate among BCSC radiologists increased from 9.7% on film-screen mammography during 1996 to 2002 to 10.8% on DM during 2007 to 2013.2,6
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