title: Additional double reading of screening mammograms by radiologic technologists: impact on screening performance parameters.
abstract: BACKGROUND
  Studies have shown that having mammography technologists review screening mammograms in addition to radiologist review may increase the number of breast cancers that are detected at screening mammography. We prospectively examined the effects on screening performance of adding independent double reading of screening mammograms by technologists to standard double reading by radiologists.
  
  
  METHODS
  Twenty-one screening mammography technologists and eight certified screening radiologists participated in this study. From January 1, 2003, to January 1, 2005, all 61,251 screening mammograms obtained at two mammography screening units in The Netherlands were independently read (although the second reader was not blinded to the first reader's interpretation) by two technologists and, in turn, by two radiologists. Radiologists were blinded to the referral opinion of the technologists. During a 2-year follow-up period, we collected clinical data, breast imaging reports, biopsy results, and breast surgery reports of all women with a positive screening result (i.e., those that required additional imaging) from any reader. The distributions of categorical variables between subgroups were compared using chi-square or Fisher's exact tests. Differences in referral and detection by radiologists and technologists were assessed using McNemar's test. All statistical tests were two-sided.
  
  
  RESULTS
  The radiologists referred 905 women (referral rate = 1.48%, 95% confidence interval [CI] = 1.38% to 1.57%), of whom 323 had breast cancer, corresponding to a positive predictive value of referral (PPV) of 35.7% (95% CI = 32.6% to 38.8%). Review of 446 additional technologist-positive readings led to another 80 referrals, resulting in the detection of 22 additional cancers. These extra referrals increased the initial referral rate from 1.48% to 1.61% (difference = 0.13%; 95% CI = 0.10% to 0.16%) and the cancer detection rate (CDR) from 5.27 to 5.63 cancers per 1000 women screened (difference = 0.36 cancers per 1000 women screened; 95% CI = 0.24 to 0.55). With technologist double reading only, 829 women would have been referred (referral rate = 1.35%, 95% CI = 1.26% to 1.45%); among these women, 286 cancers were diagnosed (PPV = 34.5%, 95% CI = 31.3% to 37.7%; CDR = 4.67 cancers per 1000 women screened, 95% CI = 4.13 to 5.21). Referral of all 1351 radiologist- and/or technologist-positive readings would have led to 362 cancers found at screening. The cancer detection rate for radiologist double reading would have increased from 5.27 to 5.91 cancers per 1000 women screened (relative increase = 12.1%, 95% CI = 8.8% to 16.5%; difference = 0.64 cancers per 1000 women screened, 95% CI = 0.47 to 0.87).
  
  
  CONCLUSIONS
  A referral strategy that includes all technologist-positive readings, which would have increased the cancer detection rate while maintaining a low referral rate, should be considered.
authors.affiliation: Department of Radiology, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands. lemduijm@hotmail.com
authors.forename: Lucien E M
authors.initials: LE
authors.lastname: Duijm
authors.forename: Johanna H
authors.initials: JH
authors.lastname: Groenewoud
authors.forename: Jacques
authors.initials: J
authors.lastname: Fracheboud
authors.forename: Harry J
authors.initials: HJ
authors.lastname: de Koning
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000453:epidemiology; D005188:False Negative Reactions; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D008327:Mammography; D008403:Mass Screening; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D015588:Observer Variation; D010820:Physicians / Q000523:psychology; D015995:Prevalence; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D011871:Radiology; D012017:Referral and Consultation; D015203:Reproducibility of Results; D016037:Single-Blind Method; D013679:Technology, Radiologic