New mammography screening performance metrics based on the entire screening episode

Cancer. 2020 Jul 15;126(14):3289-3296. doi: 10.1002/cncr.32939. Epub 2020 May 6.


Background: Established mammography screening performance metrics use the initial screening mammography assessment because they were developed for radiologist performance auditing, yet these metrics are frequently used to inform health policy and screening decision making. The authors have developed new performance metrics based on the final assessment that consider the entire screening episode, including diagnostic workup.

Methods: The authors used data from 2,512,577 screening episodes during 2005-2017 at 146 facilities in the United States participating in the Breast Cancer Surveillance Consortium. Screening performance metrics based on the final assessment of the screening episode were compared with conventional metrics defined with the initial assessment. Results were also stratified by breast density and breast cancer risk.

Results: The cancer detection rates were similar for the final assessment (4.1 per 1000; 95% confidence interval [CI], 3.8-4.3 per 1000) and the initial assessment (4.1 per 1000; 95% CI, 3.9-4.3 per 1000). The interval cancer rate was 12% higher when it was based on the final assessment (0.77 per 1000; 95% CI, 0.71-0.83 per 1000) versus the initial assessment (0.69 per 1000; 95% CI, 0.64-0.74 per 1000), and this resulted in a modest difference in sensitivity (84.1% [95% CI, 83.0%-85.1%] vs 85.7% [95% CI, 84.8%-86.6%], respectively). Absolute differences in the interval cancer rate between final and initial assessments increased with breast density and breast cancer risk (eg, a difference of 0.29 per 1000 for women with extremely dense breasts and a 5-year risk >2.49%).

Conclusions: Established screening performance metrics underestimate the interval cancer rate of a mammography screening episode, particularly for women with dense breasts or an elevated breast cancer risk. Women, clinicians, policymakers, and researchers should use final-assessment performance metrics to support informed screening decisions.

Keywords: breast density; breast neoplasms; mammography; mass screening; outcome assessment.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Benchmarking / methods*
  • Breast / diagnostic imaging
  • Breast / pathology
  • Breast Density
  • Breast Neoplasms / diagnostic imaging*
  • Breast Neoplasms / epidemiology
  • Breast Neoplasms / pathology
  • Early Detection of Cancer / methods*
  • Female
  • Follow-Up Studies
  • Humans
  • Mammography / methods*
  • Mass Screening / methods*
  • Middle Aged
  • Prospective Studies
  • Registries*
  • Risk Assessment
  • United States / epidemiology