The controversy over mammography is often focused on whether or not it should be used as a screening tool. But another equally important issue, given its widespread use, is the optimization of mammography…. Considerable effort should, therefore, be devoted to determining how to make mammography as effective as it can be and to reduce the tremendous variation in interpretation and biopsy rates.
This chapter examines critical issues in providing high-quality breast screening services. The fundamental criterion for implementing a screening program for all women in a particular target group is that the screening tests should have an acceptable level of accuracy, cost-effectiveness, and a favorable balance of benefits to harms. Although different programs might place relatively greater emphasis on detecting small tumors or on reducing the false-positive rate, there is little disagreement that achieving the highest practical balance between sensitivity and specificity is central to ongoing efforts to improve the quality of mammography services. This chapter reviews alternative approaches to the organization of breast screening services, ways that mammography could be improved, technologies that might augment or replace mammography in breast cancer screening, and the challenges in supporting and developing a well-trained workforce.
Most women who undergo biopsies will not have breast cancer. Although some might describe these biopsies as “needless,” in reality they reflect the lack of precision of current detection methods. Some of the imprecision is likely due to the quality of the mammographic interpretation, and some is due to the inherent limitations of the technology. Some solutions to the problem lie in organizational changes, such as adopting different procedures for interpreting mammograms, different standards, and different ways of organizing mammography services. Other solutions might lie in technological improvements.