The Influence of Mammographic Technologists on Radiologists' Ability to Interpret Screening Mammograms in Community Practice

Published:November 27, 2014DOI:

      Rationale and Objectives

      To determine whether the mammographic technologist has an effect on the radiologists' interpretative performance of screening mammography in community practice.

      Materials and Methods

      In this institutional review board–approved retrospective cohort study, we included Carolina Mammography Registry data from 372 radiologists and 356 mammographic technologists from 1994 to 2009 who performed 1,003,276 screening mammograms. Measures of interpretative performance (recall rate, sensitivity, specificity, positive predictive value [PPV1], and cancer detection rate [CDR]) were ascertained prospectively with cancer outcomes collected from the state cancer registry and pathology reports. To determine if the mammographic technologist influenced the radiologists' performance, we used mixed effects logistic regression models, including a radiologist-specific random effect and taking into account the clustering of examinations across women, separately for screen-film mammography (SFM) and full-field digital mammography (FFDM).


      Of the 356 mammographic technologists included, 343 performed 889,347 SFM examinations, 51 performed 113,929 FFDM examinations, and 38 performed both SFM and FFDM examinations. A total of 4328 cancers were reported for SFM and 564 cancers for FFDM. The technologists had a statistically significant effect on the radiologists' recall rate, sensitivity, specificity, and CDR for both SFM and FFDM (P values <.01). For PPV1, variability by technologist was observed for SFM (P value <.0001) but not for FFDM (P value = .088).


      The interpretative performance of radiologists in screening mammography varies substantially by the technologist performing the examination. Additional studies should aim to identify technologist characteristics that may explain this variation.

      Key Words

      To read this article in full you will need to make a payment


      Subscribe to Academic Radiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Cancer Society
        What are the key statistics about breast cancer?.
        In: Society AC, 2013
        • National Cancer Institute
        Breast cancer screening (PDQ).
        National Cancer Institute, In. Bethesda, MD2010
        • Miglioretti D.L.
        • Smith-Bindman R.
        • Abraham L.
        • et al.
        Radiologist characteristics associated with interpretive performance of diagnostic mammography.
        J Natl Cancer Inst. 2007; 99: 1854-1863
        • Elmore J.G.
        • Miglioretti D.L.
        • Reisch L.M.
        • et al.
        Screening mammograms by community radiologists: variability in false-positive rates.
        J Natl Cancer Inst. 2002; 94: 1373-1380
        • Barlow W.E.
        • Chi C.
        • Carney P.A.
        • et al.
        Accuracy of screening mammography interpretation by characteristics of radiologists.
        J Natl Cancer Inst. 2004; 96: 1840-1850
        • Carney P.A.
        • Elmore J.G.
        • Abraham L.A.
        • et al.
        Radiologist uncertainty and the interpretation of screening.
        Med Decis Making. 2004; 24: 255-264
        • Elmore J.G.
        • Jackson S.L.
        • Abraham L.
        • et al.
        Variability in interpretive performance at screening mammography and radiologists' characteristics associated with accuracy.
        Radiology. 2009; 253: 641-651
        • Elmore J.G.
        • Wells C.K.
        • Howard D.H.
        Does diagnostic accuracy in mammography depend on radiologists' experience?.
        J Womens Health. 1998; 7: 443-449
        • Molins E.
        • Macia F.
        • Ferrer F.
        • et al.
        Association between radiologists' experience and accuracy in interpreting screening mammograms.
        BMC Health Serv Res. 2008; 8: 91
        • Esserman L.
        • Cowley H.
        • Eberle C.
        • et al.
        Improving the accuracy of mammography: volume and outcome relationships.
        J Natl Cancer Inst. 2002; 94: 369-375
        • Beam C.A.
        • Layde P.M.
        • Sullivan D.C.
        Variability in the interpretation of screening mammograms by US radiologists. Findings from a national sample.
        Arch Intern Med. 1996; 156: 209-213
        • Elmore J.G.
        • Wells C.K.
        • Lee C.H.
        • et al.
        Variability in radiologists' interpretations of mammograms.
        N Engl J Med. 1994; 331: 1493-1499
        • van den Biggelaar F.J.
        • Flobbe K.
        • van Engelshoven J.M.
        • et al.
        Pre-reading mammograms by specialised breast technologists: legal implications for technologist and radiologist in The Netherlands.
        Eur J Health Law. 2009; 16: 271-279
        • Wivell G.
        • Denton E.R.
        • Eve C.B.
        • et al.
        Can radiographers read screening mammograms?.
        Clin Radiol. 2003; 58: 63-67
        • Pauli R.
        • Hammond S.
        • Cooke J.
        • et al.
        Radiographers as film readers in screening mammography: an assessment of competence under test and screening conditions.
        Br J Radiol. 1996; 69: 10-14
        • Bassett L.W.
        • Hollatz-Brown A.J.
        • Bastani R.
        • et al.
        Effects of a program to train radiologic technologists to identify abnormalities on mammograms.
        Radiology. 1995; 194: 189-192
        • Haiart D.C.
        • Henderson J.
        A comparison of interpretation of screening mammograms by a radiographer, a doctor and a radiologist: results and implications.
        Br J Clin Pract. 1991; 45: 43-45
      1. Breast Cancer Surveillance Consortium glossary of terms.
        in: Data dictionary version 5.0. Breast Cancer Surveillance Consortium, Seattle, WA2009
        • Taplin S.H.
        • Ichikawa L.E.
        • Kerlikowske K.
        • et al.
        Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography.
        Radiology. 2002; 222: 529-535
        • American College of Radiology
        Illustrated Breast Imaging Reporting and Data System (BI-RADS).
        American College of Radiology, Reston, VA1998
        • Rosenberg R.D.
        • Yankaskas B.C.
        • Abraham L.A.
        • et al.
        Performance benchmarks for screening mammography.
        Radiology. 2006; 241: 55-66
        • Wolfinger R.
        • O'Connell M.
        Generalized linear mixed models a pseudo-likelihood approach.
        J Stat Comput Simul. 1993; 48: 233-243
        • Carney P.A.
        • Cook A.J.
        • Miglioretti D.L.
        • et al.
        Use of clinical history affects accuracy of interpretive performance of screening mammography.
        J Clin Epidemiol. 2012; 65: 219-230
        • Cook A.J.
        • Elmore J.G.
        • Miglioretti D.L.
        • et al.
        Decreased accuracy in interpretation of community-based screening mammography for women with multiple clinical risk factors.
        J Clin Epidemiol. 2010; 63: 441-451
        • Miglioretti D.L.
        • Gard C.C.
        • Carney P.A.
        • et al.
        When radiologists perform best: the learning curve in screening mammogram interpretation.
        Radiology. 2009; 253: 632-640
        • Buist D.S.
        • Anderson M.L.
        • Haneuse S.J.
        • et al.
        Influence of annual interpretive volume on screening mammography performance in the United States.
        Radiology. 2011; 259: 72-84
        • Geller B.M.
        • Bowles E.J.
        • Sohng H.Y.
        • et al.
        Radiologists' performance and their enjoyment of interpreting screening mammograms.
        AJR Am J Roentgenol. 2009; 192: 361-369
        • Smith-Bindman R.
        • Chu P.
        • Miglioretti D.L.
        • et al.
        Physician predictors of mammographic accuracy.
        J Natl Cancer Inst. 2005; 97: 358-367
        • Tan A.
        • Freeman Jr., D.H.
        • Goodwin J.S.
        • et al.
        Variation in false-positive rates of mammography reading among 1067 radiologists: a population-based assessment.
        Breast Cancer Res Treat. 2006; 100: 309-318
        • Theberge I.
        • Hebert-Croteau N.
        • Langlois A.
        • et al.
        Volume of screening mammography and performance in the Quebec population-based Breast Cancer Screening Program.
        CMAJ. 2005; 172: 195-199
        • Taplin S.
        • Abraham L.
        • Barlow W.E.
        • et al.
        Mammography facility characteristics associated with interpretive accuracy of screening mammography.
        J Natl Cancer Inst. 2008; 100: 876-887
        • Leader J.K.
        • Hakim C.M.
        • Ganott M.A.
        • et al.
        A multisite telemammography system for remote management of screening mammography: an assessment of technical, operational, and clinical issues.
        J Digit Imaging. 2006; 19: 216-225
        • Sumkin J.H.
        • Klaman H.M.
        • Graham M.
        • et al.
        Prescreening mammography by technologists: a preliminary assessment.
        AJR Am J Roentgenol. 2003; 180: 253-256
        • Tonita J.M.
        • Hillis J.P.
        • Lim C.H.
        Medical radiologic technologist review: effects on a population-based breast cancer screening program.
        Radiology. 1999; 211: 529-533
        • Apffelstaedt J.
        • Steenkamp V.
        • Baatjes K.
        Surgeon-read screening mammography: an analysis of 11,948 examinations.
        Ann Surg Oncol. 2010; 17: 249-254
        • Duijm L.E.M.
        • Groenewoud J.H.
        • Fracheboud J.
        • et al.
        Additional double reading of screening mammograms by radiologic technologists: impact on screening performance parameters.
        J Natl Cancer Inst. 2007; 99: 1162-1170
        • Duijm L.E.M.
        • Groenewoud J.H.
        • Fracheboud J.
        • et al.
        Introduction of additional double reading of mammograms by radiographers: effects on a biennial screening programme outcome.
        Eur J Cancer. 2008; 44: 1223-1228
        • Duijm L.E.M.
        • Louwman M.W.J.
        • Groenewoud J.H.
        • et al.
        Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome.
        Br J Cancer. 2009; 100: 901-907
        • Moran S.
        • Warren-Forward H.
        A retrospective study of the performance of radiographers in interpreting screening mammograms.
        Radiography. 2011; 17: 126-131
        • Mucci B.
        • Lawson S.
        • Athey G.
        • et al.
        Radiographers as readers in breast screening: experience with a ‘red dot’ method.
        The Breast. 1997; 6: 183-185
        • Alcorn F.S.
        • O'Donnell E.
        • Ackerman L.V.
        The protocol and results of training nonradiologists to scan mammograms.
        Radiology. 1971; 99: 523-529
        • Engelman K.K.
        • Cizik A.M.
        • Ellerbeck E.F.
        Women's satisfaction with their mammography experience: results of a qualitative study.
        Women Health. 2005; 42: 17-35
        • Ndikum-Moffor F.M.
        • Braiuca S.
        • Daley C.M.
        • et al.
        Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women.
        Womens Health Issues. 2013; 23: e395-402
        • Fox S.A.
        • Klos D.S.
        • Worthen N.J.
        • et al.
        Improving the adherence of urban women to mammography guidelines: strategies for radiologists.
        Radiology. 1990; 174: 203-206
      2. Administration USFDA. Radiologic Technologist Mammography Specific Training. Mammography Quality Standards Act and Program Policy Guidance Help System. Available at: Accessed November 6, 2013.

      3. FDA - MQSA Rules and Regulations. Available at: Accessed April 15, 2014.