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Reality Check: Perceived Versus Actual Performance of Community Mammographers

¹ Department of Family and Community Medicine, University of California, Davis, 4860 Y St., Ste 2300, Sacramento, CA 95817.
² Disease Control and Vector Biology Unit, Department of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, England.
³ Department of Family & Community Medicine, Dartmouth Medical School, Lebanon, NH.
⁴ Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL.
⁵ Breast Imaging Center, The Emory Clinic, Atlanta, GA.
⁶ Department of Radiology, University of California, San Francisco, San Francisco, CA.
⁷ Division of General Internal Medicine, University of Washington, Harborview Medical Center, Seattle, WA.
⁸ Group Health Cooperative, Center for Health Studies, Seattle, WA.
⁹ Present address: Applied Research Program, National Cancer Institute, Bethesda, MD.
¹⁰ Cancer Research and Biostatistics, Seattle, WA.
¹¹ Northwestern Memorial Hospital, Lynn Sage Breast Cancer Center, Chicago, IL.

OBJECTIVE. Federal regulations mandate that radiologists receive regular albeit limited feedback regarding their interpretive accuracy in mammography. We sought to determine whether radiologists who regularly receive more extensive feedback can report their actual performance in screening mammography accurately.

SUBJECTS AND METHODS. Radiologists (n = 105) who routinely interpret screening mammograms in three states (Washington, Colorado, and New Hampshire) completed a mailed survey in 2001. Radiologists were asked to estimate how frequently they recommended additional diagnostic testing after screening mammography and the positive predictive value of their recommendations for biopsy (PPV₂). We then used outcomes from 336,128 screening mammography examinations interpreted by the radiologists from 1998 to 2001 to ascertain their true rates of recommendations for diagnostic testing and PPV₂.

RESULTS. Radiologists' self-reported rate of recommending immediate additional imaging (11.1%) exceeded their actual rate (9.1%) (mean difference, 1.9%; 95% confidence interval [CI], 0.9-3.0%). The mean self-reported rate of recommending short-interval follow-up was 6.2%; the true rate was 1.8% (mean difference, 4.3%; 95% CI, 3.6-5.1%). Similarly, the mean self-reported and true rates of recommending immediate biopsy or surgical evaluation were 3.2% and 0.6%, respectively (mean difference, 2.6%; 95% CI, 1.8-3.4%). Conversely, radiologists' mean self-reported PPV₂ (18.3%) was significantly less than their mean true PPV₂ (27.6%) (mean difference, -9.3%; 95% CI, -12.4% to -6.2%).

CONCLUSION. Despite regular performance feedback, community radiologists may overestimate their true rates of recommending further evaluation after screening mammography and underestimate their true positive predictive value.

Keywords: breast cancer • breast imaging • mammography

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