Breast Cancer Screening and Diagnosis Research Group

Currently Funded Projects

“Understanding Variability in Community Mammography”
(a.k.a “FAVOR: Factors Affecting Variability of Radiologists”)

Funded by the Agency for HealthCare Research and Quality (R01 HS-010591) and t he National Cancer Institute (R01 CA-107623)

PI: Joann G. Elmore

Subcontract PIs:
Patricia Carney, Ph.D, Oregon Health and Science University
Alan Gelfand, Ph.D., Duke University
Berta Geller, Ph.D., University of Vermont
Diana Miglioretti, Ph.D., Group Health Cooperative Center For Health Studies
Bonnie Yankaskas, Ph.D., Carolina Mammography Registry

Project description and aims

Background:
Despite the proven value of mammography, its efficacy depends in large part on radiologists' interpretations, and radiologists differ substantially in their interpretations.

Hypotheses:
Community mammography performance can be enhanced by better understanding sources of variability among radiologists and by working directly with radiologists to improve evaluation of their individual performance.

Specific Aims:
Aim 1)  To use statistical methods to estimate the accuracy of mammography at the level of individual radiologists and better understand reasons for variability. 
Aim 2)  To better understand radiologist-level characteristics associated with interpretive performance. 
Aim 3)  To evaluate the feasibility and impact of an interactive web-based educational intervention and new audit reporting system.

Study Design:
This cohort study will be organized within a conceptual framework previously proven to result in both physician behavior change and improved patient outcomes.  Hierarchical statistical models will be developed using Breast Cancer Surveillance Consortium (BCSC) data from four population-based mammography registries in New Hampshire, Colorado, North Carolina, and Washington (Aim 1).  Data from these BCSC registries are available on more than two million mammography encounters.  A survey, which will augment existing BCSC data, will be sent to 400 radiologists to determine if radiologists understand concepts of numeracy (rates, risks and probability) in general and specifically related to breast cancer screening (Aim 2).  Survey data will be linked with BCSC data at the individual radiologist level.  Information learned from Aims 1 and 2 will guide development and testing of an interactive web-based educational tool designed to improve radiologists' understanding of their own interpretive performance and to enhance use of audit reporting systems (Aim 3).

Relevance:
Mandatory “skills testing” is being considered in Congressional hearings as the Mammography Quality Standards Act (MQSA) is reviewed.  Current methods of assessing the accuracy of individual radiologists are inadequate, and there is no data to show that individual skills testing will improve accuracy of radiologists.  This work builds on previous model development and is a natural extension in a timely and important clinical area.

Studies, results, and plans:
Aim 1) Findings from Aim 1 have been published by Woodard et al. in Statistics in Medicine, entitled “Performance Assessment for Radiologists Interpreting Screening Mammography” (2007 Mar 30;26(7):1532-51).  This article reports statistical models which estimate the accuracy of mammography and aid us in a better understanding of radiologist variability.  The data being utilized for these models was gathered from the FAVOR I radiologist survey in 2001.  Findings were replicated by Gavino Puggioni, a biostatistics graduate student, and were additionally reported at the BCSC Statistical conference in April 2006.

 Several additional manuscripts from the FAVOR I survey of radiologists are in progress, many pending publications in professional journals.

Aim 2) Data collection for Aim II is nearly complete, with our radiologist survey being distributed to over 400 radiologists in seven states (Washington, Colorado, New Hampshire, North Carolina, Vermont, California and New Mexico) at various times during 2006.  Several research questions of interest have been developed from the survey data and are being developed into scholarly work.

Aim 3) With preliminary data from our FAVOR II survey, we have begun the development and pilot-testing of our web-based CME course for radiologists.  We anticipate fielding the CME course in the states of Washington, North Carolina, New Hampshire and Vermont in 2007.  We would specifically like to learn what topics are most useful to radiologists working in breast imaging, and determine if the intervention has any impact on future performance.

"Improving Accuracy & Outcomes of Breast Cancer Screening"

Funded by the National Cancer Institute (K05 CA-104699)

PI: Joann G. Elmore

Project description and aims
The goal of this project is to support Dr. Elmore in mentoring junior investigators cancer-related clinical research.  This award entails three projects exploring breast cancer screening and detection:

Project 1 (Mammography) utilizes hierarchical modeling techniques to explore the extent to which fiscal, legal, clinical and personal characteristics of radiologists and facilities could be varied to lower the recall rates for community-based mammography while maintaining high levels of accuracy.  Its aim is to explore the relationship between patient-level characteristics and mammographic accuracy—especially the influence of body mass index on the accuracy of screening mammography.  

Project 2 (Breast Self-Examination) studies a breast cancer screening program in a defined population with the aim of describing self-reported breast self-examination behavior and associated outcomes.

Project 3 (Clinical Breast Examination) assesses the efficacy of breast cancer screening among women in two age cohorts at two different breast cancer risk levels in a multi-center case-control study.  The aim of Project 3 is to assess performance characteristics of clinical breast examination in subjects of a case-control study.

The unique breadth of the research projects, which include mammography, clinical breast examination and self-examination, reflect Dr. Elmore’s broad perspective as a primary care clinician.  All three projects use data collected for ongoing funded projects.  Because clinically significant variability exists in the accuracy and outcomes of breast cancer screening, projects such as these are a critical step toward improving breast cancer screening.

Representative publications from these projects

Elmore JG, Nakano CY, Koepsell TD, Desnick L, D’Orsi C, Ransohoff DF.  International Variation in Screening Mammography Interpretations in Community-Based Programs.  JNCI 2003;95:1384-93.

Barlow WE, Chi C, Carney PA, Taplin SH, D’Orsi C, Cutter G, Hendrick RE, Elmore JG.  Accuracy of Screening Mammography Interpretation by Characteristics of Radiologists. J Natl Cancer Inst 2004;96(24):1840-50.

Elmore JG, Nakano CY, Linden HM, Reisch LM, Ayanian JZ, Larson EB.  Racial Inequities in the Timing of Breast Cancer Detection, Diagnosis and Initiation of Treatment. Medical Care 2005;Feb;43(2),141-8.

D’Orsi C, Tu S-P, Nakano C, Carney P, Abraham L, Taplin S, Hendrick E, Cutter G, Berns E, Barlow W, Elmore JG.  The Current Realities of Delivering Mammography in the Community:  Do Challenges with Staffing and Scheduling Exist? Radiology. 2005 May;235(2):391-5.

Hendrick RE, Cutter G, Berns E, Nakano C, Egger J, Carney PA, Abraham L, Taplin S, D’Orsi C, Barlow W, Elmore JG.  Community- Based Mammography Practice:  Services, Charges, and Interpretation Methods. Am J Roentgenol. 2005 Feb;184(2):433-8.

Egger JR, Cutter GR, Carney PA, Taplin, SH, Barlow WE, Hendrick RE, D’Orsi CJ, Fosse JS, Abraham L, Elmore JG.  Mammographers’ Perception of Women’s Breast Cancer Risk. Med Decis Making, May-June 2005;25(3):283-289.

Fenton JJ, Barton MB, Geiger AM, Herrinton LJ, Rolnick SJ, Harris EL, Barlow WE, Reisch LM, Fletcher SW, Elmore JG.  Screening clinical breast examination:  how often does it miss lethal breast cancer?  J Natl Cancer Inst Monogr. 2005;(35):67-71.

Fenton JJ, Egger  MA, Carney PA, Cutter G, D’Orsi C, Sickles EA, Fosse J, Abraham L, Taplin SH, Barlow W, Hendrick RE, Elmore JG. Reality Check: Perceived versus Actual Performance of Community Mammographers. Am J Roentgenol. 2006 Jul;187(1):42-6.

West CN, Geiger AM, Greene SM, Harris E, Liu IA, Barton MD, Elmore JG, Rolnick S, Nekhlyudov L, Altschuler A, Herrinton LJ, Fletcher SW, Emmons K. Race and ethnicity: comparing medical records to self-reports. J Natl Cancer Inst Monogr. 2005;(35):72-4.

Paliwal P, Gelfand AE, Abraham L, Barlow W, Elmore JG.  Examining Accuracy of Screening Mammography using An Event Order Model.  Stat Med.  2006;25(2):267-83.

Greene SM, Geiger AM, Harris EL, Altschuler A, Nekhlyudov L, Barton MB, Rolnick SJ, Elmore JG, Fletcher S.  Impact of IRB requirements on a multi-site cancer research network study.  Annals of Epidemiology 2006;16(4):275-8.

Tu SP, Reisch LM, Taplin SH, Kreuter W, Elmore JG.  Breast Self-Examination:  Self-reported Frequency, Quality, and Associated Outcomes. J Cancer Educ. 2006;21:175-181.

Carney PA, Yi JP, Abraham LA, Miglioretti DL, Aiello EJ, Gerrity MS, Resich LM, Berns EA, Sickles EA, Elmore JG.  Reactions to uncertainty and the accuracy of diagnostic mammography. J Gen Intern Med. 2007;22(2):234-241.

Fenton JJ, Cai Y, Weiss NS, Elmore JG, Pardee RE, Reid RJ, Baldwin LM.  Delivery of Cancer Screening: How Important is the Preventive Health Examination? Arch Intern Med. 2007;167:580-585.

Fenton JJ, Taplin SH, Carney PA, Abraham LA, Sickles EA, D’Orsi C, Berns EA, Cutter G, Hendrick RE, Barlow WE, Elmore JG.  Influence of Computer-Aided Detection on Performance of Screening Mammography.  N Engl J Med. 2007;356(14):1399-1409.

GIM Home | UW Home | SoM Home | DoM Home
Academic Medical Center | HMC | Academic HealthLinks

Please honor our copyrights and disclaimer.
Copyright ©1998 University of Washington. All rights reserved.
Comments to General Internal Medicine, gim@u.washington.edu
Last reviewed: May 11, 2007 - Last updated: May 11, 2007 (js)