{"id":1164,"date":"2016-10-13T14:57:45","date_gmt":"2016-10-13T14:57:45","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1164"},"modified":"2017-08-21T10:47:04","modified_gmt":"2017-08-21T10:47:04","slug":"primary-care-corner-with-geoffrey-modest-md-radiologist-variability-in-mammography-readings","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/13\/primary-care-corner-with-geoffrey-modest-md-radiologist-variability-in-mammography-readings\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Radiologist Variability in Mammography Readings"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A recent article revealed the dramatic variability in radiologists\u2019 interpretations of mammographic breast density\u00a0(see Sprague BL. Ann Intern Med 2016; 165: 457).\u00a0Determining breast density accurately is certainly important because increased breast density leads to difficulty in reading mammograms and\u00a0is an independent risk factor for breast cancer.\u00a0In this light, one prerequisite for us in primary care is that the radiologic determination of breast density is consistent and accurate. But, details, from an NIH supported study:<\/p>\n<ul>\n<li>Data from 216,783 screening mammograms from 145,123 women aged 40 to 89 were included, from 30 radiology facilities within three breast cancer screening research centers of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.<\/li>\n<li>83 radiologists\u00a0were involved; each interpreted at least 500 screening mammograms from 2011-3, using the BIRADS reporting system, along with patients age, race, and BMI<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>9% of mammograms were rated as showing dense breasts<\/li>\n<li>Across radiologists, the finding of dense breasts\u00a0<strong>ranged from 6.3% to 84.5%<\/strong> (median 38.7%, interquartile range 28.9% to 50.9%).<strong> !!!!<\/strong><\/li>\n<li>Variation in breast\u00a0density assessment was pervasive in all but the most extreme patient age and BMI combinations<\/li>\n<li>Among women with consecutive mammograms interpreted by different radiologists, 17.2% had discordant assessments of breast density.<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>One of\u00a0the scariest issues to me as a clinician is that I need to rely on an accurate interpretation of medical tests in order to inform my patient management. The sheer magnitude of the variation in breast density assessment is quite striking.<\/li>\n<li>There are also other studies, mostly 10-20 years old,\u00a0showing that the general radiologic interpretation of mammograms has considerable variability as well.<\/li>\n<li>There are certainly other tests that\u00a0have significant variability andhighlight\u00a0this issue more broadly &#8212; for example\u00a0finding significant spine MRI abnormalities in totally asymptomatic patients:\n<ul>\n<li>One study\u00a0(see Jensen MC. N Engl J Med 1994; 331: 69) looked at 98 people without back pain, where their\u00a0MRI scans were interpreted by two experienced neuroradiologists at the Cleveland Clinic, finding that 52% had a bulge in at least one intervertebral disc, 27% had a protrusion, and 1% had an extrusion. 38% had multilevel abnormalities. <strong>Only 36% had a normal MRI<\/strong>.<\/li>\n<li>A systematic review (see Brinjikji W. AJNR2015\u00a036:\u00a0811-816)\u00a0found dramatic MRI or CT\u00a0changes in asymptomatic people, which increased with age. \u00a0For example,\u00a0the prevalence of <strong>disc degeneration went from 37% at age 20<\/strong> to 96% at age 80, <strong>bulges went from 30% at age 20<\/strong> to 84% at age 80, <strong>disc protrusion from 29% age 20<\/strong> to 43% at age 80, <strong>annular fissure from 19% age 20<\/strong> to 29% at age 80. \u00a0so, lots and lots of impressive disc changes even in asymptomatic\u00a020 year olds&#8230;&#8230;<\/li>\n<\/ul>\n<\/li>\n<li>Another issue, which we tend to understand more intuitively, is that of ultrasounds, which are clearly operator-dependent. But we had a patient with chronic hepatitis B, who had a \u201cnormal\u201d screening RUQ ultrasound for hepatocellular cancer, but a <strong>CT revealed a 9cm cancer<\/strong>!! I spoke with a trusted hepatologist who commented that he used a CT to scan to screen for really high-risk patients because of the variability of ultrasounds (though that is not exactly a clear-cut, or generally accepted algorithm\u2026.)<\/li>\n<li>One major concern about over-reading breast\u00a0density (as well as potentially\u00a0scaring patients that they might be at higher breast cancer risk) is that this findingoften leads to further studies such as ultrasound, digital breast tomosynthesis, and MRI examination (though there is minimal evidence to support these tests, and they may well lead to unnecessary biopsies, more radiation exposure, etc. And the USPSTF formally gives these procedures an \u201cI\u201d rating, for insufficient evidence)<\/li>\n<li>And, another issue:\u00a0\u00a0half of the United States has legislation currently requiring disclosure of mammographic breast density, in some cases advising women to discuss supplemental screening tests with\u00a0their providers if they have dense breasts (again without supportive medical evidence). And even theFDA is considering a legislative requirement to report breast density information to patients.\u00a0I think there is a real\u00a0concern about\u00a0non-medical legislators enacting medical legislation, where legislators may be swayed by patients pleading for unproved treatments, perhaps with the support of an \u201cexpert witness\u201d. Or, perhaps the legislature decides to require a certain treatment based on small or flawed studies, writes the treatment into law, but then\u00a0new and better studies contradict\u00a0this legislative imperative. One recent example is\u00a0in Massachusetts, where a law was passed\u00a0requiring insurance to cover long-term antibiotic\u00a0therapy for chronic\u00a0Lyme disease, though several studies, including a new one\u00a0(see\u00a0Berende .\u00a0N Engl J Med2016;374:1209-1220), have not found benefit from long-term antibiotics. Or, in the past,\u00a0there has been legislation supporting the availability of\u00a0bone marrow transplants for women with breast cancer,\u00a0but without any evidence of benefit (and pretty clear harm). I do realize that there have been egregious, inappropriate treatment denials by some health insurers in the past which has led to some of this legislation and public\/medical community outrage. But legislating medical diagnostics and therapies is fraught&#8230;..<\/li>\n<li>So, this inconsistency\/unreliability\u00a0in breast density interpretation\u00a0may subject many people\u00a0to potentially dangerous interventions. I think\u00a0it is really important that we as clinicians understand that many procedures we order are subject to large variability, as above. So, what can we do??\n<ul>\n<li>Whenever possible, we should interpret these \u201cobjective\u201d data in the context of the clinical situation of the patient, and not always reflexively respond to the test results (it is just another piece of data, such as from the history or physical, which should be put in the overall gestalt of what is going on with the patient). Of course, some of these objective findings, even unsuspected, may be very important and not dismissed (e.g., the incidental finding of early pancreatic or renal cancers).<\/li>\n<li>Maybe we should consider getting second opinions more often than we currently do, to assess interobserver agreement<\/li>\n<li>Perhaps there should be triggers in place for certain findings (such as dense breasts on mammogram), requiring a blinded read by another radiologist, or?? always having mammograms automatically re-read by another radiologist??, or having an automatic second-read whenever a radiologist comments \u201cshould be repeated in 3-6 months by another test\u201d, which puts the medicolegal imperative on us in primary care to do yet another test with potentially more radiation exposure, cost, possible unnecessary procedures, etc.<\/li>\n<li>Perhaps there needs to be much more transparency in the system overall, maybe\u00a0requiring those reporting on these results to have regular standardized testing themselves and posting the results (sort of like requiring hospitals to report their C-section rates).<\/li>\n<li>Perhaps we need a good computer program????<\/li>\n<\/ul>\n<\/li>\n<li>I realize this blog is more tangential than others, but i do think this issue of inconsistency in mammography reading does bring up a slew of general issues in clinical medicine&#8230;..<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Radiologist Variability in Mammography Readings [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/13\/primary-care-corner-with-geoffrey-modest-md-radiologist-variability-in-mammography-readings\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1164","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1164","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1164"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1164\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1164"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1164"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1164"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}