Understanding Mammographic Quality: Insights and Actions

By Kelly Hackett, MPH
Program Manager, Mammographic Quality Initiative
Wisconsin Women's Health Foundation

When it comes to breast cancer screening, mammograms are a critical tool. However, the quality of mammographic services can significantly affect outcomes. Research indicates that higher quality mammography can lead to earlier detection of breast cancer, which is crucial for successful treatment. In fact, studies have shown that the sensitivity of mammography can vary widely, from 68% to 90% (1-4), depending on the quality of the equipment and the skill of the radiologist . Additionally, false-negative rates can range from 10% to 30%, (5) emphasizing the importance of high standards in mammographic services. Unfortunately, disparities in mammographic quality and outcomes persist, particularly among racial and ethnic minorities. For example, African American women are more likely to receive lower-quality mammography services, contributing to a higher mortality rate from breast cancer compared to their white counterparts. (6-8)

The Mammographic Quality Initiative (MQI) is leveraging the Community and Cancer Science Network (CCSN) transdisciplinary approach to delve into the factors influencing mammography quality. By building a shared measurement system, MQI aims to monitor and enhance mammographic quality comprehensively.

Since its inception, the leadership team has made significant progress within Southeastern Wisconsin’s healthcare systems. They have engaged mammography facility leaders and providers, patient navigators, Wisconsin Well Woman Program coordinators, and patients and community members with mammography experiences, in thoughtful, responsive collaborations, expanding the scope of who provides insights into mammographic quality and understanding what quality means from various perspectives.

One striking revelation from MQI’s work is the general lack of knowledge about screening mammograms among first-time patients. Most individuals are only aware that they need a mammogram or have heard from family members about the potential discomfort. This lack of information can be a barrier to scheduling and following through with these crucial screenings.

We’ve also learned that while access to facilities is undoubtedly important (and Wisconsin has made considerable efforts to improve this), financial support, a comfortable and safe environment during procedures, and addressing mental models and power dynamics are equally vital to ensure patients return for future screenings.

Additionally, quality standards and annual audits, mandated by the Mammography Quality Standards Act, ensure the safety and efficacy of all U.S. mammography facilities. Despite this, many quality markers remain unrecorded or are inconsistently reported due to variations in electronic medical records systems and provider documentation practices. This inconsistency complicates efforts to track follow-up timeliness from screening to biopsy or to identify patients who never completed their recommended follow-up diagnostics.

Finally, patient navigators and Wisconsin Well Woman Program (WWWP) coordinators have proven to be invaluable assets. Their dual perspectives as providers and patient advocates enhance the understanding of mammogram quality within MQI.

There are several actionable steps we recommend based on our learning and experiences to date:

1. Understand the Process Yourself. Familiarize yourself with the mammogram process if you don’t yet understand it. Numerous credible online resources explain the steps, from initial screenings to ultrasounds, MRIs, and biopsies. Examples include information from reputable organizations like the National Breast Cancer Foundation, or videos from health systems like Froedtert.
2. Promote, Educate & Discuss the details! Talk about mammograms with family and friends. Go beyond telling someone to get a mammogram, and get into the details of the screening process. Knowledge about mammograms is surprisingly limited among patients before their first screening, apart from hearing from family members that it might hurt. Sharing accurate information can demystify the process, encourage people to schedule their screenings, and empower people with knowledge to reduce fear and anxiety.
3. Support Local Programs: Advocate for programs that provide exceptional services to patients across Wisconsin. The WWWP, for instance, has been offering breast and cervical cancer screening support for thirty years to tens of thousands of patients. Despite changes like mergers and acquisitions, the program maintains partnerships in all counties and tribal nations in Wisconsin, providing timely and excellent services.
4. Encourage Transformational Change: Critically assess your work, beliefs, institutions, and norms. Question existing systems and the decisions that shaped them. MQI is bring collective impact into the health care system - collaborating with a diverse range of mammogram providers from various Southeastern Wisconsin systems to understand and enhance quality across health systems, and expanding our definition of quality beyond what has always been measured. We cannot do what has always been done, and expect real transformational change.

By actively participating in discussions, familiarizing ourselves with the mammogram process, supporting local initiatives, and advocating for systemic change, we can collectively enhance the quality of mammographic services. The Mammographic Quality Initiative exemplifies how a collaborative, transdisciplinary approach can lead to significant improvements in healthcare outcomes, ultimately ensuring better and more equitable breast cancer screening for all.

Together, we can make a difference in the fight against breast cancer, one high-quality mammogram at a time.

Sources:

1. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. "Screening for breast cancer." JAMA. 2005 Mar 9;293(10):1245-56.
2. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. "Likelihood ratios for modern screening mammography: risk of breast cancer based on age and mammographic interpretation." JAMA. 1996 May 1;275(17):1318-25.
3. Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, Conant EF, Fajardo LL, Bassett L, D'Orsi C, Jong R, Rebner M; Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group. "Diagnostic performance of digital versus film mammography for breast-cancer screening." N Engl J Med. 2005 Oct 27;353(17):1773-83.
4. Duffy SW, Tabár L, Vitak B, Chen TH, Yen MF, Chiang CF, Smith RA, Khan K, Rosen M, Stenbeck M, Holmberg L, Fagerberg G. "The Swedish Two-County Trial of mammographic screening: cluster randomisation and end point evaluation." Ann Oncol. 2003 Aug;14(8):1196-8.
5. https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/limitations-of-mammograms.html
6. https://www.bcrf.org/blog/black-women-and-breast-cancer-why-disparities-persist-and-how-end-them/
7. Fayanju, O.M., Edmonds, C.E., Reyes, S.A. et al. The Landmark Series—Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women. Ann Surg Oncol 30, 58–67 (2023). https://doi.org/10.1245/s10434-022-12535-8
8. Lee, C.S., Goldman, L., Grimm, L.J. et al. Screening mammographic performance by race and age in the National Mammography Database: 29,479,665 screening mammograms from 13,181,241 women. Breast Cancer Res Treat 203, 599–612 (2024). https://doi.org/10.1007/s10549-023-07124-6