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Original Investigation | Less Is More

Diagnostic Accuracy of Digital Screening Mammography With and Without Computer-Aided Detection

Constance D. Lehman, MD, PhD1; Robert D. Wellman, MS2; Diana S. M. Buist, PhD2; Karla Kerlikowske, MD3; Anna N. A. Tosteson, ScD4; Diana L. Miglioretti, PhD2,5 ; for the Breast Cancer Surveillance Consortium
[+] Author Affiliations
1Department of Radiology, Massachusetts General Hospital, Boston
2Group Health Research Institute, Seattle, Washington
3Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
4Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, New Hampshire
5Department of Public Health Sciences, School of Medicine, University of California, Davis
JAMA Intern Med. 2015;175(11):1828-1837. doi:10.1001/jamainternmed.2015.5231.
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Importance  After the US Food and Drug Administration (FDA) approved computer-aided detection (CAD) for mammography in 1998, and the Centers for Medicare and Medicaid Services (CMS) provided increased payment in 2002, CAD technology disseminated rapidly. Despite sparse evidence that CAD improves accuracy of mammographic interpretations and costs over $400 million a year, CAD is currently used for most screening mammograms in the United States.

Objective  To measure performance of digital screening mammography with and without CAD in US community practice.

Design, Setting, and Participants  We compared the accuracy of digital screening mammography interpreted with (n = 495 818) vs without (n = 129 807) CAD from 2003 through 2009 in 323 973 women. Mammograms were interpreted by 271 radiologists from 66 facilities in the Breast Cancer Surveillance Consortium. Linkage with tumor registries identified 3159 breast cancers in 323 973 women within 1 year of the screening.

Main Outcomes and Measures  Mammography performance (sensitivity, specificity, and screen-detected and interval cancers per 1000 women) was modeled using logistic regression with radiologist-specific random effects to account for correlation among examinations interpreted by the same radiologist, adjusting for patient age, race/ethnicity, time since prior mammogram, examination year, and registry. Conditional logistic regression was used to compare performance among 107 radiologists who interpreted mammograms both with and without CAD.

Results  Screening performance was not improved with CAD on any metric assessed. Mammography sensitivity was 85.3% (95% CI, 83.6%-86.9%) with and 87.3% (95% CI, 84.5%-89.7%) without CAD. Specificity was 91.6% (95% CI, 91.0%-92.2%) with and 91.4% (95% CI, 90.6%-92.0%) without CAD. There was no difference in cancer detection rate (4.1 in 1000 women screened with and without CAD). Computer-aided detection did not improve intraradiologist performance. Sensitivity was significantly decreased for mammograms interpreted with vs without CAD in the subset of radiologists who interpreted both with and without CAD (odds ratio, 0.53; 95% CI, 0.29-0.97).

Conclusions and Relevance  Computer-aided detection does not improve diagnostic accuracy of mammography. These results suggest that insurers pay more for CAD with no established benefit to women.

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Figure 1.
Screening Mammography Patterns From 2000 to 2012 in US Community Practices in the Breast Cancer Surveillance Consortium (BCSC)

Data are provided from the larger BCSC population including all screening mammograms (5.2 million mammograms) for the indicated time period.

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Figure 2.
Receiver Operating Characteristic Curves for Digital Screening Mammography With and Without the Use of CAD, Estimated From 135 Radiologists Who Interpreted at Least 1 Examination Associated With Cancer

Each circle represents the true-positive or false-positive rate for a single radiologist, for examinations interpreted with (orange) or without (blue) computer-aided detection (CAD). Circle size is proportional to the number of mammograms associated with cancer interpreted by that radiologist with or without CAD. PAUC indicates partial area under the curve.

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