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72 Breast Cancers Missed After Digital Switch

June 4, 2013
Written by: , Filed in: Breast Imaging, Practice Management
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A switch from analog to digital mammography equipment gets the official blame for 72 missed cases of breast cancer out of 53,104 mammograms in the Australian state of South Australia.

According to an independent report, radiologists were slow in learning, or were never properly trained, to use the digital equipment.

BreastScreen SA, the state branch of the national government mammography screening program, began switching from film to digital mammography on September 6, 2010. Before the transition was finally completed on October 18, 2012, BreastScreen SA became concerned that the rate of breast cancers detected had decreased sharply.

Eventually, 53,104 digital mammograms taken from September 6, 2010, through June 30, 2012, were reread by radiologists from other Australian states. All of the initial readings had been negative, but rereadings revealed 72 cases of breast cancer.

An independent report released last week concluded:

Screen reading practices were identified as a major cause of the lower than expected cancer reduction rate under digital mammography.

The report said that of the women who received mammograms from September 6, 2010, through June 30, 2012, 1.26 percent were recalled for further testing. That low recall rate triggered the investigation. “Modelling has shown that cancer detection rates are optimal at the 4% level,” the report said.

“This review was not designed to determine reasons behind the reduced recall rates,” the report said. “However, it is thought that it relates primarily to failure of recognition of differences in the mammographic appearances of breast lesions between analogue mammography and digital mammography and changes in reading practices, the so-called learning curve.”

The report recommended a number of changes in reading protocols, all of which BreastScan SA said it had accepted. The report also noted that the outside radiologists who did the rereading found that a significant number of the missed lesions “were not subtle lesions” and should have been caught fairly easily.

The South Australian health minister, Jack Snelling, took responsibility for the problem and said it wouldn’t happen again. He also apologized to the women whose cancers were missed. Snelling was quoted by the national newspaper The Australian.

Related CME seminar: UCSF Breast Imaging and Digital Mammography (free domestic shipping!)


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