Elmore J G, Wells C K, Lee C H, Howard D H, Feinstein A R
Department of Internal Medicine, Yale University, New Haven, Conn.
N Engl J Med. 1994 Dec 1;331(22):1493-9. doi: 10.1056/NEJM199412013312206.
Despite the proved value of mammography in screening for breast cancer, its efficacy depends on radiologists' interpretations. The variability in such interpretations is not well understood.
Using a technique of stratified random sampling, we selected 150 mammograms obtained in 1987: 27 from women with histopathologically confirmed breast cancer and 123 from women with no evidence of breast cancer after three years of follow-up examinations. Ten radiologists, who were unaware of the diagnoses and research hypothesis, each interpreted the 150 mammograms. Disagreement was analyzed within pairs of the 10 radiologists, as well as for the group of 150 women as a whole.
The diagnostic consistency between pairs of radiologists was moderate, with a median weighted percentage of agreement of 78 percent (weighted kappa, 0.47). The frequency of the radiologists' recommendations for an immediate workup ranged from 74 to 96 percent for mammograms from the women with cancer and from 11 to 65 percent for films from the women without cancer. A substantial disagreement in management recommendations--in which one radiologist recommended routine follow-up and another recommended a biopsy for the same patient--occurred in 3 percent of the pairwise comparisons but in 25 percent of the comparisons for the group of women as a whole. When two or more radiologists recommended a biopsy for the same patient, a disagreement in the stated location (right or left breast) occurred in 2 percent of the pairwise comparisons among the radiologists but in 9 percent of comparisons for the group of women as a whole. Because some disagreement was likely, given that 10 radiologists read each film, the pairwise comparison is a more conservative estimate of disagreement.
Although mammography is of value in screening women for breast cancer, radiologists can differ, sometimes substantially, in their interpretations of mammograms and in their recommendations for management. Efforts to improve accuracy and reduce variability in interpretation may increase the effectiveness of mammography in detecting early breast cancers.
尽管乳房X线摄影术在乳腺癌筛查中的价值已得到证实，但其功效取决于放射科医生的解读。对此类解读的变异性尚了解不足。
我们采用分层随机抽样技术，选取了1987年获取的150份乳房X线照片：27份来自组织病理学确诊为乳腺癌的女性，123份来自经过三年随访检查无乳腺癌证据的女性。10位不知晓诊断结果和研究假设的放射科医生分别对这150份乳房X线照片进行解读。分析了10位放射科医生两两之间的分歧，以及150名女性整体的分歧情况。
放射科医生两两之间的诊断一致性中等，一致率加权中位数为78%（加权kappa值为0.47）。对于癌症女性的乳房X线照片，放射科医生建议立即进行进一步检查的频率在74%至96%之间；对于无癌症女性的乳房X线照片，这一频率在11%至65%之间。在3%的两两比较中出现了管理建议方面的重大分歧——即一位放射科医生建议常规随访，而另一位建议对同一患者进行活检——但在女性整体的比较中，这一比例为25%。当两名或更多放射科医生建议对同一患者进行活检时，在放射科医生两两之间的比较中，2%出现了所提及位置（右乳或左乳）的分歧，但在女性整体的比较中，这一比例为9%。鉴于每位放射科医生都阅读了每一张照片，必然会存在一些分歧，因此两两比较是对分歧的一种更为保守的估计。
尽管乳房X线摄影术在筛查女性乳腺癌方面具有价值，但放射科医生对乳房X线照片的解读及其管理建议有时可能存在很大差异。提高准确性并减少解读变异性的努力可能会提高乳房X线摄影术在检测早期乳腺癌方面的有效性。
