Strategy and Measures to Improve Breast Imaging Services at General Facility Hospital

Abstract

Background

Breast cancer is one of the most commonly diagnosed cancers worldwide and is the most common cancer affecting women in Saudi Arabia. This research aims to highlight the strategy and measures needed to improve breast imaging services focusing on imaging justification, optimization, acquisition, and interpretation.

Patients and Methods

The Find, Organize, Clarify, Understand, Select – Plan, Do, Check, Act (FOCUS-PDCA) methodology of quality improvement was adopted. In phase one, identification of deficiencies or problems was made by evaluating imaging requests, time management, workforce, and resource utilization between 2015 and 2017 (3 years). These were presented on a fishbone diagram. Optimization of services was made by appointing or training reliable breast imaging staff. The action plan and changes were subsequently implemented and their effects, in terms of improvement in justified imaging requests, increase in the number of screening studies, imaging acquisition, reporting by specialists, and adherence to a standard Breast Imaging-Reporting and Data System mammography reporting format, were evaluated from 2018 till the end of 2021.

Results

Total mammographic studies almost doubled in a year (from an average of 225 per annum in preintervention years to 443 exams postintervention), in which mammography screening studies increased three times in the postintervention period. Breast imaging referrals were streamlined primarily under primary care physicians and breast surgeons, with more than double referrals for the screening studies. Standard reporting was achieved in more than 90% of studies compared to 60% initially.

Conclusion

Breast imaging services can be improved by promoting awareness and education to patients and primary physicians, streamlining imaging requests, properly utilizing time and resources, ensuring imaging acquisition, and interpretation by specialists.

Keywords

breast cancer - screening - imaging - quality assessment - fishbone diagram - FOCUS-PDCA

Introduction

Breast cancer is one of the most commonly diagnosed cancers worldwide, accounting for 11.6% of all cancers, and is the most common cancer affecting women in Saudi Arabia.[1] [2] In Saudi Arabia, breast cancer is the most common malignancy among women, accounting for 17.7% of all cancers and 30.9% of all cancers reported in women of all ages.[3] [4]

Early detection of breast cancer and receiving state-of-the-art screening and diagnostic facilities are critical for preventing and reducing breast cancer mortality.[2] [5] [6] Most recent data in breast cancer research showed that with earlier diagnosis and better treatment options, breast cancer survival in women is steadily increasing, and the 5-year net survival rate in high-income countries is now 85 to 90%.[6] Currently, there are three methods of clinical breast imaging, with examination used as the primary diagnostic tool: mammography, magnetic resonance imaging (MRI), and ultrasound are the standard methods of screening and diagnosis.[7] [8] [9] In the Kingdom of Saudi Arabia (KSA), however, three main screening methods are used: self-breast examination, clinical breast examination (CBE), and mammographic screening.[10] [11]

Since the advent of mammography about 30 years ago, imaging of the breast with this method has improved significantly.[7] [8] [9] Whereas film mammography is the gold standard for breast cancer imaging. Mammography has been used as a screening tool for breast cancer detection particularly in women at and above the age of 40 and for high-risk women under 40 years. Although screening interval is different in different parts of the world, yet its role as a screening tool for cancer detection and suspicious microcalcifications has been well documented.[8] [11] [12] Breast Imaging-Reporting and Data System (BI-RADS) is a classification system proposed by the American College of Radiology and released in 1993.[12] [13] [14] BI-RADS was implemented to standardize risk assessment and quality control for mammography and ensure consistent reporting.[9] [11] Another important aspect of the BI-RADS was categorizing the overall assessment of the imaging findings, providing an approximate risk of malignancy. BI-RADS was designed to be flexible and adaptable to accommodate new methods and research.[11]

Mammography was introduced in the KSA in 2002, and in 2007 a nationwide breast cancer screening center was opened, in which 1,215 people were examined in the first year of its operation.[10] Moreover, the Saudi Ministry of Health provides free mammography services. Despite the availability of screening services throughout the country, the National Saudi Health Interview Survey 2015 reported a significantly lower rate of breast cancer screening (8%); 57% of respondents reported not having had a CBE in the past year and 92% reported never having had a mammogram.[11]

Given the low rates of medical screening for breast imaging, it was hypothesized that improving the interpretive performance of specialized breast radiologists, as demonstrated in studies with large national databases, could potentially lead to higher willingness of Saudi women to undergo screening. Therefore, this quality improvement research project was initiated to examine how the improvement strategy required and implemented to transition breast imaging services from a general to a specialized facility contributes to higher targeting rates, prudent use of workforce, and reporting of imaging.

Patients and Methods

This quality improvement research was carried out in the radiology department at the general facility hospital in Dhahran. The methodology of the quality improvement FOCUS-PDCA (Find, Organize, Clarify, Understand, Select – Plan, Do, Check, Act) was adopted. As part of this research, in phase one, gaps or problems were identified by evaluating imaging requests, workforce, and general facilities over a 3-year period from 2015 to the end of 2017. Special forms indicating proper referrals, image quality, and checking for standardized reporting were developed to address the research aims.

The results were presented in a fishbone diagram. This was followed by the development of a fishbone diagram (cause and effect diagram) to visualize the root cause analysis (RCA) of the problem and generate ideas for possible actionable changes, as shown in [Fig. 1]. The head of the fish represents the problem that has arisen or the area for improvement; in this case, improving the quality of breast cancer imaging. The bone of the diagram corresponds to the main category of causes associated with the effect ([Fig. 1]).

Fig. 1 The fishbone diagram demonstrates areas of improvements.

In the second phase, the action plan and changes were implemented and evaluated from 2018 until 2021. Outline of research design, organizing a team, explanation of changes, adaptation to the local environment prior to implementation, and multiple measures were used to implement or enforce changes. Awareness sessions and regular meetings were organized to improve the flow of breast screening referrals or requests from the clinicians, including primary care physicians and other specialties. The rationale for imaging requests in terms of screening and diagnostic studies (in combination with ultrasound or tomosynthesis) was ensured by the involvement of referral services and patients.

Optimization of services was made by appointing or training reliable breast imaging staff. In addition, specialized breast technicians and radiologists were recruited to improve the quality and interpretation of breast images. BI-RADS lexicon and interpretation were strictly followed. Further imaging or test (biopsy) and referral to a breast surgeon were ensured if needed after effective communication with the patients and their referring services.

Results

The current research consisted of two phases. In phase one, gaps or problems were identified by evaluating imaging requests, workforce, and general facilities over a 3-year period from 2015 to the end of 2017. Phase one allowed to develop a fishbone diagram and look at the cause and effect relationships, thereby determining next steps ([Fig. 1]). Thus, the research findings resulted in the following areas of improvement that required definite actions ([Table 1]).

Table 1 Problems, strategy, measures, and action for improvement

Areas needing improvement	Problems and deficiencies	Strategy and measures	Action
A. Imaging Justification (Patient and clinicians' awareness and orientation)	Lack of awareness among patients (or women) and clinicians	Improving patients' awareness toward signs and symptoms of breast cancer Improving patients' timely referral by clinicians	Regularly organizing patients' awareness programs and lectures for clinicians in a week or month
	Random referral of breast imaging requests	Streamlining the referral by GP and breast surgeon	Monthly meetings with clinicians and breast surgeon
B. Imaging optimization (Time allocation and imaging acquisition)	Lack of breast team and department policies	Organizing breast committee and establishing breast imaging unit	Regular monthly meeting with department Head to discuss progress and feedback
	Random distribution of breast imaging requests	Segregating breast imaging (mammography) requests into screening and diagnostic	Weekly meetings with clinicians and radiology reception
	Random allocation of timings of breast imaging in between routine scheduling	Allotment of specific timings in a day for screening and diagnostic studies	Weekly meetings and discussions with Chief tech, radiology reception, and staff radiologists
	Breast imaging acquisition by general technicians	Breast imaging needs to be performed by dedicated breast imaging technicians	Monthly meetings with chief tech, selection, and training of technicians
C. Imaging interpretation (Standard reporting)	Random reporting of breast imaging by general radiologists	Breast imaging reporting by dedicated breast imaging specialist	Monthly meeting with staff radiologists

Abbreviation: GP, general practitioner.

Imaging Justification: Creating Awareness among Population and Clinicians for Medical Advice, and Timely Referrals for Appropriate Imaging

There was a lack of awareness among patients and clinicians, in addition to the random referral of breast imaging requests. Therefore, a strategy was developed to raise patient awareness about the signs and symptoms of breast cancer, early seeking of medical advice in case of symptoms, and timely patient referral by clinicians and breast surgeons to get screening or diagnostic tests. The action plan included the regular organization of patient awareness programs and lectures for clinicians on a weekly or monthly basis and monthly meetings with clinicians and breast surgeons ([Table 1]). This step allows for improved patient knowledge and forms a long-term perspective to offer similar strategies in other health care facilities in Saudi Arabia.

Imaging Optimization: Allocating Proper Time for Screening and Diagnostic Studies, and Imaging Acquisition by Dedicated Staff

The lack of breast team and department policies, random allocation of timings for breast imaging (in between routine scheduling), and breast imaging acquisition by general technicians were identified as key problem areas for improvement. The strategy to address this problem included organizing a breast committee and establishing a breast imaging unit, segregating breast imaging (particularly mammography) requests into screening and diagnostic ([Fig. 2]), distribution of specific timings in a day for screening and diagnostic studies, and breast imaging acquisition by dedicated breast imaging technicians assisted by dedicated nursing staff. Furthermore, the action plan included regular monthly meetings with the department head to discuss progress and feedback, weekly meetings with clinicians and radiology reception, weekly meetings and discussions with chief tech, radiology reception, and staff radiologists, monthly meetings with chief tech, selection, and training of technicians ([Table 1]). This step not only improved the efficiency of physicians but also allowed for smarter resource allocation, improved time management, and an increase in the number of proper screening referrals.

Fig. 2 Strategy for streamlining breast imaging referral requests and procedural pathways.

Imaging Interpretation: Ensuring Standard Reporting and Providing Feedback/Auditing

Random reporting of breast imaging by general radiologists was identified as a deficient area for quality reporting. As a result, a strategy was developed to address this problem whereby a dedicated breast imaging specialist (a breast radiologist) should interpret breast imaging studies. The action plan included monthly meetings with staff radiologists ([Table 1]).

Outcome of Interventions

Total breast imaging mammographic studies almost doubled in a year. From an average of 225 per annum in preintervention years, the number increased to 443 annual exams postintervention. In addition, screening studies increased three times in the postintervention period from 78 in 2015 to 325 in 2021 ([Fig. 3A] and [B]).

Fig. 3 Line graph with red line highlighting time of intervention shows: (A) the improved number of breast imaging referrals and studies during the pre- and postintervention period; (B) the improved number of screening and diagnostic breast imaging studies during the pre- and postintervention period; and (C) main referral specialties for the breast imaging requests with an increasing trend from the primary care services.

Compared to random breast imaging referrals in 2015, in 2021, breast imaging referrals were streamlined mainly under two modalities: family/community medicine: 67 referrals in 2015 versus 172 referrals in 2021, and breast surgery: 78 referrals in 2015 versus 126 referrals in 2021 ([Fig. 3C]). In addition, more than double referral for screening studies from the primary care physicians highlighted increased patients' orientation and seeking medical advice. Standardized reporting (i.e., BI-RADS) was achieved in more than 90% of studies compared to 60% initially. This highlights the importance of consistent accountability in breast cancer diagnosis and treatment, which can be achieved through a systematic and carefully planned approach to task assignment and patient care.

Discussion

The current study aimed to highlight the improvement strategy needed and implemented to move breast imaging services from general to specialist and evaluate outcomes in terms of imaging targeting, workforce utilization, and imaging reporting. The areas of weakness and deficiencies were evaluated by identifying these on a fishbone diagram. The fishbone diagram is a widely used patient safety tool that helps to facilitate the discussion of RCA.[15] [16] Originally developed for use in quality assurance programs in the manufacturing industry, fishbone diagrams are now widely used as a patient safety tool for designing RCA of system errors in health care. These diagrams allow the categorization of complex medical errors into discrete categories, understanding why a problem occurred, and finding root causes.[15] [16]

FOCUS-PDCA is an improvement methodology introduced by quality expert Dr. Edwards Deming in the 1950s and has been used by many organizations to guide their improvement efforts.[17] [18] This methodology aims to help identify and solve problems and is also applicable to continuously improving the quality of various clinical aspects.[17] [18] The modification methodology used in this research resulted in several outcomes. The fishbone method has proven to be fruitful in increasing the number of patients seeking health care, especially in the primary health care sector, and increasing the number of referrals to specialists outside the hospital given timely and effective management options. This finding is consistent with the study by Reilly et al, who described how two health centers had applied a fishbone diagram to study diagnostic errors in a way that better suits the patient safety and educational needs of their respective institutions. As a result, multiple contributors to diagnostic errors that might have gone unnoticed were identified, and specific measures were developed to prevent the recurrence.[19]

The effectiveness of mammography screening and the corresponding frequency of screening among women of different age groups is a subject of continued debate.[20] [21] [22] However, understanding the multilayered impact on cancer screening is critical to designing interventions to improve evidence-based screening.[20] [21] [22] Therefore, the current research focused on various aspects of breast imaging services and care simultaneously. This included the patient-clinician-radiologist-surgeon chain, promoting awareness among patients and women toward signs and symptoms of breast cancer, breast self-examination, and seeking early medical advice. In addition, it was important to engage primary physicians for discussions regarding proper referral and selection of imaging requests. For instance, ultrasound as a baseline modality for a woman under 40 years, a mammogram for a woman above 40 years, or a patient with a known family history of breast cancer.

According to the World Health Organization,[23] a timely referral from primary to secondary care is essential for early diagnosis as late-stage cancer is still common. Early diagnosis improves cancer outcomes by providing care at the earliest stage.[24] [25] In addition, breast screening in asymptomatic women reduces breast cancer mortality through early diagnosis at the preclinical stage, and timely referral of patients to appropriate specialists improves treatment outcomes.[24] [25] [26] [27] Thus, the approach of current research in segregating breast imaging requests, particularly mammography, whether screening or diagnostic, helped in proper time allocation and resource utilization. A screening study was not coupled with an ultrasound, but a diagnostic mammogram was linked to onsite-radiologist interpretation and dedicated ultrasound. Finally, in this research, timely reporting and ensuring standardized reporting was achieved in 90% of cases by the breast radiologist, compared with 55% initially before the intervention. It has also increased confidence in the need for early referral to a specialist or further investigation when needed, thereby helping to improve patient management and care.

Overall, the findings and conclusions of the current research, consistent with international evidence, can provide the basis for a strategic plan and implementation of effective breast imaging services, from general to specialized care. This study focused mainly on key aspects of general breast imaging services provided by a general facility hospital; however, for improving imaging services in a specialist center many other aspects need to be considered, namely, bulk and number of batch reading of mammograms by an individual radiologist, double-reading, computer-aided detection, advanced imaging services (like tomosynthesis, elastography, MRI, and imaging biopsies), patient feedback, auditing, and even newer strategies (like radiogenomics).[28]

Future multicenter studies evaluating the impact of manpower and resource utilization may also be considered for determining the efficiency of a breast imaging unit. Knowledge and awareness remain the key to the success of any initiative or screening program and to overcome any social hindrances and inertia toward its execution particularly in Saudi Arabia.[29]

Successful breast cancer detection programs provide a uniform, standardized system for interpreting breast images.[30] [31] The use of BI-RADS, FOCUS-PDCA, and the fishbone diagram in this study improved communication between radiologists and other health care providers. Given the rise in the incidence of breast cancer in Saudi Arabia and the reluctance of patients to be screened, this example can serve as a basis for future research. In addition, this approach to improving services allowed to monitor patient outcomes by guiding performance targets. However, since there is an ongoing need for better quality, radiologists and other health care providers can practice this research model and continue to share their skills and acquired knowledge.[30] [31]

Despite the positive results of this study, there is also a need to understand better the limits of these interventions and how they should be combined in a meaningful way, as more than one study is required to assess quality for the entire country. Therefore, it is important to measure efficacy consistently to allow for comparison, taking into account differences in patient populations and other confounding factors, that is, quality improvement depends on data collection and sharing short- and long-term effects rather than adherence to specific recommendations.[32] [33] Further to this, although this study did not examine early detection rates, reduction in misdiagnosis, or mortality, standardization of the process through FOCUS-PDCA has created a foundation for future studies that can examine broader objectives. In addition, future studies may benefit from qualitative data collection involving both physicians and patients examining perceptions of breast cancer screening, barriers, and facilitators.

Breast ultrasound represents an important step toward diagnosis. The successful implementation of full BI-RADS requires advanced feedback mechanisms and significant experience of medical professionals and an infrastructure capable of collecting patient data and providing follow-up in specialized diagnostic centers for further improvement.[32] [33] [34] [35] [36] Despite the complexity, addressing these issues will play a decisive role in developing quality programs for the early detection of breast cancer. Finally, if applied correctly, this strategy can improve the care of other noncommunicable disease patients requiring interdisciplinary care.

This research should be considered in light of several limitations. First, there was a staff shortage, both of a technologist and breast radiologists. During the vacation or leave period, the alternatives were general technologist and general radiologist to acquire and interpret images, respectively, that impacted the outcomes. Second, the lack of mammographic breast biopsy and MRI units led to many patients being referred to a specialized hospital, thereby increasing the number of lost to follow-ups at our hospital. Third, there was an increase in outside imaging referral requests (from other hospitals due to machine maintenance issues or lack of facilities there) that were difficult to accommodate under limited working hours due to an already tight schedule. Third, while this study addressed common gaps and challenges in terms of patient reluctance to be screened, as well as issues at one center, more research is needed across various institutions in the Kingdom that can improve performance of health care providers and enrich the knowledge of medical students. Finally, factors that may have influenced the outcome but were not examined in this study, such as changes in the health care system and sociocultural factors influencing patient behavior, should also be explored in more detail.

Conclusion

Based on observations from this research, it is safe to conclude that breast imaging services can be improved by raising awareness and educating patients and primary care physicians, monitoring and activating imaging requests methodically, ensuring imaging acquisition and interpretation through specialists, and following standards. These improvements can serve as a model for other hospitals in Saudi Arabia that can improve the perception of the general public, especially women, regarding cancer awareness and thus contribute to higher screening rates. Local standard policies and rules should be updated to overcome obstacles and promote better service outcomes. When performing actions, constant monitoring and teamwork are required. This research can serve as a reference guide for creating new policies and guidelines for a quality breast imaging center.

Conflict of Interest

None declared.

Data Availability Statement

Data associated with the research will be provided upon reasonable request from the authors.

Authors' Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by K.B.W., A.A.G.A., S.A.A., and M.Z.U.H. The first draft of the manuscript was written by K.B.W., A.W., L.H.A.-J., M.A.A. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Compliance with Ethical Principles

This article does not contain any studies with human or animal subjects performed by any of the authors.

• References

• 1 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68 (06) 394-424
• 2 Waheed KB, Hassan MZU, Hassan DA. et al. Breast cancers missed during screening in a tertiary-care hospital mammography facility. Ann Saudi Med 2019; 39 (04) 236-243
• 3 Culbertson MG, Bennett K, Kelly CM, Sharp L, Cahir C. The psychosocial determinants of quality of life in breast cancer survivors: a scoping review. BMC Cancer 2020; 20 (01) 948
• 4 American Cancer Society. Recommendations for the Early Detection of Breast Cancer. 2021 . Accessed December 30, 2021 at: https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection.html
• 5 Iranmakani S, Mortezazadeh T, Sajadian F. et al. A review of various modalities in breast imaging: technical aspects and clinical outcomes. Egypt J Radiol Nucl Med 2020; 51: 1-22
• 6 Drukteinis JS, Mooney BP, Flowers CI, Gatenby RA. Beyond mammography: new frontiers in breast cancer screening. Am J Med 2013; 126 (06) 472-479
• 7 World Health Organization. International Agency for Research in Cancer (IARC) Saudi Arabia. Source: Globocan 2018. . Accessed January 5, 2022 at: https://gco.iarc.fr/today/data/factsheets/populations/682-saudi-arabia-fact-sheets.pdf
• 8 Narayan AK, Lee CI, Lehman CD. Screening for breast cancer. Med Clin North Am 2020; 104 (06) 1007-1021
• 9 Coleman C. Early detection and screening for breast cancer. Semin Oncol Nurs 2017; 33 (02) 141-155
• 10 AlSaleh KA. Efficacy of breast cancer screening program in Kingdom of Saudi Arabia. Saudi Med J 2022; 43 (04) 428-430
• 11 Abulkhair OA, Al Tahan FM, Young SE, Musaad SM, Jazieh AR. The first national public breast cancer screening program in Saudi Arabia. Ann Saudi Med 2010; 30 (05) 350-357
• 12 da Costa Vieira RA, Biller G, Uemura G, Ruiz CA, Curado MP. Breast cancer screening in developing countries. Clinics (Sao Paulo) 2017; 72 (04) 244-253
• 13 Gastounioti A, McCarthy AM, Pantalone L, Synnestvedt M, Kontos D, Conant EF. Effect of mammographic screening modality on breast density assessment: digital mammography versus digital breast tomosynthesis. Radiology 2019; 291 (02) 320-327
• 14 Magny SJ, Shikhman R, Keppke AL. Breast Imaging Reporting and Data System. August 31, 2021. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; ; January 2022
• 15 Brown SL, Massoudi BL, Pina JM, Madamala K. Public health quality improvement exchange: a tool to support advancements in public health practice. Online J Public Health Inform 2018; 10 (03) e223
• 16 Cox M, Sandberg K. Modeling causal relationships in quality improvement. Curr Probl Pediatr Adolesc Health Care 2018; 48 (07) 182-185
• 17 Kryzanowski J, Bloomquist CD, Dunn-Pierce T, Murphy L, Clarke S, Neudorf C. Quality improvement as a population health promotion opportunity to reorient the healthcare system. Can J Public Health 2019; 110 (01) 58-61
• 18 Kudla AU, Brook OR. Quality and efficiency improvement tools for every radiologist. Acad Radiol 2018; 25 (06) 757-766
• 19 Reilly JB, Myers JS, Salvador D, Trowbridge RL. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl) 2014; 1 (02) 167-171
• 20 Duffy SW, Vulkan D, Cuckle H. et al. Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial. Lancet Oncol 2020; 21 (09) 1165-1172
• 21 Oshima SM, Tait SD, Fish L, Greenup RA, Grimm LJ. Primary care provider perspectives on screening mammography in older women: a qualitative study. Prev Med Rep 2021; 22: 101380
• 22 Haas JS, Barlow WE, Schapira MM. et al; PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium. Primary care providers' beliefs and recommendations and use of screening mammography by their patients. J Gen Intern Med 2017; 32 (04) 449-457
• 23 World Health Organization. Promoting Cancer Early Diagnosis. 2021 . Accessed December 29, 2021 at: https://www.who.int/activities/promoting-cancer-early-diagnosis#:~:text=Early%20diagnosis%20of%20cancer%20focuses,and%20higher%20costs%20of%20care
• 24 Greenfield G, Foley K, Majeed A. Rethinking primary care's gatekeeper role. BMJ 2016; 354: i4803
• 25 National Cancer Institute. Mammograms. 2021 . Accessed January 2, 2022 at: https://www.cancer.gov/types/breast/mammograms-fact-sheet#what-is-a-mammogram
• 26 Valier ARS. Looking to improve your practice? Consider the science of quality improvement to get started. J Athl Train 2020; 55 (11) 1137-1141
• 27 Ramzi S, Cant PJ. Comparison of the urgent referral for suspected breast cancer process with patient age and a predictive multivariable model. BJS Open 2021; 5 (02) zraa023
• 28 Leithner D, Horvat JV, Ochoa-Albiztegui RE. et al. Imaging and the completion of the omics paradigm in breast cancer. Radiologe 2018; 58 (Suppl. 01) 7-13
• 29 Al-Zalabani AH, Alharbi KD, Fallatah NI, Alqabshawi RI, Al-Zalabani AA, Alghamdi SM. Breast cancer knowledge and screening practice and barriers among women in Madinah, Saudi Arabia. J Cancer Educ 2018; 33 (01) 201-207
• 30 National Cancer Policy Forum, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. Assessing and Improving the Interpretation of Breast Images: Workshop Summary. Washington, DC: National Academies Press (US); ; October 23, 2015
• 31 Pollack EB, Abbey G, DuCharme P. et al. Developing breast imaging services in low-resource settings. Appl Radiol 2022; 51 (02) 28-32
• 32 Ginsburg O, Yip CH, Brooks A. et al. Breast cancer early detection: a phased approach to implementation. Cancer 2020; 126 (Suppl. 10) 2379-2393
• 33 González Moreno IM, Trejo-Falcón J, Matsumoto MM. et al. Radiology volunteers to support a breast cancer screening program in Peru: description of the project, preliminary results, and impressions. Radiologia (Engl Ed) 2022; 64 (03) 256-265
• 34 Scheel JR, Nealey EM, Orem J. et al. ACR BI-RADS use in low-income countries: an analysis of diagnostic breast ultrasound practice in Uganda. J Am Coll Radiol 2016; 13 (02) 163-169
• 35 Mariani G, Kasznia-Brown J, Paez D. et al. Improving women's health in low-income and middle-income countries. Part I: challenges and priorities. Nucl Med Commun 2017; 38 (12) 1019-1023
• 36 Hickman SE, Baxter GC, Gilbert FJ. Adoption of artificial intelligence in breast imaging: evaluation, ethical constraints and limitations. Br J Cancer 2021; 125 (01) 15-22

Publication History

Article published online:
31 March 2025