For clarifying both the current circumstances and problems of closed examination performed at facilities equipped for detailed examination in Mie Prefecture, we analyzed the results of closed examinations carried out on 1,001 responders who were selected by primary mammography screening done at 87 facilities in 2006. The overall breast cancer detection rate was 3.3%, with a range of 0-10.3%, for facilities that included family doctors, and 13 hospitals having performed the closed examination on 21 women or more. Although the location of a facility for closed examination and the background of examinees might be taken into consideration, it appeared that a higher cancer detection rate was obtained when more pathological examinations were carried out, and that the indications for pathological examination varied among physicians. At facilities where pathological examinations were frequently performed, mostly clinicians specializing in breast cancer performed either fine-needle aspiration biopsy or large-needle biopsy (a specific aspiration biopsy technique for calcified lesions), whereas at facilities with low rates of pathological examination, most surgeons not specializing in breast cancer performed open biopsy.
These results suggest a need to draw up guidelines for detailed examination, including the standard of facilities for closed examination, clinicians who perform the examinations, and the examination methods.

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In cancer screening, especially in organized screening, it is essential to employ effective and appropriate methodology. Although we have organized a mammographic screening system in accordance with the Japanese Guidelines for Quality Assurance in Mammography Screening in Sendai city, a high recall rate and low positive predictive value indicate that the results have been unfavorable. We checked various indices of the screening process and analyzed the reasons for these results. Unfamiliarity of the first screener with mammography reading and unfamiliarity with a new screening system were factors affecting the poor results. Therefore the personnel were required to participate in an annual lecture class on mammography screening. We also held a meeting to share consensus of screening with all concerned. An obvious improvement in the indices of the screening process was seen; for example, the recall rate was reduced from 10.1% in 2001 to 6.6% in 2006 without a fall in the cancer detection rate. To perform good screening, it is important to control not only screening accuracy but also improvement of all screening systems including detailed examination. Although there are many problems involved in the smooth administration of such a system, it is necessary to maintain efforts to properly understand the importance of quality control and to make the screening efficient.

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We made an effort to resolve the problems between mammography screening institutions and our hospital by means of lectures, conferences and frank exchanges of views in a local society for radiographers specializing in breast imaging. Lack of detection of abnormal findings in screening mammography is addressed at our hospital by asking recalled individuals to bring their screening mammograms. The incidence of a specific finding being recorded as abnormal each time may arise for two reasons: (1) a previous report is not referred to when reading the mammogram, and (2) comparative mammography is not available at some screening institutions. In order to solve these problems, supplying a detailed report and asking for the cooperation of the reading physician and radiographer at each institution did not yield good results. As a result of advice from the radiographer, there is now a decreased incidence of recalled individuals initially visiting their home doctor, and not a breast specialist, and subsequently consulting a breast surgeon after obtaining a letter of introduction from the home doctor.

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Although the introduction of mammography for breast cancer screening has been slightly delayed in Akita Prefecture, the quality control of mammographic screening carried out by the Akita Foundation for Health Care has recently been maintained at a satisfactory level. In the year of 2007, the breast cancer detection rate, the rate of closed examination, the rate of responders for closed examination, and the positive predictive value were 0.22%, 8.7%, approximately 80% and 3.2%, respectively, which were almost the same levels as the national standard. Since women who were recommended to undergo a closed examination did not bring an initial screening mammogram, they underwent mammography again within a short time following the first one. About 15% of all facilities for closed examination did not report the results. These two points should be amended in the future.
We have held a study meeting for mammography reading once a year at one location in order to maintain good communication between facilities for primary screening and those for closed examination. The materials selected for presentation were about 50 examinee mammograms taken in the previous year which seemed to have educational value. We discussed the validity of the reported diagnoses. One of the selected cases was initially reported as a benign lesion, but the final diagnosis was changed to breast cancer after a detailed examination.
Of a total of 30 facilities for detailed examination in Akita Prefecture, only 11 were the authorized imaging units, among which the specialized doctors authorized by the Japan Breast Cancer Society resided at four institutions and mammography-qualified doctors resided at three. Although it was difficult to derive a distinct figure, facilities for detailed examination appeared to have individually different levels of ability. In the future, the standard that a facility for detailed examination should fulfill must be determined from the standpoint of quality control. At least in Akita Prefecture, however, urgent limitation of facilities for detailed examination to only authorized institutions seems to be impractical. In order to further promote breast cancer screening, we must improve both the quality of facilities for detailed examination and communication between facilities for primary screening and those for closed examination.

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We report (1) the current status of cooperation between facilities for primary screening of the general public, those for detailed examination and those for treatment in Fukui Prefecture and (2) the present screening status for the working population, and discuss quality control from the standpoint of information delivery and information management.
All information about breast cancer screening of the general public in Fukui Prefecture has been collected by one foundation from all facilities including those for primary screening, those for detailed examination and those for treatment, so that the quality of each screening step can be evaluated periodically. In contrast, such evaluation has been impossible for screening of the working population, because the information has not been unified.
In order to maintain high quality of breast cancer screening, it is important not only to confirm the quality of each step at screening facilities, namely those for primary screening, for detailed examination and for treatment, but also to transmit information precisely between those facilities and to use it effectively. For this purpose, a system need to be established. Hereafter, in addition to quality control of persons and equipment, it is necessary to pay attention to the quality control of information management, and to acquire financial support for establishing a control system. Legislative measures are urgently needed for screening of the working population.

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Breast cancer screening in Japan actually started in 2004, when mammography was first introduced, and the need for strict quality control began to be promoted under the leadership of the Japan Association of Breast Cancer Screening. However, there have been a surprisingly small number of reports on quality control of detailed examinations. In fact, the standards required by a facility for detailed examinations were established only recently by the Association.
Detailed examination has usually been carried out at hospitals dealing with health insurance. The detection rate of breast cancer diagnosed at these hospitals is known as the “ positive predictive value ” (PPV). The PPV is an index figure representing an individual facility's ability to detect breast cancer by detailed examination, but almost no reports have adopted PPV as a standard for hospital evaluation. Results of detailed examination are reported to both facilities for primary screening and cities, towns and villages, and then the results are registered at municipal health centers and by the prefectural government. The prefectural government collects all reports from municipalities and organizes a central database, from which PPV can be easily calculated.
We analyzed the 3-year screening results for a total population of 83,888 at three primary screening facilities that covered 4/5 of all screenings in Niigata Prefecture. Detailed examinations of 7,364 women were carried out at 105 hospitals, which were selected freely by the responders. The results indicated that PPV could be used as an index showing the ability of individual hospitals to perform detailed examinations.

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We report our primary experience of using a computer-aided detection system (CAD) for soft-copy reading of screening mammograms. Between February and October 2008, 66 of 547 first-time screening mammograms taken at our institution were diagnosed as Category 3 to 5 (recall) on the basis of double reading performed by two physicians. Among these cases, 5 were diagnosed as false negative with the CAD, and the sensitivity was 92%. One false-negative case was Category 4 and finally diagnosed as invasive breast cancer. During the same period at our institution, 1,797 first-time mammograms were obtained for symptomatic patients, of whom 64 were finally diagnosed as having breast cancer histologically. In this group of cases, 6 were diagnosed as false negative using the CAD, and the sensitivity was 915. Because of the small number of cases and our short period of experience, we cannot make a conclusion about the value of the CAD. However, it is necessary to recognize and comprehend the characteristics and applicability of the CAD when used for mammogram reading.

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The majority of digital mammography machines in Japan utilize computed radiography (CR). Despite the overall increase of licensed mammographers and radiologists in Japan who can participate in mammographic screening, their uneven distribution has led to a shortage of such staff in certain, especially rural, localities. A telemammography network using soft-copy CR may be one strategy for resolving this problem.
As one of ten model projects sponsored by the Japanese Ministry of Health, Labor and Welfare, we have constructed the “ Kochi Telemammography Network ” that includes five facilities: Kochi Kenshin Clinic, Kochi Rehabilitation Hospital, and the Tonan, Niyodo and Hata Kenimin Hospitals, which are connected to Kochi Medical School via optic fibers. All of the five facilities have CR, 3PCM (Konica Minolta Health Care) and 2FCR (Fuji Film Medical). The network security is protected by a Virtual Private Network (VPN) and encoding. We interpret soft-copy CR on a 5M-pixel monitor using two kinds of mammography viewing system: Senoadvantage (GEYM) and a viewer produced by Carestream Health.
We are attempting to expand the network to cover all of Kochi Prefecture, thus enabling us to use on-line teleconferencing in the near future. Moreover, connection of the network with others will enable us to consult skilled radiologists at other sites in Japan.
There are still some problems concerning interpretation and network management. Interpretation of two or more kinds of soft-copy CR using one mammography viewing system is difficult without soft-copy standardization. Costs of data transport, data storage and network maintenance exceed the total value of mammography interpretations.

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In order to grasp the current status of breast cancer screening in Japan, a questionnaire was distributed to all local self-governing bodies (LSGB).
The results indicated that breast cancer screening with mammography was performed by 97.9% of LSGB. Breast cancer screening was started for women aged less than 40 years at 11.9% of the LSGB, and from 40 years of age at 86.8%. Breast cancer screening for women aged 30-39 years was performed at 51.2% of the LSGB. The proportions of studies involving palpation, mammography, and US were 34.0%, 24.5%, and 41.6%, respectively.
The coverage of screening invitations between April 2006 and March 2007 was grasped at 94.7% of LSGB. At 23.2%, the coverage was less than 10%, and at 33.8% was 10-19.9%. At 7.1%, the coverage was 50% or more. The national average for coverage was 10%, and was especially low in large cities.
The recall rate for LSBG between April 2006 and March 2007 was 85.2%. At 22.4% of the LSBG, recall rates were less than 5%, and at 15.6% the recall rates were 50% or more.
Screening mammography for women aged 30-39 years needs to be examined in the future. When recall rates exceed 20%, it is necessary to re-examine the accuracy management of breast cancer screening.

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Objectives: To evaluate the supplementary significance of real-time elastography and color Doppler scan with B-mode ultrasonography for the differentiation and characterization of benign and malignant breast lesions, with histologic diagnosis as a reference standard.
Materials and Methods: B-mode ultrasonography with real-time elastography (EUB 7500, Hitachi Medical) and color Doppler scan was carried out in 101 patients (all women, median age, 54 years) with 104 breast lesions between November 2006 and January 2008 at Mastue Red Cross Hospital. After B-mode diagnosis based on the classification of the Japan Association of Breast and Thyroid Sonology, the performance of elastography and color Doppler scan for each B-mode category was compared prospectively with the histological results obtained from resected and biopsied specimens.
Results: Fifteen non-tumor-forming lesions (5 benign, 10 malignant) and 89 tumor-forming lesions (41 benign, 48 malignant) were included. Five of 10 malignant non-tumor-forming lesions showed an elasticity score of 2, and a different evaluation of these lesions by elastography was needed. Of the 32 tumor-forming lesions classified as category 3 by B-mode ultrasonography, 18 (56.3%) with an elasticity score of 3 or below, and less vascularity were all found to be benign, possibly constituting a subgroup for which less invasive diagnostic examination might be justified.
Conclusion: Combined assessment using elastography and color-Doppler imaging may improve the diagnostic accuracy of B-mode ultrasonography, thus providing efficient evaluation after primary breast cancer screening.

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