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4) breast compression

Right

2) scattered fibroglandular densities 4) extremely dense

Findings: Yes No

Note: If there are NO findings, the assessment is: (1) (N) negative—return to screening

FIGURE 11 Observer form for mammograms: This part is completed for each case.

to what is done in clinical practice except for the requirement that the markings be made on copies. The judges were allowed to use a magnifying glass to examine the films.

Although the judging form is not standard, the ACR Lexicon is used to report findings, and hence the judging requires no special training. The reported findings permit subsequent analysis of the quality of an image in the context of its true use, finding and describing anomalies and using them to assess and manage patients.

To confirm that each radiologist identifies and judges a specific finding, the location of each lesion is confirmed both on the clear overlay and the judging form. Many of these lesions were judged as "A" (assessment incomplete), since it is often the practice of radiologists to obtain additional views in two distinct scenarios: (1) to confirm or exclude the presence of a finding, that is, a finding that may or may not represent a true lesion, or (2) to further characterize a true lesion, that is, to say a lesion clearly exists but is incompletely evaluated.

The judging form allows for two meanings of the "A" code. If the judge believes that the finding is a possible lesion, this is indicated by answering "yes" to the question "are you uncertain if the finding exists?" Otherwise, if the lesion is definite, the judges should give their best management decision based on the standard two-view mammogram.

The initial question requesting a subjective rating of diagnostic utility on a scale of 1-5 is intended for a separate evaluation of the general subjective opinion of the radiologists of the images. The degree of suspicion registered in the Management portion also provides a subjective rating, but this one is geared towards the strength of the opinion of the reader regarding the cause of the management decision. It is desirable that obviously malignant lesions in a gold standard should also be obviously malignant in the alternative method.

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