Internet based screening mammography training: an interview with Dr. Holzhauer

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insights from industryDr. Markus HolzhauerWindsong Radiology, Williamsville NY.

Please can you give a brief introduction to MammoCoach and why it was created?

MammoCoach is an internet based teaching program which helps Radiologists to improve their screening mammography skills.

About half of Radiologists in the USA who participate in breast imaging are estimated to read less than 2,000 screening mammograms per year. This is a suboptimal number, given that only 3-5 cancers in average are seen among 1,000 screening mammograms.

First internet based screening mammography training site simulating real life scenarios and results

What is the minimum number of screening mammograms a radiologist is required to read in the US per year to participate in the screening program? How does this compare to other countries?

In the USA, a Radiologist is required to read a minimum of 480 screening mammograms per year or 960 exams every two years, according to the Mammography Quality Standards Act (MQSA) passed in congress in 1992.

In most European countries, such as in United Kingdom or Germany, a Radiologist has to read a minimum of 5,000 mammograms a year to be able to participate in the Mammography Screening Program.

All mammograms are being read by two independent readers, and if the reads are discordant a third “super reader” makes the final call and discusses the discordant reads in a weekly conference.

Does the number of mammograms read per year correlate to the performance of the radiologist?

Like in any field of medicine, performance correlates with experience. Although the number of screening mammograms is only one factor and there seems to be no linear correlation with the number of screening mammograms being read, there is a certain range (“sweet spot”) of exams which correlates with better performance.

The “sweet spot” of a better performance is likely around the number of 3,000 screening mammogram being read per year.

What experience level is MammoCoach aimed at?

MammoCoach is aimed in particular at Radiologists who read less than 2,000 mammograms per year.

However, since MammoCoach does provide not only a large number and a quantitative feedback for the user, it also provides a qualitative feedback which we believe will be appealing to all Radiologists who want to improve their screening mammography skills.

The quantitative feedback is provided by the fact that the program provides for the user the option to review all screening cases, including statistics and benchmarks and the qualitative feedback by reviewing how experts in the field (“super readers”) would have decided, including what they would not have called back, based on different criteria.

How many cases are there to go through and how realistic are the cases?

There are three steps the user will go through to be able to receive 35 hours of CME category I through the University of Nevada:

First the user will go through 1,000 mammograms in batches of 100 exams and will make a decision which patients will be recalled. Then the user will go through the diagnostic work up of the recalled patients, which were also recalled by the faculty.

User will then be provided with quantitative (false positives, false negatives, benchmarks such as recall rate, cancer detection rate, etc.) feedback and with qualitative (decision of “super readers” and peers, dependent on level of expertise) feedback.

The second step will be for the user to review teaching material in the form of a large electronic file of cases to improve the cognitive and decision skills, tailored to the weakness of the user detected by the program.

The third step will be for the user to go through another 500 screening cases in the same way as in step 1 and to assess improvement of performance based on the benchmarks.

MammoCoach provides a realistic screening environment. Almost all cases have 2 year old prior images, some are baseline exams. Among the 1,000 screening cases are 100 recalls, 15 biopsies and 5 biopsy proven malignancies. All cases are presented on a viewer software which includes the use of a hanging protocol and of an electronic magnification glass.

What feedback is provided and is there a facility to interact with the faculty?

MammoCoach is a purely internet based product without any “brick and mortar” facility at this point.

However, it does not only provide the quantitative and qualitative feedback as already outlined as well as a large collection of teaching cases but also a chat function which allows the user to interact with the faculty individually.

What impact do you hope MammoCoach will have?

MammoCoach closes a gap among available teaching and CME products currently available, since it  focuses entirely on improving screening Mammography skills in a web based 24/7 approach.

MammoCoach has not only the potential to help Radiologists in the US but also could be attractive for other countries, where there is no formal mammography screening program in place.

MammoCoach can also be considered as a contribution by Radiologists into the ongoing discussion with Insurance Companies in the US, how to improve standards for Screening for Breast Cancer.

Are there any other comparable screening mammography training sites available and how does MammoCoach compare?

To our knowledge - and some of us have roots in Europe and Asia - there is no comparable product currently available, worldwide.

In what ways do you hope to improve MammoCoach going forwards?

MammoCoach and its current release will be only the first step which could trigger improvements, which should be based also on the feedback of the users.

One possibility, for example, would be to exchange the images on a regular basis; expand the teaching case collection; incorporate 'brake out' teaching sessions for a small group of users with the faculty online or eventually also to include tomosynthesis.

Where can readers find more information?

Go to

About Dr. Holzhauer

Dr. Holzhauer is a graduate from Heidelberg Medical School/Germany, he completed a Radiology residency at the Medical Center in Hannover (MHH) and a Breast Imaging fellowship at Duke University. He is board certified (ABR) and in private practice at Windsong Radiology in Williamsville NY.

April Cashin-Garbutt

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April Cashin-Garbutt

April graduated with a first-class honours degree in Natural Sciences from Pembroke College, University of Cambridge. During her time as Editor-in-Chief, News-Medical (2012-2017), she kickstarted the content production process and helped to grow the website readership to over 60 million visitors per year. Through interviewing global thought leaders in medicine and life sciences, including Nobel laureates, April developed a passion for neuroscience and now works at the Sainsbury Wellcome Centre for Neural Circuits and Behaviour, located within UCL.


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