Diagnostic Reference Levels in Mammography in the Asian Context
Keywords:
mammography, diagnostic reference level, mean glandular dose
Abstract
Background: Breast cancer is the most frequent cancer among the female population
globally. Therefore, early detection is helpful for effective treatments and to reduce
the mortality rate. Mammography is a radiological examination done with low-energy
X-rays to detect abnormalities in breast tissue. This study aims to review the literature
to evaluate the techniques, protocols, and conversion factors used to determine the
diagnostic reference levels (DRLs); within the Asian continent using both phantom- and
patient-based data.
Methods: Related articles were systematically reviewed via Pub Med, Google scholar,
and freehand search with the aid of relevant terms. Related abstracts in English were
screened, and suitable articles were selected after reviewing the full-text. Four hundred
and thirty abstracts were screened for relevance, and 12 articles were selected.
Results: The study comprises four phantom-based and eight patient-based studies.
The studies varied between the types of test subjects, conversion factors, breast
compression thickness, and dose calculation protocols. This obstructs continuing the
DRLs with the updates and comparisons among countries. Establishments of DRLs
in Asian countries are less than the rest of the world. DRLs should be measured
continuously, and should be updated based on other clinical parameters of the
patients.
Conclusion: DRLs in mammography were measured from time to time in different
geographical locations in Asia by following various techniques. But when compared
with the other regions of the world, there is less consideration for establishing DRLs in
Asia. There should be standard protocols and updated conversion factors according
to the advancements of the technology to ensure radiation protection with optimal
absorbed dose with appropriate image quality
References
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Diagnostic reference levels in medical imaging. Annals of the ICRP, 44(1).
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8043(98)00047-5
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https://doi.org/10.1259/0007-1285-54-639-212
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report of their joint findings and recommendations. Journal of the National Cancer
Institute, 69, 467–541.
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patient in xeroradiography. The British Journal of Radiology, 49, 253–261.
https://doi.org/10.1259/0007-1285-49-579-253
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mammary radiography. Acta Radiologica: Therapy, Physics, Biology, 15(3), 252–258.
https://doi.org/10.3109/02841867609131962
[13] Fintor, L., Alciati, M. H., & Fischer, R. (1995). Legislative and regulatory mandates
for mammography quality assurance. Journal of Public Health Policy, 16, 81–107.
https://doi.org/10.2307/3342978
[14] Vañó, E., Miller, D. L., Martin, C. J., Rehani, M. M., Kang, K., Rosenstein, M., OrtizLópez, P., Mattsson, S., Padovani, R., Rogers, A., & the Authors on behalf of ICRP.
(2017). ICRP Publication 135: Diagnostic reference levels in medical imaging. Annals
of the ICRP, 46(1), 1–144. https://doi.org/10.1177/0146645317717209
[15] Tenforde, T. S. (2004). A guide to mammography and other breast imaging
procedures. NCRP Report.
[16] Jamal, N., Ng, K. H., & McLean, D. (2003). A study of mean glandular dose during
diagnostic mammography in Malaysia and some of the factors affecting it. The British
Journal of Radiology, 76, 238–245. https://doi.org/10.1259/bjr/66428508
[17] Strudley, C., Looney, P., & Young K. C. (2014). Technical evaluation of Hologic Selenia
Dimensions digital breast tomosynthesis system: NHSBSP Equipment Report 1307
Version 2. NHS.
[18] Suleiman, M. E., Bernnan, P. C., & McEntee, F. M. (2014). Diagnostic reference levels in
digital mammography: A systematic review. Radiation Protection Dosimetry, 167(4).
[19] Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & the PRISMA Group. (2009).
Preferred reporting items for systematic reviews and meta-analyses: The PRISMA
statement. BMJ, 339(7716), b2535. https://doi.org/10.1136/bmj.b2535
[20] Hendrick, M. J., Bassett, L., Botsco, M., Deibel, D., Feig, S., Gray, J., Haus, A., Heinlei,
R., & Kitts, E., (2018). Mammography quality control manual. American College of
Radiology.
[21] Perry, N., Broeders, M., de Wolf, C., Törnberg, S., Holland, R., & von Karsa, L. (2008).
European guidelines for quality assurance in breast cancer screening and diagnosis.
Fourth edition. Summary Document, 19(4). https://doi.org/10.1093/annonc/mdm481
[22] Wu, X., Gingold, E. L., Barnes, G. T., & Tucker, D. M. (1994). Normalized
average glandular dose in molybdenum target-rhodium filter and
rhodium target-rhodium filter mammography. Radiology, 193(1), 83–89.
https://doi.org/10.1148/radiology.193.1.8090926
[23] Sharma, R., Sharma, S. D., Mayya, Y. S., & Chourasiya, G. (2012). Mammography
dosimetry using an in-house developed polymethyl methacrylate phantom.
Radiation Protection Dosimetry, 151(2), 379–385. https://doi.org/10.1093/rpd/ncr476
[24] Dance, D. R., Skinner, C. L., Young, K. C., Beckett, J. R., & Kotre, C. J. (2000).
Additional factors for the estimation of mean glandular breast dose using the UK
mammography dosimetry protocol. Physics in Medicine and Biology, 45(11), 3225–
3240. https://doi.org/10.1088/0031-9155/45/11/308
[25] Hwang, Y. S., Tsai, H. Y., Chen, C. C., Chia, S. H., Lin, J. H., Wan, Y. L., & Hsu, G.
C. (2009). Survey of radiation dose, image quality and equipment performance of
mammography units in Taiwan. Springer.
[26] Parmaks????z, A., Ayd????nAtaç, G. K., Bulur, E., Alhan, T., & Alhan, A. (2020). Average
glandular doses and national diagnostic reference levels in mammography
examinations in Turkey. Radiation Protection Dosimetry, 190(1), 100–107.
[27] Jamal, N., Ng, K.-H., & McLean, D. (2003). A study of mean glandular dose during
diagnostic mammography in Malaysia and some of the factors affecting it. British
Journal of Radiology, 76(905), 238–245. https://doi.org/10.1259/bjr/66428508
[28] Bor, D., Akyol, O., & Olgar, T. (2008). Performance measurements of
mammographic systems. Radiation Protection Dosimetry, 129, 165–169.
https://doi.org/10.1093/rpd/ncn141
[29] National Council on Radiation Protection and Measurements, & National Council on
Radiation Protection. (2004). A guide to mammography and other breast imaging
procedures. National Council on Radiation Protection.
[30] Wu, X., Barnes, G. T., & Tucker, D. M. (1991). Spectral dependence of
glandular tissue dose in screen-film mammography. Radiology, 179(1), 143–148.
https://doi.org/10.1148/radiology.179.1.2006265
[31] Asada, Y., Suzuki, S., Minami, K., & Shirakawa, S. (2014). Results of a 2011 national
questionnaire for investigation of mean glandular dose from mammography in Japan.
Journal of Radiological Protection, 34(1), 125–132. https://doi.org/10.1088/0952-
4746/34/1/125
[32] Kawaguchi, A., Matsunaga, Y., Otsuka, T., & Suzuki, S. (2014). Patient investigation
of average glandular dose and incident air kerma for digital mammography.
Radiological Physics and Technology, 7(1), 102–108. https://doi.org/10.1007/s12194-
013-0239-9
[33] AlNaemi, H., Aly, A., Omar, A. J., AlObadli, A., Ciraj-Bjelac, O., Kharita, M. H., & Rehani,
M. M. (2020). Evaluation of radiation dose for patients undergoing mammography in
Qatar. Radiation Protection Dosimetry, 189(3), 354–361.
[34] Bahreyni Toossi, M. T., Zare, H., Bayani Roodi, Sh., Hashemi, M., Akbari, F., &
Malekzadeh, M. (2013). Towards proposition of a diagnostic reference level for
mammographic examination in the greater Khorasan Province, Iran. Radiation
Protection Dosimetry, 155, 96–99. https://doi.org/10.1093/rpd/ncs317
[35] Du, X., Wang, J., Yang, C. Y., Zhou, X. F., Chen, W., Cao, X. J., Zhou, Y. Y., Le Yu, N.,
& the N. L. Y. Xiang DU. (2014). Investigation of mean glandular dose in diagnostic
mammography in China. Biomedical and Environmental Sciences, 27(5), 396–399.
[36] Baek, J. E., Kang, B. J., Kim, S. H., & Lee, H. S. (2017). Radiation dose affected by
mammographic composition and breast size: First application of a radiation dose
management system for full-field digital mammography in Korean women. World
Journal of Surgical Oncology, 15, 38. https://doi.org/10.1186/s12957-017-1107-6
[37] Geeraert, N., Klausza, R., Muller, S., Bloch, I., & Bosmans, H. (2012). Breast
characteristics and dosimetric data in X-ray mammography – A large sample
worldwide survey. IAEA 2012 - International Conference on Radiation Protection
in Medicine [Conference session]. Bonn, Germany
[2] Bray, F., McCarron, P., & Parkin, D. M. (2004). The changing global patterns of female
breast cancer incidence and mortality. Breast Cancer Research, 6(6), 229–239.
https://doi.org/10.1186/bcr932
[3] Bhoo-Pathy, N., Yip, C. H., Hartman, M., Uiterwaal, C. S., Devi, B. C., Peeters, P. H.,
Taib, N. A., van Gils, C. H., & Verkooijen, H. M. (2013). Breast cancer research in Asia:
Adopt or adapt Western knowledge? European Journal of Cancer (Oxford, England),
49(3), 703–709. https://doi.org/10.1016/j.ejca.2012.09.014
[4] Saz-Parkinson, Z., Duffy, S. W., Canelo-Aybar, C., Gräwingholt, A., Quinn, C., Follmann,
M., & Schünemann, H. J. (2012). Breast cancer screening and diagnosis. Annals of
Internal Medicine, 172(12), 109–127. https://doi.org/10.7326/L20-0254
[5] Vañó, E., Miller, D. L., Martin, C. J., Rehani, M. M., Kang, K., Rosenstein, M., OrtizLo´pez, P., Mattsson, S., Padovani, R., Rogers, A. (2017). ICRP Publication 135 –
Diagnostic reference levels in medical imaging. Annals of the ICRP, 44(1).
[6] Dance, D. R., Skinner, C. L., & Alm Carlsson, G. (1999). Breast dosimetry.
Applied Radiation and Isotopes, 50(1), 185–203. https://doi.org/10.1016/S0969-
8043(98)00047-5
[7] Dance, D. R. (1990). Monte Carlo calculation of conversion factors for the estimation
of mean glandular breast dose. Physics in Medicine and Biology, 35, 1211–1219.
https://doi.org/10.1088/0031-9155/35/9/002
[8] Butler, P. F., & Jensen, J. E. Breast exposure: Nationwide trends; A mammographic
quality assurance program–Results to date. Radiologic Technology, 50(3), 251–257.
[9] Fitzgerald, M., White, D. R., White, E., & Young, J., (1981). Mammographic practice
and dosimetry in Britain. The British Journal of Radiology, 54(639), 212–220.
https://doi.org/10.1259/0007-1285-54-639-212
[10] Breslow L., & Thomas, L. B. (1977). Final reports of the National Cancer Institute ad hoc
Working Groups on Mammography in Screening for Breast Cancer and a summary
report of their joint findings and recommendations. Journal of the National Cancer
Institute, 69, 467–541.
[11] Boag, J. W., Stacey, A. J., & Davis, R. (1976). Radiation exposure to the
patient in xeroradiography. The British Journal of Radiology, 49, 253–261.
https://doi.org/10.1259/0007-1285-49-579-253
[12] Karlsson, M., Nygren, K., Wickman, G., & Hettinger, G. (1976). Absorbed dose in
mammary radiography. Acta Radiologica: Therapy, Physics, Biology, 15(3), 252–258.
https://doi.org/10.3109/02841867609131962
[13] Fintor, L., Alciati, M. H., & Fischer, R. (1995). Legislative and regulatory mandates
for mammography quality assurance. Journal of Public Health Policy, 16, 81–107.
https://doi.org/10.2307/3342978
[14] Vañó, E., Miller, D. L., Martin, C. J., Rehani, M. M., Kang, K., Rosenstein, M., OrtizLópez, P., Mattsson, S., Padovani, R., Rogers, A., & the Authors on behalf of ICRP.
(2017). ICRP Publication 135: Diagnostic reference levels in medical imaging. Annals
of the ICRP, 46(1), 1–144. https://doi.org/10.1177/0146645317717209
[15] Tenforde, T. S. (2004). A guide to mammography and other breast imaging
procedures. NCRP Report.
[16] Jamal, N., Ng, K. H., & McLean, D. (2003). A study of mean glandular dose during
diagnostic mammography in Malaysia and some of the factors affecting it. The British
Journal of Radiology, 76, 238–245. https://doi.org/10.1259/bjr/66428508
[17] Strudley, C., Looney, P., & Young K. C. (2014). Technical evaluation of Hologic Selenia
Dimensions digital breast tomosynthesis system: NHSBSP Equipment Report 1307
Version 2. NHS.
[18] Suleiman, M. E., Bernnan, P. C., & McEntee, F. M. (2014). Diagnostic reference levels in
digital mammography: A systematic review. Radiation Protection Dosimetry, 167(4).
[19] Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & the PRISMA Group. (2009).
Preferred reporting items for systematic reviews and meta-analyses: The PRISMA
statement. BMJ, 339(7716), b2535. https://doi.org/10.1136/bmj.b2535
[20] Hendrick, M. J., Bassett, L., Botsco, M., Deibel, D., Feig, S., Gray, J., Haus, A., Heinlei,
R., & Kitts, E., (2018). Mammography quality control manual. American College of
Radiology.
[21] Perry, N., Broeders, M., de Wolf, C., Törnberg, S., Holland, R., & von Karsa, L. (2008).
European guidelines for quality assurance in breast cancer screening and diagnosis.
Fourth edition. Summary Document, 19(4). https://doi.org/10.1093/annonc/mdm481
[22] Wu, X., Gingold, E. L., Barnes, G. T., & Tucker, D. M. (1994). Normalized
average glandular dose in molybdenum target-rhodium filter and
rhodium target-rhodium filter mammography. Radiology, 193(1), 83–89.
https://doi.org/10.1148/radiology.193.1.8090926
[23] Sharma, R., Sharma, S. D., Mayya, Y. S., & Chourasiya, G. (2012). Mammography
dosimetry using an in-house developed polymethyl methacrylate phantom.
Radiation Protection Dosimetry, 151(2), 379–385. https://doi.org/10.1093/rpd/ncr476
[24] Dance, D. R., Skinner, C. L., Young, K. C., Beckett, J. R., & Kotre, C. J. (2000).
Additional factors for the estimation of mean glandular breast dose using the UK
mammography dosimetry protocol. Physics in Medicine and Biology, 45(11), 3225–
3240. https://doi.org/10.1088/0031-9155/45/11/308
[25] Hwang, Y. S., Tsai, H. Y., Chen, C. C., Chia, S. H., Lin, J. H., Wan, Y. L., & Hsu, G.
C. (2009). Survey of radiation dose, image quality and equipment performance of
mammography units in Taiwan. Springer.
[26] Parmaks????z, A., Ayd????nAtaç, G. K., Bulur, E., Alhan, T., & Alhan, A. (2020). Average
glandular doses and national diagnostic reference levels in mammography
examinations in Turkey. Radiation Protection Dosimetry, 190(1), 100–107.
[27] Jamal, N., Ng, K.-H., & McLean, D. (2003). A study of mean glandular dose during
diagnostic mammography in Malaysia and some of the factors affecting it. British
Journal of Radiology, 76(905), 238–245. https://doi.org/10.1259/bjr/66428508
[28] Bor, D., Akyol, O., & Olgar, T. (2008). Performance measurements of
mammographic systems. Radiation Protection Dosimetry, 129, 165–169.
https://doi.org/10.1093/rpd/ncn141
[29] National Council on Radiation Protection and Measurements, & National Council on
Radiation Protection. (2004). A guide to mammography and other breast imaging
procedures. National Council on Radiation Protection.
[30] Wu, X., Barnes, G. T., & Tucker, D. M. (1991). Spectral dependence of
glandular tissue dose in screen-film mammography. Radiology, 179(1), 143–148.
https://doi.org/10.1148/radiology.179.1.2006265
[31] Asada, Y., Suzuki, S., Minami, K., & Shirakawa, S. (2014). Results of a 2011 national
questionnaire for investigation of mean glandular dose from mammography in Japan.
Journal of Radiological Protection, 34(1), 125–132. https://doi.org/10.1088/0952-
4746/34/1/125
[32] Kawaguchi, A., Matsunaga, Y., Otsuka, T., & Suzuki, S. (2014). Patient investigation
of average glandular dose and incident air kerma for digital mammography.
Radiological Physics and Technology, 7(1), 102–108. https://doi.org/10.1007/s12194-
013-0239-9
[33] AlNaemi, H., Aly, A., Omar, A. J., AlObadli, A., Ciraj-Bjelac, O., Kharita, M. H., & Rehani,
M. M. (2020). Evaluation of radiation dose for patients undergoing mammography in
Qatar. Radiation Protection Dosimetry, 189(3), 354–361.
[34] Bahreyni Toossi, M. T., Zare, H., Bayani Roodi, Sh., Hashemi, M., Akbari, F., &
Malekzadeh, M. (2013). Towards proposition of a diagnostic reference level for
mammographic examination in the greater Khorasan Province, Iran. Radiation
Protection Dosimetry, 155, 96–99. https://doi.org/10.1093/rpd/ncs317
[35] Du, X., Wang, J., Yang, C. Y., Zhou, X. F., Chen, W., Cao, X. J., Zhou, Y. Y., Le Yu, N.,
& the N. L. Y. Xiang DU. (2014). Investigation of mean glandular dose in diagnostic
mammography in China. Biomedical and Environmental Sciences, 27(5), 396–399.
[36] Baek, J. E., Kang, B. J., Kim, S. H., & Lee, H. S. (2017). Radiation dose affected by
mammographic composition and breast size: First application of a radiation dose
management system for full-field digital mammography in Korean women. World
Journal of Surgical Oncology, 15, 38. https://doi.org/10.1186/s12957-017-1107-6
[37] Geeraert, N., Klausza, R., Muller, S., Bloch, I., & Bosmans, H. (2012). Breast
characteristics and dosimetric data in X-ray mammography – A large sample
worldwide survey. IAEA 2012 - International Conference on Radiation Protection
in Medicine [Conference session]. Bonn, Germany
Published
2022-10-04
Section
Review article
