Diagnostic reference levels (DRLs) in digital mammography in the European context – a systematic review

• Autorzy: Arifi Mirjeta Mediji , Ristova Mimoza M.

Identyfikatory

DOI

10.2478/pjmpe-2025-0028

• Języki publikacji: EN

Abstrakty

EN

This systematic review examines the establishment of Diagnostic Reference Levels (DRLs) in digital mammography across 18 European countries, based on studies from 2005-2025. A total of 353 articles were identified through the comprehensive search of academic networks: Google Scholar, PubMed, Research Gate, Academia. Only 18 peer-reviewed studies met inclusion criteria – reporting Mean Glandular Dose (MGD)-based DRLs from Finland to Malta. Eight studies used patient data, four used phantom measurements, and six used both. To overcome the challenging comparison of the variety of reported parameters, we undertook some data harmonisation procedures, focusing on a common Compressed Breast Thickness (CBT) range of 50-59 mm. The DRLs varied notably by country, with 75th percentile MGDs ranging from 1.1 to 2.6 mGy and 95th percentile from 1.6 to 2.9 mGy, averaging to 1.44 mGy, which is lower than the achievable European level (2 mGy). The harmonisation approach enabled the derivation of a comparable dataset of average MGDs, facilitating cross-country comparisons and insights into radiation dose optimisation in digital mammography across Europe.

Słowa kluczowe

EN

digital mammography; Mean Glandular Dose; MGD; Compressed Breast Thickness; CBT; Diagnostic Reference Level; DRL; European countries

• Wydawca: Polskie Towarzystwo Fizyki Medycznej
• Czasopismo: Polish Journal of Medical Physics and Engineering
• Rocznik: 2025
• Tom: Vol. 31, Iss. 3
• Strony: 246--255
• Opis fizyczny: Bibliogr. 38 poz., rys., tab.

Twórcy

autor

Arifi Mirjeta Mediji

• Faculty of Natural Sciences and Mathematics, Physics Department, Cyril and Methodius University of Skopje, Skopje, North Macedonia
• Faculty of Natural Sciences and Mathematics, Physics Department, State University of Tetovo, Tetovo, North Macedonia

autor

Ristova Mimoza M.

• Faculty of Natural Sciences and Mathematics, Physics Department, Cyril and Methodius University of Skopje, Skopje, North Macedonia

• https://orcid.org/0000-0002-8042-8087

Bibliografia

• 1. Boyle P, Ferlay J. Cancer incidence and mortality in Europe, 2004. Ann Oncol. 2005;16(3):481-488. doi:10.1093/annonc/mdi098
• 2. Hendrick RE, Botsco M, Plott CM. Quality control in mammography. Radiol Clin North Am. 1995;33(6):1041-1057. PMID: 7480654.
• 3. European Commission: Directorate-General for Health and Consumers, Karsa, L. v., Holland, R., Broeders, M., Wolf, C. d. et al., European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis.4th Edition, Supplements. Publications Office of the European Union; 2013. Accessed January 28, 2025. https://data.europa.eu/doi/10.2772/13196
• 4. Dosimetry in Diagnostic Radiology: An International Code of Practice. INTERNATIONAL ATOMIC ENERGY AGENCY, Technical Reports Series No. 457, IAEA, Vienna 2007; https://www.iaea.org/publications/7638/dosimetry-in-diagnostic-radiology-an-international-code-of-practice
• 5. Quality Assurance Programme for Digital Mammography. INTERNATIONAL ATOMIC ENERGY AGENCY; Human Health Series No. 17, IAEA, Vienna 2011. https://www.iaea.org/publications/8560/quality-assurance-programme-for-digital-mammography
• 6. Sechopoulos I, Dance DR, Boone JM, Bosmans HT, Caballo M, et al. Joint AAPM Task Group 282/EFOMP Working Group Report: Breast dosimetry for standard and contrast-enhanced mammography and breast tomosynthesis. Med Phys. 2024;51(2):712-739. doi:10.1002/mp.16842
• 7. Dance DR, Sechopoulos I. Dosimetry in x-ray-based breast imaging. Phys Med Biol. 2016;61(19):R271. doi:10.1088/0031-9155/61/19/R271
• 8. Vañó E, Miller DL, Martin CJ, Rehani MM, Kang K, et al. ICRP Publication 135: Diagnostic Reference Levels in Medical Imaging. Ann ICRP. 2017;46(1):1-144. doi:10.1177/0146645317717209
• 9. Pereira L, Ferreira MT, Lima AGF, Lima I, Morandi V, et al. Biological effects induced by doses of mammographic screening. Phys Medica PM Int J Devoted Appl Phys Med Biol Off J Ital Assoc Biomed Phys AIFB. 2021;87:90-98. doi:10.1016/j.ejmp.2021.06.002
• 10. Suleiman ME, McEntee MF, Cartwright L, Diffey J, Brennan PC. Diagnostic reference levels for digital mammography in New South Wales. J Med. Imaging Radiat Oncol. 2017;61(1):48-57. doi:10.1111/1754-9485.12540
• 11. Jensen JE, Butler PF. Breast exposure: nationwide trends; a mammographic quality assurance program results to date. Radiol Technol. 1978;50(3):251-257.
• 12. Suleiman ME, Brennan PC, McEntee MF. Diagnostic reference levels in digital mammography: a systematic review. Radiat Prot Dosimetry. 2015;167(4):608-619. doi:10.1093/rpd/ncu365
• 13. Hemamala U, Weerakoon BS. Diagnostic Reference Levels (DRLs) in Digital Mammography: A Systematic Review. 2022; 5(2): 1080https://www.semanticscholar.org/paper/Diagnostic-Reference-Levels-(DRLs)-in-Digital-A-Hemamala-Weerakoon/95b77470d5b70e5bb462ccd4e85508d87e7111b6
• 14. Buhari S, Mohammed R. Mammography Diagnostic Reference Level for Breast Cancer Screening Procedures: A Systematic Review. Nursing Clinics of North America. (2023). 2. 3. 10.31579/2835-8147/020.
• 15. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. doi:10.1136/bmj.b2700
• 16. Cornell JE. The PRISMA extension for network meta-analysis: bringing clarity and guidance to the reporting of systematic reviews incorporating network meta-analyses. Ann Intern Med. 2015;162(11):797-798. doi:10.7326/M15-0930
• 17. Wu X, Barnes GT, Tucker DM. Spectral dependence of glandular tissue dose in screen-film mammography. Radiology. 1991;179(1):143-148. doi:10.1148/radiology.179.1.2006265
• 18. Boone JM. Glandular Breast Dose for Monoenergetic and High-Energy X-ray Beams: Monte Carlo Assessment. Radiology. 1999;213(1):23-37. doi:10.1148/radiology.213.1.r99oc3923
• 19. Dance DR, Skinner CL, Young KC, Beckett JR, Kotre CJ. Additional factors for the estimation of mean glandular breast dose using the UK mammography dosimetry protocol. Phys Med Biol. 2000;45(11):3225-3240. doi:10.1088/0031-9155/45/11/308
• 20. Perry N, Broeders M, Wolf C de, Törnberg S, Holland R, et al. European Commission, eds. European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis. Fourth edition. Publications Office; 2006.
• 21. Lekatou A, Metaxas V, Messaris G, Antzele P, Tzavellas G, Panayiotakis G. INSTITUTIONAL BREAST DOSES IN DIGITAL MAMMOGRAPHY. Radiat Prot Dosimetry. 2019;185(2):239-251. doi:10.1093/rpd/ncz005
• 22. Parmaksız A, Ataç GK, Bulur E, İnal T, Alhan A. AVERAGE GLANDULAR DOSES AND NATIONAL DIAGNOSTIC REFERENCE LEVELS IN MAMMOGRAPHY EXAMINATIONS IN TURKEY. Radiat Prot Dosimetry. 2020;190(1):100-107. doi:10.1093/rpd/ncaa080
• 23. Rafajlovic S, Ciraj-Bjelac O, Bozovic P. Towards National Diagnostic Reference Levels for Mammography in Serbia. Radiat Prot Dosimetry. Published online November 24, 2020:ncaa173. doi:10.1093/rpd/ncaa173
• 24. Dupont L, Aberle C, Botsikas D, Ith M, Lima TVM, et al. Proposed DRLs for mammography in Switzerland. J Radiol Prot Off J Soc Radiol Prot. 2024;44(2). doi:10.1088/1361-6498/ad37c8
• 25. Kelaranta A, Toroi P, Timonen M, Komssi S, Kortesniemi M. Conformance of mean glandular dose from phantom and patient data in mammography. Radiat Prot Dosimetry. 2015;164(3):342-353. doi:10.1093/rpd/ncu261
• 26. Sá dos Reis C, Fartaria MJ, Garcia Alves JH, Pascoal A. PORTUGUESE STUDY OF MEAN GLANDULAR DOSE IN MAMMOGRAPHY AND COMPARISON WITH EUROPEAN REFERENCES. Radiat Prot Dosimetry. 2018;179(4):391-399. doi:10.1093/rpd/ncx300
• 27. Hauge IHR, Bredholt K, Olerud HM. New diagnostic reference level for full-field digital mammography units. Radiat Prot Dosimetry. 2013;157(2):181-192. doi:10.1093/rpd/nct136
• 28. Michielsen K, Jacobs J, Lemmens K, Nens, J, Zoetelief, J, et al. Results of a European dose survey for mammography. Radiat Prot Dosimetry. 2008;129(1-3): 199-203. doi:10.1093/rpd/ncn152
• 29. Chevalier M, Morán P, Ten JI, Fernández Soto JM, Cepeda T, Vañó E. Patient dose in digital mammography. Med Phys. 2004;31(9):2471-2479. doi:10.1118/1.1784591
• 30. Ślusarczyk-Kacprzyk W, Skrzyński W, Fabiszewska E. Evaluation of Doses and Image Quality in Mammography with Screen-Film, CR, and DR Detectors - Application of the ACR Phantom. Pol J Radiol. 2016;81:386-391. doi:10.12659/PJR.897304
• 31. Loveland J, Young KC, Oduko JM, Mackenzie A. Radiation doses in the United Kingdom breast screening programmes 2016-2019. Br J Radiol. 2022;95(1135):20211400. doi:10.1259/bjr.20211400
• 32. Mediji-Arifi M, Ristova M. Establishing Diagnostic Reference Levels in Digital Mammography from Eight Mammography Units Using over 30,000 Images. Diagnostics. 2025;15(6):682. doi:10.3390/diagnostics15060682
• 33. Avramova-Cholakova S, Vassileva J. A survey of the state of mammography practice in Bulgaria. Radiat Prot Dosimetry. 2011;147(1-2):184-186. doi:10.1093/rpd/ncr320
• 34. Borg M, Badr I, Royle GJ. Mammography equipment performance, image quality, and mean glandular dose in Malta. Radiat Prot Dosimetry. 2013;156(2):168-183. doi:10.1093/rpd/nct051
• 35. Baldelli P, McCullagh J, Phelan N, Flanagan F. Comprehensive dose survey of breast screening in Ireland. Radiat Prot Dosimetry. 2011;145(1):52-60. doi:10.1093/rpd/ncq375
• 36. Faj D, Posedel D, Stimac D, Ivezic Z, Kasabasic M, et al. Survey of mammography practice in Croatia: equipment performance, image quality and dose. Radiat Prot Dosimetry. 2008;131(4):535-540. doi:10.1093/rpd/ncn283
• 37. Ghetti C, Ortenzia O, Palleri F, Sireus M. Definition of Local Diagnostic Reference Levels in a Radiology Department Using a Dose Tracking Software. Radiat Prot Dosimetry. 2017;175(1):38-45. doi:10.1093/rpd/ncw264
• 38. Kunosic S, Čeke D, Kopric M, Lincender L. Determination of mean glandular dose from routine mammography for two age groups of patients. Healthmed. 2010 4(1):125-131.