Enhancing Radiologist Reading Performance by Ordering Screening Mammograms Based on Characteristics That Promote Visual Adaptation

Background: Mammographic background characteristics may stimulate human visual adaptation, allowing radiologists to detect abnormalities more effectively. However, it is unclear whether density, or another image characteristic, drives visual adaptation. Purpose: To investigate whether screening performance improves when screening mammography examinations are ordered for batch reading according to mammographic characteristics that may promote visual adaptation. Materials and Methods: This retrospective multireader multicase study was performed with mammograms obtained between September 2016 and May 2019. The screening examinations, each consisting of four mammograms, were interpreted by 13 radiologists in three distinct orders: randomly, by increasing volumetric breast density (VBD), and based on a self-supervised learning (SSL) encoding (examinations automatically grouped as "looking similar"). An eye tracker recorded radiologists'eye movements during interpretation. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of random-ordered readings were compared with those of VBD- and SSL-ordered readings using mixed- model analysis of variance. Reading time, fixation metrics, and perceived density were compared using Wilcoxon signed-rank tests. Results: Mammography examinations (75 with breast cancer, 75 without breast cancer) from 150 women (median age, 55 years [IQR, 50-63]) were read. The examinations ordered by increasing VBD versus randomly had an increased AUC (0.93 [95% CI: 0.91, 0.96] vs 0.92 [95% CI: 0.89, 0.95]; P = .009), without evidence of a difference in specificity (89% [871 of 975] vs 86% [837 of 975], P = .04) and sensitivity (both 81% [794 of 975 vs 788 of 975], P = .78), and a reduced reading time (24.3 vs 27.9 seconds, P < .001), fixation count (47 vs 52, P < .001), and fixation time in malignant regions (3.7 vs 4.6 seconds, P < .001). For SSL-ordered readings, there was no evidence of differences in AUC (0.92 [95% CI: 0.89, 0.95]; P = .70), specificity (84% [820 of 975], P = .37), sensitivity (80% [784 of 975], P = .79), fixation count (54, P = .05), or fixation time in malignant regions (4.6 seconds, P > .99) compared with random-ordered readings. Reading times were significantly higher for SSL-ordered readings compared with random-ordered readings (28.4 seconds, P = .02). Conclusion: Screening mammography examinations ordered from low to high VBD improved screening performance while reducing reading and fixation times.