The Effects of Gray Scale Image Processing on

Digital Mammography Interpretation Performance1

Elodia B. Cole, MS, Etta D. Pisano, MD, Donglin Zeng, PhD, Keith Muller, PhD, Stephen R. Aylward, PhD,
Sungwook Park, Cherie Kuzmiak, DO, Marcia Koomen, MD, Dag Pavic, MD, Ruth Walsh, MD, Jay Baker, MD,
Edgardo I. Gimenez, MD, Rita Freimanis, MD

Rationale and Objectives. To determine the effects of three image-processing algorithms on diagnostic accuracy of digi-
tal mammography in comparison with conventional screen-film mammography.
Materials and Methods. A total of 201 cases consisting of nonprocessed soft copy versions of the digital mammograms
acquired from GE, Fischer, and Trex digital mammography systems (1997–1999) and conventional screen-film mammo-
grams of the same patients were interpreted by nine radiologists. The raw digital data were processed with each of three
different image-processing algorithms creating three presentations—manufacturer’s default (applied and laser printed to
film by each of the manufacturers), MUSICA, and PLAHE—were presented in soft copy display. There were three radiol-
ogists per presentation.
Results. Area under the receiver operating characteristic curve for GE digital mass cases was worse than screen-film for all
digital presentations. The area under the receiver operating characteristic for Trex digital mass cases was better, but only with
images processed with the manufacturer’s default algorithm. Sensitivity for GE digital mass cases was worse than screen film
for all digital presentations. Specificity for Fischer digital calcifications cases was worse than screen film for images processed
in default and PLAHE algorithms. Specificity for Trex digital calcifications cases was worse than screen film for images pro-
cessed with MUSICA.
Conclusion. Specific image-processing algorithms may be necessary for optimal presentation for interpretation based on
machine and lesion type.
Key Words. Digital mammography; ROC curve; image processing.
© AUR, 2005

The separation of acquisition from display, in full-field
digital mammography, allows for optimization of image
Acad Radiol 2005; 12:585–595
1 From the Department of Radiology and Lineberger Comprehensive Can-
cer Center (E.B.C., E.D.P.) and Department of Radiology (S.R.A.), University
of North Carolina, CB#7515, Radiology Research Labs, 106 Mason Farm
Road, Chapel Hill, NC 27599; University of North Carolina, Department of
Biostatistics, Chapel Hill, NC (D.Z., K.M.); WiBro Terminals Labs, Telecom-
munication R&D Center, Samsung Electronics Co., Gyenoggi-do, Korea
(S.P.); Department of Radiology, University of North Carolina, Chapel Hill,
NC (C.K., M.K., D.P.); Department of Radiology, Duke University Medical
Center, Durham, NC (R.W., J.B., E.I.G.); Department of Radiology, Wake
Forest University, Winston-Salem, NC (R.F.). Received October 28, 2004;
revision received and accepted January 6, 2005. Supported by Susan G.
Komen Foundation Grant. Address correspondence to: E.B.C. e-mail:
ecole@unc.edu
© AUR, 2005
doi:10.1016/j.acra.2005.01.017
display at each point in the image formation chain. Be-
fore display of the final image, some type of image pro-
cessing is applied to the raw digital mammographic im-
age. Ideally, the application of an image processing algo-
rithm will function to improve the visibility of lesions
rather than just improving the aesthetic appeal of images.
Several studies have specifically evaluated the effect of
various types of image processing algorithms on radiolo-
gist performance (1–7).
Image processing can take place in several places in
the imaging chain: at the acquisition station, at the review
station, or in between. Generally, the end user presses a
predefined button that will display a processed image.
Beyond the individuals who actually developed the algo-
rithms or were responsible for implementing them in the
various digital mammography systems, very little is

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Table 1
Lesion Type and Cancer Status for All 201 Cases
Calcifications Masses
Benign Malignant Benign Malignant Normals
Fischer 16 8 22 14 14
GE 10 9 14 10 9
Trex 22 8 20 13 12
known about why specific algorithms were chosen or un-
der what conditions they are applied (ie, Is the specific
image processing algorithm more suitable for mass char-
acterization or calcification characterization? Is the spe-
cific image processing algorithm better suited for applica-
tion to specific breast densities? Does the specific algo-
rithm improve lesion visibility or radiologist diagnostic
accuracy?). The purpose of this study was to quantify the
effect of algorithms applied to digital mammograms of
women with dense breasts acquired from three different
digital mammography systems on radiologist performance
when compared with screen-film mammography.
METHODS AND MATERIALS
A total of 201 cases were obtained from the Interna-
tional Digital Mammography Development Group image
archive. This case set is described in detail in a previous
article (8). Table 1 shows the breakdown of the cases by
lesion type and cancer status. Each case consisted of four
standard view digital and screen-film mammograms of the
same patients. The patients were enrolled and imaged at
one of seven institutions under the protocols of a previous
study (8). Three digital mammography systems were test-
ed: the SenoScan (Fischer Imaging Corp, Denver, CO),
the Senographe 2000D (General Electric Corp., Wauke-
sha, WI), and the Trex Digital Mammography System
(Hologic Inc., Bedford, MA). Each patient was imaged on
only one type of digital mammography system. Available
screen-film mammography systems at each site were used
to obtain the screen-film mammograms during this study.
Three algorithms were applied to each of the digital im-
ages: MultiScale Image Contrast Amplification
(MUSICA), a commercially available algorithm (Agfa-
Gevaert N.V., Belgium); Power Law Adaptive Histogram
Equalization (PLAHE), an algorithm developed at our
institution; and the manufacturer’s recommended or de-
fault algorithm, the algorithms recommended and imple-
mented by each manufacturer at the time this data was
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collected between 1997 and 1999. The Food and Drug
Administration had not yet clinically approved any of the
full-field digital mammography systems at the time these
data were collected. Each was in various stages of the
clinical trials process. However, the machines used were
the same as the ones ultimately approved for clinical use
by the Food and Drug Administration. The MUSICA and
PLAHE algorithms were applied to all 201 cases. Each
manufacturer’s default algorithm was applied to the cases
acquired using that manufacturer’s digital mammography
system.
The algorithms were not always applied successfully
because of incorrect interpretation of image parameters by
the image processing software. Image format standardiza-
tion had not yet been implemented at the start of this
study. Therefore, across platforms, the image formats var-
ied considerably from one manufacturer to the next and
even within manufacturer. Cases acquired from one proto-
type system differed in format (byte order, image size,
gray-scale representation) from another provided by the
same manufacturer. Table 2 shows the distribution of
cases that were successfully processed and thus used for
the final reader study. The application of an algorithm
was considered successful for an image if the resultant
image was interpretable in the judgment of a board-certi-
fied Mammography Quality Standards Act (MQSA)-quali-
fied breast imaging radiologist (E.D.P.). The processing
success rate was 93.5% (188/201) for the MUSICA algo-
rithm, 89.1% (179/201) for the manufacturer’s default
algorithms, and 67.2% (135/201) for the PLAHE
algorithm.
The default algorithms were applied by each manufac-
turer to the images acquired on their respective machines
by applications specialists. The default processed digital
mammograms were subsequently printed to film for radi-
ologist interpretation in the reader study. Agfa Corpora-
tion provided a stand-alone version (version 2.0.0) of
their MUSICA software for use in this study. Research
personnel at our institution applied PLAHE and MUSICA
algorithms to all digital mammograms. For radiologist
interpretation in the reader study, PLAHE and MUSICA
cases were displayed in soft copy format using a mam-
mography soft copy review workstation (Sun platform,
two high-resolution high contrast monitors) running Mam-
moview software, as described elsewhere (9).
Nine readers participated in the reader study. All had
mammography experience, with an average experience of
11 years (range 1–18 years). Eight of nine readers were
American Board of Radiology (ABR) -certified attending
radiologists. One reader was a breast imaging fellow. The
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Table 2
Lesion Type and Cancer Status Case Distributions for Successfully Processed
Cases Used in Reader Study per Image Processing Algorithm

MUSICA PLAHE Default

Calcifications 16 16 16
Benign
Mass 20 19 20
Fischer Calcifications 8 8 8
Malignant
Mass 13 13 13
Normal 10 10 8
Fischer totals 67 66 65

Calcifications 10 8 10
Benign
Mass 13 3 12
GE Calcifications 9 3 9
Malignant
Mass 8 5 9
Normal 9 4 8
GE totals 49 23 48

Calcifications 22 14 22
Benign
Mass 19 10 15
Trex Calcifications 8 4 7
Malignant
Mass 12 10 12
Normal 11 8 10
Trex totals 72 46 66

MUSICA: MultiScale Image Contrast Amplification; PLAHE: Power Law Adaptive His-
togram Equalization.

mograms. Another three readers were assigned to read all

Figure 1. Time spent reading mammograms is between 10 and
40 hours for our nine readers. On average, 55% of their time is
spent on screening mammography and 45% is spent on diagnos-
tic mammography.
average amount of time spent by the readers as a group
interpreting mammograms per week was 28.11 hours
(range 10 – 40 hours/week; 55% screening, 45% diagnos-
tic) (Fig 1).
Three readers were assigned to read all readable cases
for MUSICA and to the corresponding screen film mam-
readable cases for PLAHE and to the corresponding
screen film mammograms. Yet another three readers were
assigned to read all readable cases for default and to the
corresponding screen film mammograms. All nine readers
began the reader study by completing the screen film
mammograms interpretations first on a standard radiology
multiviewer appropriately masked for mammography.
After a minimum 4-week washout period, each of the
nine readers then read the digital mammograms to which
they were assigned.
The readers were provided with structured paper forms
to facilitate consistent reporting of mammographic find-
ings. The readers reported clinically significant lesion lo-
cation (breast, o’clock location, anteroposterior depth),
lesion-specific Breast Imaging Reporting and Data Sys-
tems (BI-RADS) (American College of Radiology, Res-
ton, VA) characteristics, and a probability of malignancy
based on a 5-point scale (1 definitely not malignant, 2
probably not malignant, 3 possibly malignant, 4 probably
malignant, and 5 definitely malignant). Responses for le-
sion location and probability of malignancy were com-
pared with ground truth based on biopsy or 1-year fol-
low-up using methods described elsewhere (8). If the

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reader determined there were no significant findings, no
probability of malignancy was recorded.
Three primary outcomes were analyzed separately: 1)
area under the receiver operating characteristic (ROC)
curve (AUC) from a nonparametric ROC analysis of can-
cer/no cancer; 2) sensitivity, with no findings and 1–2
defined as “benign” and 3–5 as “malignant”; and 3) speci-
ficity, with no findings and 1–2 defined as “benign” and
3–5 as “malignant.” For each outcome, a general linear
multivariate model analysis was used to fit data and re-
peated measures tests based on the Geisser-Greenhouse
test were used to test the significance of main effects as
well as interactions among the factors of machines, lesion
types, and digital display methods.
In the multivariate linear model, the outcome was the
repeated measurements of outcomes (AUC difference,
sensitivity of specificity differences) of a particular reader
in different conditions of three machines and two lesion
types; the design matrix included a three-level categorical
predictor of three display methods and the baseline per-
formance with film screen was also adjusted in the model.
“Main effects” refer to the overall effects of each factor.
The interaction factors were put in the model at the same
time. All the results from the residual analysis indicated a
goodness of fit and showed evidence of validity of nor-
mality assumption. Thus the identity link function we
used in the model fits the data well. Data analysis was
performed using SAS Software, Version 8.0 (SAS Insti-
tute, Cary, NC).
RESULTS
ROC curve analysis was performed. The outcomes
measured were area under the ROC curve, sensitivity, and
specificity. Figure 2 shows the ROC curves for digital
and screen film mammography by machine type and le-
sion type across all image processing algorithms. The
ROC curves for digital and screen film mammography by
machine type and lesion type per image processing algo-
rithm are displayed in Fig 3–5.
AUC
The primary outcome of interest was the area under
the ROC curve difference between digital mammography
and screen film mammography. Table 3 reports the aver-
age of this difference by machine type and lesion type.
The AUC for digital mammography was worse than
screen film for all machine and lesion combinations ex-
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cept for the Trex mass cases. The variance of the AUC
difference of digital and screen film mammography was
relatively large between Fischer digital mammograms and
screen film mammograms. Likewise, the variance of the
AUC difference was relatively large between GE digital
mammograms and the screen-film mammograms (Fig 6).
Tests based on the multivariate analysis of AUC data
show that, on average, the digital mammograms produced
by the GE system showed a significantly worse AUC than
the screen film mammograms (P ⫽ .009). In addition, the
digital mammograms across all machine types showed a
worse AUC for both mass (P ⫽ .007) and calcifications
(P ⫽ .042) lesion types (Table 3).
To study which of the machine type, lesion type, and
processing method variables produce the difference between
digital mammography and screen film mammography, multi-
variate analysis was conducted of AUC data including the
interactions among these factors. Trex digital mammography
produced a larger AUC difference with screen film mam-
mography than Fischer (P ⫽ .019), but no significant differ-
ence was observed between GE and Fischer (P ⫽ .193).
There was no significant difference seen among the three
processing methods (MUSICA, PLAHE, default) (P ⫽
.0.168, P ⫽ .485) or between the two lesion types (P ⫽
.0.822). The resulting 95% confidence intervals for AUC
difference are shown in Fig 6. GE mass cases processed
with each of the three image processing methods produced a
significantly worse AUC than screen film. Trex mass cases
processed with default produced significantly better AUC
than screen film. All other digital combinations were statisti-
cally indistinguishable from screen film.
Sensitivity
The sensitivity difference between digital mammogra-
phy and screen-film mammography was calculated. Table
3 reports the average of this difference by machine type
and lesion type and shows that the sensitivity from GE
digital mammography was lower than the sensitivity from
screen film mammography. However, the opposite was
seen when digital mammograms were generated from the
Trex system for both lesion types and for the Fischer sys-
tem for calcifications. The variation of the sensitivity dif-
ference was relatively large for the digital mammograms
generated by Fischer and GE systems and screen film
mammograms.
Tests based on multivariate analysis of sensitivity data
shows that, on average, GE digital mammography had
significantly less sensitivity than screen film mammogra-
phy (P ⫽ .011); and, on average, the digital mammo-
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Figure 2. Area under the receiver operating characteristic curves by machine and lesion type
across all image processing algorithms; value presented in parentheses for each modality.

grams across all machine types had less sensitivity for
mass lesion type (P ⫽ .014) (Table 1).
To study which combinations of the machine type,
lesion type, and image processing algorithm factors pro-
duce the difference between digital mammography and
screen film mammography, multivariate analysis was con-
ducted of sensitivity data including the interactions among
these factors. Trex produced a larger variation in sensitiv-
ity difference with screen film mammography than Fi-
scher digital (P ⫽ .005), but no significant difference was
observed between GE and Fischer. There was no signifi-
cant difference seen between the three processing meth-
ods (P ⫽ .837 and P ⫽ .745) and between the two lesion
types (P ⫽ .229). The resulting 95% confidence intervals
for sensitivity difference are shown in Fig 7. GE mass
cases processed with each of the image processing algo-
rithms had significantly lower sensitivity than screen film.
There was no statistically significant sensitivity difference
between all other remaining digital combinations and
screen film.

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Figure 3. Area under the receiver operating characteristic curves by machine and lesion type av-
eraged across the three default readers; value presented in parentheses for each modality.

Specificity average, the digital mammograms across all digital sys-

The specificity difference between digital mammogra-
phy and screen film mammography was calculated. Table
3 reports the average of this difference by machine type
and lesion type. It shows that the specificity from digital
mammography was less than the specificity from screen
film mammography across all machine types for
calcifications.
Tests based on multivariate analysis of specificity data
show that on average, the digital mammograms produced
by the Fischer digital system gave significantly less speci-
ficity than screen film mammograms (P ⫽ .044); and, on
tems gave less specificity for calcifications (P ⫽ .003)
(Fig 8).
To study which combinations among the machine
type, lesion type, and processing method factors pro-
duced the difference between digital mammography
and screen film mammography, multivariate analysis
was conducted of specificity data including the interac-
tions among these factors. The mass cases produced
larger variation in specificity difference between digital
mammography and screen film mammography than the
calcifications cases (P ⫽ .002), but no significant dif-

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Figure 4. Area under the receiver operating characteristic curves by machine and lesion type av-
eraged across the three MultiScale Image Contrast Amplification readers; value presented in pa-
rentheses for each modality.

ference was observed among the three machine types. DISCUSSION

No difference was seen among three processing meth-
ods and between the two lesion types. The resulting
95% confidence intervals for specificity difference are
shown in Fig 8. The Fischer calcifications cases pro-
cessed with default and PLAHE, and Trex calcifica-
tions cases processed with MUSICA produced signifi-
cantly lower specificity than did screen film. All re-
maining digital combinations showed no difference in
specificity from screen film.
Radiologist sensitivity and specificity are dependent not
only on the interpretation skill of the radiologist, but also to
a certain extent on just how visible lesions actually are.
First, the lesion must be distinguishable from the surround-
ing background (normal breast tissue) to be detected mam-
mographically. Similarly, diagnosis of a lesion is only made
when the lesion’s features can be classified. Image-process-
ing algorithms are applied to digital mammograms to alter

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Figure 5. Area under the receiver operating characteristic curves by machine and lesion type av-
eraged across the three Power Law Adaptive Histogram Equalization readers; value presented in
parentheses for each modality.

the visual presentation of the digital mammograms through
manipulation of the gray-scale values of the pixels making
up the mammographic image. Ideally, this manipulation, be
it point (individual pixel), area (clustered groups of pixels),
or global (whole image) would lead to an image where le-
sions are more distinguishable from normal tissue to allow
the radiologists to use their interpretation skill. The lesion
has to be seen before it can be interpreted. An image-pro-
cessing algorithm’s effect on an input image will be depen-
dent on the spatial resolution of the input image, the contrast
resolution available in the input image, the overall breast
density of the patient, and the lesion type if there are
findings.
There are several studies that have addressed the effects
of spatial resolution on calcification detection in digital
mammography (10 –12) for 100-micron digitized images.
None showed improved sensitivity for digital mammography
over screen film. With increased spatial resolution, microcal-
cifications should be better visualized. However, this resolu-
tion does not alone provide the ability to see smaller features
such as calcifications; the available contrast resolution is also
important. We would expect calcifications to be better visu-

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Table 3
Main Effects by Machine Type and Lesion Type of AUC difference, Sensitivity Difference, and Specificity Difference Between
Digital and Screen-Film Mammography

AUC difference Sensitivity difference Specificity difference

Factor Type Mean (SD) P value Mean (SD) P value Mean (SD) P value

Machine Fischer ⫺0.042 (0.037) .321 ⫺0.029 (0.048) .581 ⫺0.061 (0.023) .044*
GE ⫺0.205 (0.043) .009* ⫺0.255 (0.056) .011* ⫺0.037 (0.039) .398
Trex 0.026 (0.012) .091 0.082 (0.032) .061 ⫺0.073 (0.038) .113
Lesion Calc ⫺0.077 (0.026) .042* ⫺0.032 (0.044) .508 ⫺0.129 (0.024) .003*
Mass ⫺0.070 (0.014) .007* ⫺0.102 (0.024) .014* 0.015 (0.040) .725

AUC: area under the receiver operating characteristic curve.

*Indicates statistically significant difference between digital and screen film mammography.

Figure 6. 95% confidence intervals for area under the receiver
operating characteristic difference between digital and screen film
mammography. Each vertical interval represents the machine
type, image processing type, and lesion type combination seen
by three readers. The intervals marked with asterisks were statis-
tically significant.
Figure 7. 95% confidence intervals for sensitivity difference be-
tween digital mammography and screen film mammography.
Each vertical interval represents the machine type, image pro-
cessing type, and lesion type combination seen by three readers.
The intervals marked with asterisks were statistically significant.

best calcification sensitivity performance relative to screen

alized on screen film compared with digital mammography
based on the higher spatial resolution for screen film, but the
increased contrast difference inherent with digital mammog-
raphy is thought to compensate (13). Based on that assump-
tion, we would also expect the sensitivity difference between
digital and screen film mammography to decrease as the
pixel size of the digital image gets smaller and smaller (in-
creasing spatial resolution). These trends were found in our
study, in which calcification visualization on these digital
mammograms was worse than screen film overall, with a
narrowing of the difference between digital mammography
and screen film mammography for sensitivity with increas-
ing spatial resolution.
The Trex digital system, which had 40 microns per pixel
size (highest spatial resolution system tested) and contrast
resolution of 14 bits (16,384 distinct gray levels), had the
film (Fig 7). The Fischer system was next with its 50 mi-
crons per pixel size and contrast resolution of 12 bits (4,096
distinct gray levels), and GE was third with spatial resolu-
tion of 100 microns per pixel size (lowest spatial resolution
system tested) and contrast resolution of 15 (32,768 distinct
gray levels) for one GE prototype and 16 bits (65,536 dis-
tinct gray levels) for another. An interesting finding in our
study was calcifications sensitivity performance in certain
instances was slightly better than the mass sensitivity perfor-
mance, for which we believe lesion subtlety (the visibility of
the lesion in relation to the surrounding breast tissue) was a
factor.
The overall breast density for each patient whose images
were included in this study was at least heterogeneously
dense (8), making this a difficult case set to interpret. The
overall breast density has been shown to affect radiologist

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Figure 8. 95% confidence interval for specificity difference be-
tween digital mammography and screen film mammography.
Each vertical interval represents the machine type, image pro-
cessing type, and lesion type combination seen by three readers.
The intervals marked with asterisks were statistically significant.
ROC performance, showing decreased sensitivity and speci-
ficity (14) with increased breast density. This effect is true
of screen film mammography and this would be true of digi-
tal mammography as well, unless significant visualization
were possible through the larger contrast range. But although
the maximum range of contrast values is set per machine
type, the actual breast tissue composition and dose dictates
the range of contrast values for each individual patient.
The relative difference between each digital mammogra-
phy system and screen film mammography for specificity is
about the same. Specificity difference between all the digital
machine types and screen film do not vary much with each
of the image processing algorithms applied, regardless of
lesion type. Both PLAHE and manufacturer’s default seem
to be specifically optimized for improved characterization of
masses across each of the machine types. A small relative
difference was noticed in specificity, regardless of machine
type for calcifications (Fig 8). This difference would be ex-
pected, given that the images used in this study were screen-
ing mammograms and not diagnostic magnification or spot
compression views, in which better characterization of calci-
fications is possible.
In assessment of the specificity (the ability to distinguish
lesion features that are suspicious for cancer from lesion
features not suspicious for cancer), it was expected that digi-
tal mammography would perform better for specificity by
benefit of the digital mammograms being acquired after the
lesion was found with screen film mammography. There
was a smaller mean difference between digital mammogra-
phy and screen film and there was less variability among
readers in regard to specificity difference between digital
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Academic Radiology, Vol 12, No 5, May 2005
mammography and screen film mammography. This speci-
ficity difference improvement is probably due to the fact that
the digital mammograms for this study were obtained with
the location of the lesion known by the technologist and
presumably optimally positioned and compressed to show
the characteristics of the lesion more clearly.
Digital mammography in general is considered more spe-
cific than screen film mammography based on previous stud-
ies (8,15,16). However, none of those studies, or the study
reported here, looked at randomly selecting the order of the
imaging modalities. However, there is a study comparing
digital mammography to screen film mammography that did
include randomization of the order of imaging modalities—
the Digital Mammography Imaging Screening Trial
(DMIST), which was open to accrual between 2001 and
2003 and is currently in analysis—should resolve whether
the increased specificity seen with digital is simply temporal.
Limitations
Although there were 201 cases included in this study,
image-processing failures resulted in a lower number of
cases being usable for the reader study. We suspect that the
use of more stable digital mammography systems now com-
mercially available and the widespread use of image format
standards in medical imaging, such as Digital Imaging and
Communications in Medicine (10), which was not available
for all machines at the time of this study, would have led to
better input image consistency in this study and fewer fail-
ures of the algorithms, especially PLAHE. More than 96%
(52/54) of the PLAHE-processed cases were not available
because of image-formatting variations within machine types
that were not anticipated at the time of algorithm develop-
ment.
The three image-processing algorithms tested in this
study— default, PLAHE, and MUSICA— had all performed
well in previous studies where they were compared with
other image-processing algorithms (3,8), although not neces-
sarily better than screen film. There certainly could be better
algorithms, even improved versions of the ones tested here,
that could lead to different results. The robustness of algo-
rithms and the parameter settings used can also be the cause
of image display differences.
All of the algorithms tested had some flexibility in regard
to optimizing parameter settings. The possibilities in some
instances were limitless. We conducted a small preference
study by one expert radiologist to determine the optimal
parameter settings for the MUSICA and PLAHE algorithms
to be used for the cases included in this study. These opti-
mal parameter settings were selected based on the radiolo-
gist’s impression of the quality of the image data in side-by-
 Academic Radiology, Vol 12, No 5, May 2005
side comparison to screen film. The most consistently pre-
ferred parameters across both lesion types (masses and
calcifications) were selected for each of the MUSICA and
PLAHE algorithms and applied to all cases in the reader
study.
There have been changes in the various digital mam-
mography systems tested here since this study was com-
pleted including: detector changes, hardware changes, and
software changes that have led to more consistent image
quality over earlier system versions. The Trex system
tested here was Food and Drug Administration–approved
in 2001 under the name Lorad by Hologic, Inc. (Bedford,
MA), but was never marketed. The Fischer SenoScan
tested here has undergone a number of software changes
throughout the years. In November 2003, Fischer intro-
duced a new image-processing algorithm that was de-
signed not only to improve the overall image presentation
quality compared with older Fischer default algorithms,
but also to improve the speed of loading images into the
review station for review. The GE Senographe 2000D has
also undergone changes in display software and now of-
fers a second image-processing algorithm, Premium View,
in addition to the default algorithm at the review worksta-
tion. Whether any of these changes results in earlier de-
tection of breast cancer by radiologists over previous ver-
sions of a given manufacturer’s digital mammography
system or over screen film mammography would require
additional reader studies.
Although image processing alone was not a main effect
of digital mammography versus screen film mammography
in our study, it does seem to have an effect when combined
with lesion and machine type. Training in the visual presen-
tation of lesion characteristics when a given image process-
ing algorithm is applied to a particular digital mammography
system should be provided during applications training for
digital mammography review workstations. Based on our
results, multiple image-processing algorithms may need to
be incorporated into future soft copy workstations to allow
for optimal viewing of specific lesion types for each of the
digital mammography systems.
ACKNOWLEDGMENTS
The authors would like to acknowledge the contributions
of the International Digital Mammography Development
Group, especially the principal investigators of the project
(3) that led to the creation of the image archive from which
the raw images used in this study were obtained: Emily Co-
nant, MD, University of Pennsylvania Medical Center, Phila-
delphia, PA; Laurie Fajardo, MD, University of Iowa, Iowa
IMAGE PROCESSING AND DIGITAL MAMMOGRAPHY
City, Iowa; Stephen Feig, MD, Mt. Sinai School of Medi-
cine, New York, NY; Brad Hemminger, PhD, University of
North Carolina, Chapel Hill, NC; Roberta Jong, MD,
FRCPC-Sunnybrook & Women’s Health Science Center,
Toronto, Ontario, Canada; Daniel Kopans, MD, Massachu-
setts General Hospital, Boston, MA; Andrew Maidment,
PhD, University of Pennsylvania Medical Center, Philadel-
phia, PA; Bahjat Qaqish, PhD, University of North Carolina,
Chapel Hill, NC; Rene Shumak, MD, Ontario Breast Screen-
ing Program, Toronto, Ontario, Canada; Melinda Staiger,
MD, Monmouth Medical Center, Long Branch, NJ; Mark
Williams, PhD, University of Virginia, Charlottesville, VA;
and Martin Yaffe, PhD, Sunnybrook & Women’s Health
Science Center, Toronto, Ontario, Canada.
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