Diagnostic reference levels in digital mammography: A systematic review

Diagnostic reference levels (DRLs) in digital mammography (DM) serve as a useful benchmark for dose monitoring and optimization, allowing comparison amongst countries, institutions and mammography units. A systematic review of DRLs in DM, published in 2014, reported a lack of consistent and internationally accepted protocol in DRLs establishment, thereby resulting in wide variations in methodologies which complicates comparability between studies. In 2017, the International Commission of Radiation Protection (ICRP) published additional guidelines and recommendations to provide clarity in the protocol used in DRLs establishment. With the continuing evolvement of technology, optimization of examinations and updates in guidelines and recommendations, DRLs should be revised at regular intervals. This systematic review aims to provide an update and identify a more consistent protocol in the methodologies used to establish DRLs. Searches were conducted through Web of Science, PubMed-MEDLINE, ScienceDirect, CINAHL and Google Scholar, which resulted in 766 articles, of which 19 articles were included after screening. Relevant data from the included studies were summarized and analyzed. While the additional guidelines and recommendations have provided clarifications in the methodologies used in DRLs establishment, such as data source (i.e., the preference to use data derived from patient instead of phantoms to establish DRLs), protocol (i.e., stratification of DRLs by compressed breast thickness and detector technology, and the use of median value for DRLs quantity instead of mean) and percentiles used to establish DRLs (i.e., set at the 75th percentile with a minimum sample size of 50 patients), other differences such as the lack of a standard dose calculation method used to estimate mean glandular dose continues to complicate comparisons between studies and different DM systems. This systematic review update incorporated the updated guidelines and recommendations from ICRP which will serve as a useful resource for future research efforts related to DRLs, dose monitoring and optimization.