Diagnostic Performance and Geographic Variation in Mammography Services: A Nine-Year Audit from Southern Jordan

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Abstract
Background: Breast cancer continues to be a major contributor to illness among women in Jordan, particularly in underserved regions. Despite the establishment of mammography services in southern Jordan, no formal quality assurance audit has evaluated diagnostic performance or geographic equity of access. This study aimed to evaluate the diagnostic performance of mammography services using established quality assurance indicators and to investigate geographic variation in mammographic findings and diagnostic pathways among women attending a regional referral center in southern Jordan. Methods: This study employed a retrospective hospital-based clinical audit that was conducted using mammography records from Ma’an Hospital between 2016 and 2024. A total of 592 women aged 20 years and older who underwent mammography were included. Data extracted from electronic and paper-based medical records included demographic characteristics, mammography indication, BI-RADS® classifications, follow-up procedures, reporting timelines, and histopathological outcomes. Histopathological confirmation served as the reference standard for diagnostic accuracy analyses. Diagnostic performance was evaluated using Cancer Detection Rate (CDR), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Geographic variation was evaluated according to place of residence, while multivariable logistic regression was used to determine whether associations remained independent of age and mammography indication. Results: Of the 592 mammography examinations, 354 (59.8%) were performed for screening purposes and 238 (40.2%) for diagnostic evaluation. BI-RADS® 1 and BI-RADS® 2 were the most frequently assigned categories, accounting for 38.3% and 28.7% of examinations, respectively, whereas BI-RADS® 4 and 5 findings accounted for 6.3% and 1.0%. The overall CDR was 52.4 per 1000 examinations with sensitivity (93.9% (95% CI 80.4–98.3%)) and specificity (97.4% (95% CI 95.3–98.5%)), positive predictive value (PPV) (73.8% (95% CI 58.0–86.1%)), and negative predictive value (NPV) (99.5% (95% CI 98.2–99.9%)). Suspicious findings (BI-RADS® 4–5) were significantly more frequent among urban than rural women (9.4% vs. 3.7%; adjusted OR 3.05, 95% CI 1.37–6.78), whereas reporting delay, ultrasound use, biopsy rate, and further follow-up did not differ significantly by residence. Conclusions: Mammography services at Ma’an Hospital exhibit high diagnostic accuracy and strong clinical performance in breast cancer detection over the nine-year study period. Women in rural areas were less likely to have suspicious mammographic findings detected than those in urban areas, regardless of age and mammography type. No significant differences were observed in reporting timelines or follow-up procedures by place of residence. These findings underscore the value of regional quality assurance audits in identifying service disparities and guiding improvements in breast cancer screening and diagnostic services, especially in underserved communities.

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