A review of more than 6,000 mammograms at an Arizona healthcare system has turned up dozens of missed tumors, including ones that should have been obvious, say breast imaging experts.

Nonprofit Northern Arizona Healthcare initiated the review at the urging of breast surgeon Dr. Beth Dupree after questioning several mammography readings performed at NAH, reported NBC News, which investigated the issue.

An additional 25 women were found to have missed cancers, and all required either surgery, chemotherapy, radiation or a mastectomy.

Some of the mammograms were “screaming cancer,” Dupree told NBC News. “I literally couldn’t believe what I was seeing. These were misses that were not subtle.”

The review focused on 6,344 mammograms interpreted by an unnamed general radiologist, employed by Northern Arizona Radiologists, which had an exclusive contract with NAH at the time.

Dupree pushed the hospital to hire dedicated breast radiologists for the review. The group identified the 25 women from over 13,000 images but feels the number is likely higher.

“We thought there was a significant chance that additional patients were in harm's way, and that we needed to expand our investigation,” said Dr. Mike Ulissey, a fellowship-trained breast radiologist.

But the hospital did not extend it, saying that it “quickly acted to address the concerns” and that “very few required follow-up.” It also said that NAR is a separate entity, and that all mammograms since the review are read by specialized breast radiologists.

“In the quality process, there was an error. We’re humans. Doctors are humans,” said the hospital chief counsel in a zoom call to community advisors.

NAR said the review results were “well within the national standards,” and that its radiologists are board-certified and meet all requirements, including those “under the Mammography Quality Standards Act.”

One patient whom Dupree consulted before the review was Patricia Ratliff, a breast cancer survivor who was given a clean bill of health at NAH. She was later diagnosed with advanced breast cancer and died two years after.

Among the 25 women with missed diagnoses was Christine Gallo, who had three tumors. “Maybe if they had caught it sooner, it could have been a lumpectomy instead of a whole mastectomy choice. But I didn’t get that choice.”

The radiologist who interpreted the scans is no longer employed by NAR and works in another state.

Dupree and Ulissey have since left NAH.

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