Nova Scotia Breast Screening Program
Annual Report
2007 (2006 Data)

  
  
  
  
  
  
  
Prepared



Contents

Chapter 1  Operational Sites


NSBSP Administration Site and Central Mammography Booking
7001 Mumford Rd 
Unit 603L 
Halifax, Nova Scotia 
B3L 2H8 
Toll Free: 1-800-565-0548 (Mobile van, fixed site and diagnostic mammography bookings)
Halifax: 902-473-3960 (District 9 fixed sites and diagnostic mammography bookings)
Fax: 902-473-3959 
Toll-Free Fax: 1-866-470-3959 
www.breastscreening.ns.ca 
 
NSBSP NAVIGATION
Toll Free: 1-877-738-9898 
Halifax: 902-473-3680 
 


CENTRAL MAMMOGRAPHY BOOKING AFFILIATES
 
District 1 District 2
 
South Shore Regional Hospital Yarmouth Regional Hospital
90 Glen Allen Dr 60 Vancouver St
Bridgewater, NS Yarmouth, NS
B4V 3S2 B5A 2P3
Tel: 902-527-5246 Tel: 902-742-3541
Fax: 902-543-9793 Fax: 902-742-5320
 
District 3 District 4
 
Valley Regional Hospital Colchester Regional Hospital
150 Exhibition St 207 Willow St
Kentville, NS Truro, NS
B4N 5E3 B2N 5A1
Tel: 902-678-7381 (2720) Tel: 902-893-5554
Fax: 902-678-0098 Fax: 902-893-5534
 
District 5 District 6
 
Cumberland Regional Health Care Complex Aberdeen Hospital
110 East Pleasant St 835 East River Rd
Amherst, NS New Glasgow N.S
B4H 1N6 B2H 3S6
Tel: 902-667-5400 (6155) Tel: 902-752-7600
Fax: 902-667-6307 Fax: 902-755-2541
 
District 8 District 9
 
Cape Breton Regional Hospital QEII Health Sciences Center
1482 George St 1278 Tower Rd
Sydney, NS Halifax, NS
B1P 1P3 B3H 2Y9
Tel: 902-567-7788 Tel: 902-473-3960
Fax: 902-567-7812 Fax: 902-473-3959
 
District 9 District 9
 
Dartmouth General Hospital Cobequid Community Health Centre
325 Pleasant St 40 Freer Lane
Dartmouth, NS Lower Sackville N.S
B2Y 4G8 B4C 0A2
Tel: 902-465-8440 Tel: 902-869-6129
Fax: 902-465-8360 Fax: 902-869-6121

Chapter 2  Management & Operations Teams


MANAGEMENT TEAM
 
Medical Director  Dr. Judy Caines
Program Manager  Theresa Foley
Department of Health Advisors  Cheryl Dioron
   Rachielle O'Sullivan
   Brenda Payne
   Lorie Currie
Consultant Epidemiologist  Dr. Jennifer Payne
Dept of Radiology,  
Dalhousie University  
 


OPERATIONS TEAM
 
Program Secretary  Joanne Fraser
 
Promotion and Navigation  Dianna Schreuer
  Susan MacNeil
  Joyce McKarney
  Crystal Hilton
 
Data Management   Theresa Foley
 
Radiologists QEII HSC Dr. Judy Caines
  (Halifax) Dr. A.J. Johnson
  Dr. Gerald Schaller
  Dr. Gordon Jones
  Dr. Joy Borgaonkar
  Dr. Robinette Butt
 
  CBHCC Dr. Sian Iles
  (Sydney) Dr. John Chadwick
  Dr. Anne Latour
 
  YRH Dr. Eric Woods
  (Yarmouth)
 
  CRH Dr. Nancy McNeil
  (Truro and Dr. John McNeil
  Amherst) Dr. Dave Gordon
 
  DGH Dr. Andrew Ingham
  (Dartmouth) Dr. Carla Pittman
  Dr. Kim Colter
 
  SSR Dr. Peter Jeffrey
  Dr. Arthur Marshall
  Dr. C.L. Church
  Dr. Chen Meng
 
  VRH Dr. Michael Dunn
  Dr. David Acton
  Dr. John Bilo
  Dr. Maureen Madigan
 
  AH Dr. Dan Hoffman
  Dr. Ronald MacEachern
  Dr. Magdalena Biernacka
 
Technical Contacts QEII HSC Bonnie Hart
  CBHCC Susan MacNeil
  YRH Crystal Hilton
  CRH Joyce McKarney
  DGH Linda Sampson
  CRHCC Sandra Rose
  SSR Linda Bowers
  VRH Debbie Bezanson
  AH Laurie Graham

Chapter 3  Executive Summary

The Nova Scotia Department of Health established and funded the NSBSP as a provincial program in 1991. All ten provinces and two territories now have breast screening programs. Evidence from randomized controlled projects has demonstrated that organized breast screening mammography maximizes the early detection of breast cancer.
On June 15th 2006 the Nova Scotia Breast Screening Program (NSBSP) celebrated the 16th year of providing an outcome driven, client oriented program to women in Nova Scotia. As of December 31, 2006 433833 screens have been performed on 133980 women finding 1936 cancers. Cancer detection rates for this period can be seen in table 3.1
NSBSP offers modified clinical breast examinations and breast health information at all sites. Currently there are thirteen screening sites and nine diagnostic sites booking procedures and contributing real-time data through the provincial Central Mammography Booking Database (CMB). Discussions with management at St. Martha's Hospital in Antigonish for future involvement with NSBSP is underway. CMB inclusion of this site will complete the organizational phase of NSBSP.
Central Mammography Booking (CMB) in both screening and diagnostic mammography is present in all sites except District 7: Guysborough/Antigonish. CMB had initially decreased wait times in all diagnostic sites dramatically; however screen wait times have since increased, predominantly due to decreased capacity. To increase capacity and provide a standardized approach to breast imaging, the NSBSP, with the support of the Nova Scotia Department of Health, has moved forward with a planned approach toward complete provincial Full Field Digital Mammography (FFDM) in both the screening and diagnostic sector.
Presently three FFDM sites are operational. The first FFDM mobile in Canada opened in Cape Breton (District 8) in July. This was followed by a fixed FFDM unit in the Cobequid Community Health Center (District 9) and a combined diagnostic and screening site at Yarmouth Regional Hospital (District 2). Included in the FFDM approach is the implementation of the diagnostic mammography reporting system throughout the province.
One main goal of the NSBSP is to standardize the mammography process throughout the entire province. “Lack of full organization may result in sub-optimal program operation, performance and resource efficiency.” Progress in Cancer Control: Screening: Canadian Cancer Society/National Cancer Institute of Canada: Canadian Cancer Statistics 2006.
There are still many challenges for the Nova Scotia Breast Screening Program which include:

3.1  Mission Statement

The Nova Scotia Breast Screening Program's goal is to reduce the mortality from breast cancer in Nova Scotia women aged 50-69 years of age by 30% within ten years following development of a province wide screening program.

3.2  Vision

The Nova Scotia Breast Screening Program's vision is to provide quality standardized mammography access with timely assessment, informed patient navigation and appropriate follow-up of women who have abnormal mammograms on screening, through diagnostic work-ups in accredited work-up centers, before consideration of surgical alternatives.

3.3  Mandate

The NSBSP was established in response to an identified serious health issue. Its mandate is:

The NSBSP works closely with other provincial and national committees and organizations in the fulfillment of its mandate. These include:

The program enjoys close ties with all DHA coordinators and is well-networked into other provincial programs. The NSBSP adheres to all of the current provincial program mandates.


Table 3.1: Cancer Detection Rates (All Ages)
 Cancer Detection Rate per 1000 Screens Cancer Detection Rate per 1000 Women
 1991-20041991-20051991-2006 1991-20041991-20051991-2006
 324745375640433833 107390119179133980
Age       
<502.42.42.3 5.65.75.6
50-594.44.34.3 14.715.215.4
60-695.96.16.2 22.924.926.5
70+9.69.89.7 363940.3

Chapter 4  Nova Scotia Breast Screening Program

4.1  (NSBSP) Organizational Chart – Oct 2006



4.2  Central Mammography Booking (CMB) Participants


Table 4.1: Central Mammography Booking (CMB) Participants
Screening Sites (13)Participation date
Mobiles (3)Mobile 1 (Cape Breton)Sept 1994
 Mobile 2 (Western)July 1997
 Mobile 3 (Northern)Jun 2003
 Mobile 4 (Replacing Mobile 1)July 2007
Fixed (10)Halifax Shopping CenterJun 1991
 Sydney - hospitalMay 2000
 Yarmouth - hospitalApr 2001
 Truro - hospitalJun 2002
 Dartmouth - hospitalJan 2003
 Amherst - hospitalJune 2004
 Bridgewater - hospitalJuly 2005
 Kentville - hospitalJan 2006
New Glasgow - hosptialJan 2007
Cobequid - Community Health CenterJuly 2007
Diagnostic Sites (9)Participation date
 HalifaxDec 2000
 SydneyMay 2001
 DartmouthApr 2003
 TruroApr 2004
 YarmouthApr 2005
 BridgewaterJuly 2005
 AhmerstJan 2006
 KentvilleJan 2006
 New GlasgowJan 2007

Chapter 5  Strategic Planning

5.1  Provincial Program Model Approach

Within the Acute and Tertiary Care Branch the following provincial programs are currently funded by the Department of Health: Cancer Care Nova Scotia, Nova Scotia Diabetes Care Program, Reproductive Care Program, Nova Scotia Breast Screening Program, Cardiac Advisory Council, Nova Scotia Provincial Blood Coordinating Program and the Nova Scotia Hearing and Speech Program.
The Acute and Tertiary Care Branch has developed an Accountability Framework for Provincial Programs to assist in determining whether a provincial program approach is the appropriate solution to address particular health care issues related to acute and tertiary care. In addition, this accountability frame-work will provide support for existing Provincial Programs where reporting relationships, roles and responsibilities are not clear. Provincial Program Model, Acute and Tertiary Care Branch Proposal, April 2, 2004.

5.2  Provincially Supported Screening Mammography Policies

The expectation of the Department of Health of the province of Nova Scotia is for all mammography facilities in N.S. to be participating in NSBSP by 2007. With 100% participation of provincial mammography sites soon to become a reality, further standardization of policies and procedures has become a priority. In past years, measures implemented with provincial approval include:

In 2005, other measures strongly supported were:

5.3  Programmatic Screening of Ages 40-49

In 1993 it was recognized that women themselves were demanding mammography at age 40 and appropriate tracking mechanisms did not exist for these examinations. Until further meta-analyses are published on the subject, NSBSP (after consultation with the Department of Health) determined these women should be able to self-refer for screening mammography. Automatic recall on an annual basis for women 40-49 was instituted in 1995. Current evidence suggests there is good evidence to screen the 40-49 age group providing quality assurance aspects of the program are in place and outcomes can be monitored. One trial presently being conducted under the auspices of the United Kingdom Coordinating Committee for Cancer Research (UKCCCR) was planned for first analysis in 2003. Similar feasibility studies are also in progress in four other European countries. These trials recognize that if early detection of breast cancer is to be effective in younger women, the intervals between screen episodes must be shorter.

Chapter 6  Requirements for a Breast Screening Program

Breast Cancer is an important health problem which has a recognizable latent or early non-symptomatic stage. The screening test must be efficacious (sensitivity and specificity) and acceptable, and diagnosis and treatment must be acceptable with facilities available. The cost must be balanced against medical care funding as a whole and should be ongoing. WHO 1968, Criteria for Screening Program.

6.1  CAR Accreditation

The Nova Scotia Breast Screening Program has been instrumental in encouraging high quality mammography through accreditation of staff and equipment by the Canadian Association of Radiologists (CAR). NSBSP has taken a lead to promote this process. It is one of many organized steps towards achieving and maintaining favorable program indicators. All mammography sites in Nova Scotia are currently accredited or in the process of accreditation. Re-accreditation is required every three years.
In 2005, it became policy in Nova Scotia that fees for mammography services would not be paid by the province unless CAR accreditation and a process for accreditation maintenance is in place. This policy was supported by the Nova Scotia Association of Radiologists, the Medical Society of Nova Scotia (Doctors, Nova Scotia), and the Department of Health.

6.2  Radiology Reading Volumes Study

Nova Scotia was one of the provinces contributing data to the Pan Canadian Study by a working group of the Canadian Breast Cancer Screening Initiative. This study was to look at cancer detection rates and radiologist performance, in relation to volumes of mammograms interpreted. The results from this study, Organized Breast Screening Programs in Canada: Effect of Radiologist Reading Volumes on Outcomes, were published in Radiology: Volume 238: Number 3, (809- 815) - March, 2006.
The working group concluded that cancer detection did not vary with reading volume. The average Positive Predictive Value (PPV) for individual radiologists improved as reading volume rose up to 2,000 mammograms per year; it stabilized at higher volumes. In North America required volumes are comparatively low, at 480 mammograms per year, compared with the 2,000 mammograms required in Australian screening programs and 5,000 mammograms required in United Kingdom Screening Programs Radiology: Volume 238: Number 3, (810) - March, 2006.
The Nova Scotia Breast Screening Program utilized the 3,000 case reading volume as its guideline from the beginning of the program in 1991. Based on NSBSP outcome results and a British Columbia study Standardized Abnormal Interpretation and Cancer Detection Ratios to Assess Reading Volume and Reader Performance in a Breast Screening Program; Radiology 2000; 215: 563-567, NSBSP lowered the reading volume recommendation to 2,500 per year in the year 2000. Future recommendations for NSBSP policy change in this area will be based on further NSBSP analysis.

6.3  Double Read System

Since the beginning of the program every tenth screening mammogram has been selected for a second interpretation by a different radiologist. These cases are computer selected and this process requires that these films be re-loaded following reporting sessions. Radiologist scheduling must be taken into consideration to avoid delays. Future reports will look at results. In addition to this formal approach, an unofficial double read system has been encouraged and may include peer review at a different hospital. Although this is work intensive for the entire NSBSP team, it has decreased work-up rates and is in the best interest of the clients.

6.4  Annual Radiologist Mailing

Each year radiologists associated with the program receive feedback containing their individual cancer detection rates and positive predictive values from the previous year. In this way the learning curve trends inherent to the interpretation of screening mammography are directly shared, and can be monitored by each screener for enhancement of results.

6.5  2004 Policy for Clinical Breast Examination

A standardized NSBSP policy for modified Clinical Breast Examination teaching was implemented for program use in all sites. This was put in place after it became apparent that sites were applying the policy differently. The policy states that all women will receive a modified clinical breast exam by the technologist prior to their screening mammogram. This is not a thorough examination but enables computer entry of significant palpable abnormalities be made of obvious findings for the radiologist reporting the films.

6.6  Cartoon Information Sheet and Client Version of CPGs “Survey”

In 1998, NSBSP began enclosing with the client abnormal letter and work-up appointment, a modified client version of the Clinical Practice Guideline for Mammography (CPG 2). The original versions had as an objective, to provide information and recommendations to facilitate decision-making when a mammographic abnormality is detected by screening. The Medical Imaging and Pathology team of NSBSP was instrumental in this publication. Although modified by NSBSP to reflect a more client-friendly handout, the feedback resulting from the survey indicated a need for a still greater degree of sensitivity. In addition, a cartoon sheet enclosure introduced in 2003 was redesigned along with the CPG brochure following survey results in 2004. Action: Continue the cartoon and CPG enclosures and share comments with physicians, staff and management of the NSBSP.

Chapter 7  Provincial Review of Mammography Units

In the interest of promoting an integrated approach to breast screening, all but one District Health Authoritiy has implemented NSBSP's screening and provincial diagnostic computer booking program. Discussions are currently underway with DHA 7 to include a fixed mammography unit with the program. NSBSP would then be able to provide a comprehensive picture of screening mammography recruitment, participation and outcomes for women in Nova Scotia.
Similar to advances for other diagnostic equipment, there is new and updated technology available for mammography. Considering new technology and the process of integrating all units plus the integration of Picture Archiving Communications Systems (PACS), in 2005 it was considered timely to conduct a provincial review of all mammography units with a goal of developing a provincial plan for the future. The Committee Members and Terms of Reference for this Provincial Review of Mammography Units is included in this document as A.
Provincial Mammography Review goals:

The review process and plan decided in June 2005, was to upgrade all fixed and mobile mammography facilities to digital mammography with wideband networking to regional and central diagnostic centers. A provincial RFP was submitted for immediate purchase of equipment for Cape Breton and Yarmouth. This was the beginning of an organized long term approach (5-7 years) to introduce digital mammography to the province. This review process is now in the implementation stage. For purposes of uniformity and quality performance execution, one successful bid for all equipment was identified, and equipment purchases have begun. A provincial mammography equipment committee (PMEC) for implementation of FFDM has been established.
Although a number of new technologies are on the horizon, they are unlikely to replace mammography in the near future for screening the general population. Mammography remains the only breast cancer screening tool proven to reduce mortality from breast cancer in the population. Public Health Agency of Canada, 2006.

Chapter 8  Core Business Functions

8.1  Population Health

Increasing the number of mammography facilities (capacity) and standardizing a mammography service province-wide to provide relevant research material for responsible health care reform

8.1.1  Mortality Rates

The most recent actual data for 2002 showed the breast cancer mortality rate in countries with “organized” breast screening programs to be at its lowest since 1950. Since 1993, incident rates for breast cancer have stabilized and death rates have declined at a rate of 2.7% annually. There is evidence for improved survival due to the organized mammography screening programs detecting cancer earlier and advances in adjuvant therapies following breast cancer surgery. National Cancer Institute of Canada: Canadian Cancer Statistics 2006.
Decreased mortality of breast cancer requires early detection of the disease as well as prompt and appropriate treatment. For 2006, it is reported that there will be an estimated 22,200 new cases of female breast cancer and 5,300 deaths in Canada. In Nova Scotia for 2006, it is estimated that there will be 700 new cases of breast cancer and 190 deaths. Breast cancer is the most common cancer and most common cause of death among females aged 20-49, accounting for 40% of cancer diagnoses and 25% of cancer deaths. Cancer Institute of Canada: Canadian Cancer Statistics, 2006.
During their lifetimes, 1 in 8.9 women (11.2%) are expected to develop breast cancer, and 1 in 27 (3.7%) are expected to die from it. Only 29% of breast cancers are diagnosed at age 70 or older, 51% between ages 50 and 69 and 20% under age 50. Presently 1.0% of females are survivors of breast cancer diagnosed within the previous 15 years. Canadian Cancer Society/National Cancer Institute of Canada: Canadian Cancer Statistics, 2006.
For 2006 estimated age standardized incidence rates for breast cancer in Nova Scotia are 106/100,000 with an estimated 700 new cases. In 2003, actual data reported 590 new cases for an actual age-standardized incident rate of 92/100,000 third lowest among all Canadian provinces. Incidence is increasing due to the implementation of breast screening programs and greatly improved methods of data collection both of which NSBSP has as been active in developing and promoting.
The estimated age standardized mortality rate for Nova Scotia for 2006 is now the third highest in Canada at 26/100,000 based on 190 estimated deaths. It is steadily decreasing. Two years ago it was the highest and one year ago, second highest. Actual data for the age standardized mortality rate for breast cancer in Nova Scotia for the year 2002 was 25/100,000, a decrease from the actual rate of 26/100,000 in 2001. There were 170 deaths recorded in Nova Scotia in both 2001 and 2002.
In Canada in 2002 there were 94,200 Potential Years of Life Lost (PYLL) due to breast cancer (18.3% of all causes of PYLL) compared to 95,000 in 2001. With regard for the most common cancers in women and men, the PYLL from breast cancer far exceeded the PYLL from prostate cancer (34,000) reflecting the relatively young age that women die from breast cancer. Canadian Cancer Statistics 2005.
The five year relative survival ratio for breast cancer cases diagnosed 1995 to 1997 in Canada was 86% (85% in Nova Scotia). Cancer Institute of Canada: Canadian Cancer Statistics 2006. On average, fourteen Nova Scotia women will be diagnosed with breast cancer every week. On average, four Nova Scotia women will die of breast cancer every week. Canadian Cancer Statistics 2005.

8.2  Database Surveillance and Evaluation

Providing quality assessment and provincial outcomes

8.2.1  Nova Scotia Mammography Database

Central Mammography Booking Database (CMB): Includes (1) screening and (2) diagnostic booking and follow-up modules

1. NSBSP Database:
Includes self referred bookings for asymptomatic women ages 40 to 69 and over age 70 (if otherwise in good health). The Canadian Association of Radiologist's Guidelines for Screening Mammography.
2. Diagnostic Mammography Database (DMB):
An improved diagnostic database which has been designed to complement the NSBSP database and to provide one provincially standardized diagnostic mammography reporting module with upgraded services. Presently it is in use at the Queen Elizabeth II Health Sciences Center (QEII HSC) in Halifax and Cape Breton Regional Hospital (CBRH) in Sydney. Plans to expand the diagnostic database for diagnostic mammography reporting are anticipated within the next year as provincial information technology support becomes available.
The NSBSP Guidelines for booking both screening and diagnostic mammography are included as Appendix B. A draft copy of the new diagnostic mammography requisition which must be correctly filled out and faxed to CMB by the referring physician (office), is included as Appendix C.

If resources are allocated for data collection and outcome analysis, it will promote the best possible quality initiatives, staff performance and results at all levels. Timely annual report production has been a significant NSBSP accomplishment, made possible by aggressive NSBSP database development. This has resulted in a yearly effort to close the books on cases, and has also provided organized safe-guards for women to prevent cases from falling through cracks in the healthcare system.
Cumulative, annual and biennial figures and charts are contained in this report. Target age group (50-69) numbers are used when calculating Program Indicators, but other charts and figures include women outside the NSBSP targeted age group. The NSBSP database also ensures that every tenth mammogram has been blind read by a second radiologist. In 2006, 6 women were classified as “Lost to follow-up”, and 6 women with abnormal screening reports refused one or more recommended follow-up procedures, resulting in a status of “Refused”.
From the beginning of the program in 1991, there have been 52 women “Lost to Follow-up” and 33 have “Refused” recommended work-up procedures. These women are therefore classified as non-compliant and are categorized appropriately for the particular screening episode. These cases have been reviewed at NSBSP team approach rounds and many have since undergone subsequent re-screening or diagnostic mammography.
Quality is the key word for successful breast cancer screening. Without a reliable database, the organization is extremely difficult. Providers of screening have a responsibility to insist that the program be well organized. If done properly, the cost-benefit analysis will reveal a reasonable cost per screen and cost per cancer detected.

8.3  Education

Promoting awareness of service availability, breast screening guidelines and the Clinical Practice Guidelines for the Care and Treatment of Breast Cancer

8.3.1  1 in 9 Workshop

As part of continuing medical education collaboration, Dalhousie University in Halifax, the Canadian Cancer Society and NSBSP organized “The 1 in 9 Workshop” for medical students and residents. This was put in place in 1997 using resources from the breast screening program and Department of Family Medicine at the university. This is a four hour intensive information session focusing on breast screening processes, clinical breast examination, breast cancer and the emotional impact of breast cancer following detection. The lectures and small group workshops present a powerful overview of this disease and it has continued as an annual event. It is a most useful tool for community education and promotion of NSBSP to health care professionals.

8.3.2  The Nova Scotia Breast Screening Program Web-site

From the web site originally designed in 2002 by a high school student as a summer project, the updated site now includes current mobile van schedules as well as program guidelines. The NSBSP site may be visited at www.breastscreening.ns.ca. It is updated yearly to coincide with annual releases of the three mobile van schedules and following policy changes. The annual report may also be accessed on the web-site.

Chapter 9  Performance Indicators

In order to achieve reductions in breast cancer mortality and morbidity and to minimize undesirable effects of breast screening, the delivery of organized screening must be of high quality. Performance Measures and Targets were selected on the basis of assessing program progress toward desired goals. The eleven performance indicators met the following criteria:

A routine biennial report is produced at the national level using data from the Canadian Breast Cancer Screening Database (CBCSD). Although there are many differences in the manner in which the provinces have set up their individual programs, this monitoring role provides useful feedback and comparisons, as well as a mechanism to share processes and provide definitions. The targets set have provided goals and formats for the ten differently structured provincial breast screening programs in the interest of producing more standardized provincial data reports. In 2006, the Evaluation Indicators Working Group, a sub-committee of the Canadian Breast Cancer Screening Initiative published the document “Guidelines for Monitoring Breast Screening Program Performance”, second edition. A list of eleven performance indicators and definitions can be seen in Section 9.1.

The NSBSP Performance Indicators for 2003, 2004, 2005 and 2006 plus the Canadian Breast Screening Database Indicators, most recently available for the combined years of 2001 and 2002 can be seen in Table 9.1. All Program Indicators are for the target age group (50-69). More information on each indicator can be found on the specified pages.

Additional imaging and interventional indicators are being looked at by some provinces as an overall client-based service delivery measure and program quality exercise. “Future methods should be directed toward developing new screening methods as well as methods of improving the sensitivity and specificity of mammography. Methods of reducing surgical biopsy rates and complications of treatment should also be studied, as should communication of the risks and benefits associated with screening.” Ann Intern Med, 2002; 137:347-360.

9.1  Definitions

Participation Rate:
Percentage of women who have a screening mammogram (calculated biennially) as a proportion of the eligible population (Section 9.2.1)
Retention Rate:
Estimated percentage of women who are re-screened within 30 months of their previous screen (Section 9.2.2)
Abnormal Call Rate:
Percentage of women screened referred for further testing because of abnormalities found with a program screen (Section 9.2.3)
Invasive Cancer Detection Rate:
Number of invasive cancers detected per 1,000 women screened (Section 9.2.4)
In Situ Cancer Detection Rate:
Number of ductal carcinoma in situ (DCIS) cancers (rather than invasive cancer) during a screening episode per 1,000 women screened (Section 9.2.5)
Diagnostic Interval:
Total duration from abnormal screen to resolution of abnormal screen (Section 9.2.6)
Positive Predictive Value:
Proportion of abnormal cases with completed follow-up found to have breast cancer (invasive or in situ) after diagnostic work-up (Section 9.2.7)
Benign to Malignant Open Biopsy Ratio:
Among open biopsies, the ratio of number of benign cases to the number of malignant cancer cases (Section 9.2.8)
Invasive Cancer Tumor Size:
Percentage of invasive cancers with tumor size of <10mm and < 15mm in greatest diameter as determined by the best available evidence: 1) pathological*, 2) radiological, 3) clinical (Section 9.2.9)
* (> 99.9% of tumor sizes input into NSBSP database are pathological)
Node Negative Rate in Cases of Invasive Cancer:
Proportion of invasive cancers in which the cancer has not invaded the lymph nodes (Section 9.2.10) **
** For Nova Scotia this figure also includes node negative cases of Dcis. Although rare, surgical pathology reports of Dcis can have positive node pathology.
Post Screen Detected Invasive Cancer Rate:
Number of women with a diagnoses of invasive breast cancer after a normal screening within 12 and 24 months of the screen date for women screened on an annual or biannual basis respectively (Section 9.2.11)

9.2  Indicators (National and Provincial)

Table 9.1 presents both the national provincial performance indicators.

9.2.1  Participation Rate

Percentage of women who have a screening mammogram (calculated biennially) as a proportion of the eligible population

Target:
70% of the target population
The NSBSP participation rate for the biennial timeframe of 2005 and 2006 was 51.77%% of the targeted age population in Nova Scotia.
Over one year there was a biennial participation rate increase of 5.36%. For the same time-frame the number of screens increased by 10.4%, compared to a 6.6% increase one year ago. The lowest participation rate of 12.04%, seen in District Health Authority (DHA)6 (New Glasgow), reflects the lack of database information from this site which began booking mammography through Central Booking and submitting data to the province in January 2007. This is not an accurate representation of the breast screening participation rate in this district.
Minimal changes can be seen in the Capital Health District (DHA 9) and Cape Breton (DHA 8), both requiring much needed additional capacity in mammography services.


Table 9.1: Performance Indicators (ages 50-69)
  CanadaNova Scotia
IndicatorCanadian Recomendations2001+022003200420052006
Number of screensN/A115945925500274822846732191
Number of 1st screensN/A3428476472547649936197
Number of cancersN/A6125108123148158
Participation Rate>70% of the eligible population23% 38.83% 43.33% 46.41% 51.77%
Retention Rate      
1st screen> 75% re-screened within 30 months69%63.3%65.6%66.5%64.7%
Re-screen>90% re-screend within 30 months88%79.4%80%79.1%78.2%
Abnormal Screen Rate      
1st screen< 10% of screens reported as abn13.1%7.187.88.6
Re-screen< 5% of screens reported as abn7.4%4.24.14.24.4
Invasive Cancer Rate      
1st screen> 5 per 100054.025.483.816.13
Re-screen> 3 per 10003.92.893.094.263.62
In Situ cancer RateSurveillance and Monitoring Only     
1st screenper 1000 screens1.21.391.10.81.29
Re-screenper 1000 screens110.910.980.77
Diagnostic Interval      
No open biopsy>90% within 5 weeks (no tissue bx)72%63.260.761.661.9
With open biopsy>90% within 7 weeks (with tissue bx)49%27.921.330.213.5
Positive Predictive Rate      
1st screen> 5% of abn screens4.8%7.6%8.1%6.1%8.6%
Re-screen> 6% of abn screens6.6%9.1%9.7%12.5%10.1%
B : M open biopsy ratio< 1:1 initial screen open biopsies1 : 10.2 : 10.4 : 10.2 : 10.2 : 1
 < 1:1 re-screen open biopsies0.9 : 10.2 : 10.2 : 10.2 : 10.2 : 1
Invasive ca tumor size> 25% < 10mm36.4%32.9136.7333.3328.68
 > 50% < 15mm64.6%63.2967.3553.8563.57
Node negative cancers> 70% node negative7577797577
  CanadaNova Scotia
IndicatorCanadian Recomendations98-992001/20022003/20042005/2006
Post Screen Detected     
Invasive Cancer Rate 1     
within 12 months< 67.7---
within 24 months<1210.2---

1
Funding by the Canadian Breast Cancer Foundation - Atlantic Chapter has enabled a retrospective study of Post Screen Cancer rates. These will be available for 2000/2001 and 2002/2003 for the 2006 Annual Report.


Table 9.2: Performance Indicators under review (ages 50-69)
  CanadaNova Scotia
  2000+012003200420052006
 
Benign open biopsy rateSurveilance and monitoring     
1st screen per 1,000 screens4.31.22.411.6
Re-screen per 1,000 screens2.70.80.60.91
 
B : M ratio - direct to open bx1 < 2 : 10.9 : 11.4 : 12.2 : 12.2 : 15.3 : 1
 
Benigh core biopsy rateSurveillance and monitoring     
1st screen per 1000 screens10.818.221.724.222.6
re-screen per 1000 screens4.19.699.29.7
 
B : M core bx ratioSurveilance and monitoring     
1st screen 2.9 : 14.1 : 14 : 15.8 : 13.3 : 1
re-screen 1.5 : 12.6 : 12.2 : 11.9 : 12.2 : 1
 

1
Captured by the province of Nova Scotia only, to obtain a quality performance indicator for facilities in this province where breast surgery is performed

The most frequent “self-reported” reason for participation in NSBSP continues to come from recommendations for regular mammography screening by family physicians. This strongly supports the Program's decision to focus promotional funding on increasing physician awareness of early detection by mammography screening and the associated cost benefit. Of interest as well, is the fact that the most common reason for Gynecological Screening is due to reminders by NSBSP, at the time of breast screening examinations.
In 2005, 10.6% of women screened were over age 69. This decreased to 10.4% in 2006. In 1997, 4% of NSBSP's clientele were over the age of 69. Following policy change in 1998 to accept these women into the program (but not send them reminder letters) these figures have been watched carefully for the resulting affect on program capacity, as it increasingly affects available bookings for the target age group of 50-69. However, many in this group had started with the program when in the target age group and if still asymptomatic, should not need to have examinations in and tie up the diagnostic system. After age 70, screening mammography is recommended if a women's life expectancy is anticipated to be ten years.
In the initial six months of the program the policy to not accept the 40-49s was clearly not enforced and 20% of women attending were in this age group. However, physicians and women in their 40s lobbied strongly in an effort for them to officially become part of the program. Following a relatively high cancer detection rate and a high number of node positive cases seen in this group in 1992, it was decided to change policy and accept these women in order to provide organized outcomes for this younger group for whom surveillance and monitoring should also occur. If this had not been done, they also would have continued to have screening mammography in the diagnostic mode, resulting in unnecessary appointments in the diagnostic sector and no tracking of outcomes. In 1995, it officially became policy to send recall letters to these younger women using the annual screen protocol.
In 2006, 33.4% of NSBSP participants were aged 40-49.


Figure 9.1: NSBSP Biennial Participation (ages 50-69)

The commitment of the Nova Scotia Department of Health to the Nova Scotia Breast Screening Program has resulted in linear increases in participation rates. Support given by the Department of Health toward provision of a truly comprehensive, provincial mammography program continues to be apparent. Increases in 2004/2005 mainly represent the addition of the screening program from Bridgewater and additional NSBSP screening appointments from the fixed site at the Yarmouth Regional Hospital. For the two year period of 2005and 2006, there were 51928 (Table 9.3) screening mammograms performed by NSBSP on women in the target age group.


Table 9.3: NSBSP Biennial Participation Rate and Trend by District Health Authority ages 50-69
District HealthTargetParticipationParticipationParticipationParticipationAnnual DHABiennial Screens
AuthorityPopulationRatesRatesRatesRatesParticipation2005+2006
DHA 2002+20032003+20042004+20052005+2006Trend 
      Per DHA 
Unknown-     3403
1 South Shore755524.39%26.57%33.77%48.02%14.26%3628
2 SW Nova724136.33%44.72%54.26%59.92%5.66%4339
3 Annapolis Valley931229.35%28.74%29.6%45.45%15.85%4232
4 Colchester E. Hants743947.92%51.94%52.18%56.28%4.1%4187
5 Cumberland404312.44%25.55%40.29%51.89%11.6%2098
6 Pictou54069.27%11.62%10.91%12.04%1.13%651
7 Guys/Ant543436.09%36.07%37.15%34.56%-2.59%1878
8 Cape Breton1576236.87%39.04%42.89%45.76%2.87%7213
9 Capital3811446.4%50.91%50.4%53.26%2.86%20299
Total100306 38.83% 43.33% 46.41% 51.77% 5.36% 51928

Table 9.4 contains in addition to data in Table 9.3, diagnostic data from facilities now booking diagnostic mammography using the Central Mammography Booking Database. The data presented in Table 9.4 shows 59056 women having at least one bilateral mammogram in a two year period at either a screening or diagnostic site. The resulting mammography participation rate is 58.88% an increase of 7% over 2005.
Italicized numbers in column three, indicate numbers of women by DHA having had a bilateral diagnostic examination outside their home district but at a facility booking and reporting through CMB, and who have not already had a screening mammogram in the same year. The majority of Nova Scotia hospitals are effectively channeling appropriate screening cases to the program mode and two have implemented the provincial diagnostic reporting system. Mammography performed in diagnostic centers must be ordered by faxed requisition. “Diagnostic” bookings comprise symptomatic cases, abnormal screen work-ups, women with previous breast cancer, and short term follow-up cases following core biopsy, surgery or previous mammography. See Appendices B and C.


Figure 9.2: 2005/2006 Combined Provincial Mammography Participation Rates per DHA (ages 50-69)

Table 9.5 has in addition to data in Table 9.3 the cancer detection rate of surgically removed cancers by district.
It is important to remember that the cancer rates in Table 9.5 do not reflect the overall provincial cancer detection rates. These figures include only findings from the Nova Scotia Breast Screening Program database and represent approximately one third of the annual cancer detections in this province.
Table 9.6 is similar to Table 9.4 except for the addition of the ages 40 to 49. This age group (recalled on an annual basis, although not actively recruited) is accepted by NSBSP for purposes of data collection and other benefits available only through the organized program. In Table 9.6 it can be seen the provincial screening plus diagnostic participation rate when including the 40-49 age group for 2006 is 50.39% (44.7% one year ago). The increase is primarily due to greater numbers of diagnostic examinations (ages 40-49) from Halifax and Sydney, following complete diagnostic data from these two sites. It is expected that there are significant numbers of this age group in other sites having mammograms and not providing outcomes. Analysis of data on women under age 50 is now possible when reporting is done through the provincial diagnostic database.

9.2.2  Retention Rate

Estimated percentage of women who are re-screened within 30 months of their previous screen

Target:
75% re-screened within 30 months


Figure 9.3: Retention Rates by Year (ages 50-69)

NSBSP Retention rates for this report are calculated on the number of eligible women that have returned to the program for a subsequent screen within 30 months of their previous screen if aged 50-69 and 18 months for ages 40-49. Women over the age of 69 are not included in this calculation as they are accepted into the program but are not sent reminders. Optimal benefits of screening are brought about by regular participation in the screening program (at least every 2 years). At present there is no indication that the benefits of screening are lost if rescreening occurs up to 6 months after the recommendation interval. "Guidelines for monitoring Breast Screening Performance" Second Edition Aug 2007 page 8.


Table 9.4: Diagnostic and Screen Biennial Participation Rates ages 50-69
DiagnosticTargetBiennialBiennialCombinedCombinedCombined
MammographyPopulationDiagnosticScreens PlusParticipationParticipationParticipation
Facilities MammogramsBiennialRatesRatesRates
by DHA 2005-2006Diagnostics2003+20042004+20052005+2006
   2005+2006Per DHAPer DHAPer DHA
Unknown-28536256   
1 South Shore Regional755566369427.5%34.6%48.9%
3.Yarmouth Regional724123436244.9%54.5%60.2%
3 Valley Regional931245427729.3%30.1%45.9%
4 Colchester Regional7439146433354.1%54.2%58.2%
5 Cumberland Regional404323212126.2%40.9%52.5%
6 Aberdeen54061967012%11.2%12.4%
7 St. Martha's543456193436.9%38%35.6%
8 Cape Breton Health Care157621037825044.9%49.1%52.3%
9 QEII HSC and DGH3811428602315957.2%57%60.8%
Total1003067128 59056 48.39% 52.11% 58.88%


Table 9.5: Biennial Participation and Cancer Detection Rate by District ages 50-69
District Health AuthorityTargetWomen ScreenedParticipationInvasiveIn situAllCancer Rate per
(DHA)PopulationbienniallyrateCancersCancersCancerswomen screened
  2005+20062005+2006   per district
Unknown District-3403 909 
1 South Shore7555362848.02%91102.8
2 South West Nova7241433959.92%130133
3 Annapolis Valley9312423245.45%141153.5
4 Colchester E. Hants7439418756.28%200204.8
5 Cumberland4043209851.89%6283.8
6 Pictou County540665112.04%1011.5
7 Guysborough / Antig5434187834.56%5163.2
8 Cape Breton15762721345.76%260263.6
9 Capital381142029953.26%504542.7
Total1003065192851.77%14491532.9


Table 9.6: Diagnostic and Screen Biennial Participation Rates ages 40-69
DiagnosticTargetBiennialBiennialCombinedCombinedCombined
MammographyPopulationDiagnosticScreens PlusParticipationParticipationParticipation
Facilities MammogramsBiennialRatesRatesRates
by DHA 2005-2006Diagnostics2003+20042004+20052005+2006
   2005+2006Per DHAPer DHAPer DHA
Unknown-58925249   
1 South Shore Regional12634121536321.8%28.9%42.4%
2 Yarmouth Regional1218260659839.5%47.8%54.2%
3 Valley Regional1600775652423.3%24.4%40.8%
4 Colchester Regional13532267697346.7%48.3%51.5%
5 Cumberland Regional658328314923%37.4%47.8%
6 Aberdeen924627104510.7%10.2%11.3%
7 St. Martha's920066273130.7%31.6%29.7%
8 Cape Breton Health Care2672217921248933.9%42.6%46.7%
9 QEII HSC and DGH7136563543930843.6%51.3%55.1%
Total1774711468289429 37.86% 44.7% 50.39%

9.2.3  Abnormal Call Rate (%)

Percentage of women screened referred for further testing because of abnormalities found within a program screen

Targets:
< 10% of 1st screens and <5 % of re-screens


Figure 9.4: Abnormal and PFNS Recall Rates by Reporting Group 2006 (ages 50-69)


In 2006, 1685 screens in the target age group were reported as abnormal (Table 9.7). Abnormal reporting rates were 5.2% overall (8.6% for 1st screens and 4.4% for re-screens). An additional 44 cases (Table 9.8) were reported based on clinical findings categorized as Physical Findings Not Seen or “PFNS”. This compares 48 a year ago and 28 in 2004. Groups 5, 6 and 7 chose not to use the PFNS option as an interpretation result. Generally however, the “PFNS” reporting selection is being used, but the number of reports is minimal and not always significant enough to reflect as a percentage in Figure 9.4.


Table 9.7: 2006 Abnormal call rates and cancer detection rates (50-69)
ScreensnAbnormalAbnormalCancersCancer detection
ReportsCall Rate Rate/1000
(%) Screens
1st61975368.6467.4
Re-Screen2599411494.41124.3
All3219116855.21584.9


Table 9.8: 2006 Physical Finding Not Seen (PFNS) call rates and cancer detection rates (50-69)
ScreensnPFNSPFNSCancersCancer detection
  ReportsCall Rate Rate/1000
   (%) Screens
1st619750.0810.16
Re-screen25994390.1510.038
All32191440.1420.062


Table 9.9: 2006 Workshop Assessment (all ages)
Assessment Tests AllAssessmentAssessment 1stAssessmentAssessment
   testing pertesting per  testing pertesting per
   all abnormalall screens  all abnormalall screens
   screens   screens 
Work-up ultrasounds 146843.25%2.52% 70551.38%4.76%
Work-up mammograms 319194.02%5.48% 125191.18%8.45%
Core Biopsies 101129.79%1.74% 41330.1%2.79%
MRI 250.74%0.04% 80.58%0.05%
Women to surgery 34110.05%0.59% 1188.6%0.8%


Table 9.10: 2006 and Cumulative Core Biopsy Outcomes (all ages)
 1991-20062006
OUTCOMEStereoU/S GuidedAllStereoU/S GuidedAll
Benign4621212483365679735
Atypical/Suspicious356636244145
Cancer1623119174219745242
Invasive1175118129314345188
DCIS433043351051
Lymphoma213000
LCIS13013303
Unsatisfactory71273628
Others13451335867673
Total702935273819731331106
Benign:Malignant22.8:11.8:12.8:13.3:11.8:13:1

1
Includes unsuccessful and equivocal cases
2
Results of atypia and LCIS are not included to determin B : M ratios


Table 9.11: 1991-2006 Core Biopsy and Definitive Surgery Outcomes
Core Biopsy and Definitive Surgery Outcome1991-20062006
Malignant cores benign at surgery174
Malignant cores atypical or benign at surgery70
Malignant cores malignant at surgery1672228
Malignant cores - no definitive surgery4610
Benign cores benign at surgery28045
Benign cores atypical or suspicious at surgery369
Benign cores malignant at surgery8411
Benign cores - no definitive surgery4433676
Atypical or suspicious cores benign at surgery749
Atypical or suspicious cores atypical or suspicious at surgery11212
Atypical or suspicious cores malignant at surgery13416
Atypical or suspicious cores - no definitive surgery428
Unsatisfactory or others43181

There were 6716 women having 7381 core biopsies (by screen exam date) through NSBSP from 1991 until 2006 (612 women had more than one core biopsy at different times or bilaterally). Of the 1106 core biopsies performed in 2006, 133 were indicated as being done using ultrasound guidance for positioning of the needle. In 2005, all positive core biopsy cases aged 50-69 proceeded to surgery. The core biopsy program also collects core biopsy data by core biopsy date for separate studies unrelated to NSBSP annual outcomes. Additional core biopsy outcome data is shown in Table 9.11.
Tables 9.12 and 9.13 are included for use at the district level to provide a baseline for each District Health Authority and perhaps assist in reform at the district level. They include Nova Scotia Breast Screening database results only. Of importance are trends that possibly could become indicators for each district and assist in utilizing resources. NSBSP considers numbers and types of assessment tests to be helpful and relevant information for both provincial and district feedback. It is particularly useful for analyzing how health service providers apply the Clinical Practice Guidelines. These outcomes may be important at the provincial level to assist in providing continuous quality improvements to all services in place in both screening and diagnostic sites. It is hoped that this data may eventually be utilized to benefit women undergoing these procedures.

9.2.4  Invasive Cancer Detection Rate

Number of women detected with invasive cancers during a screen episode per 1,000 women screened

Target: 1
st screen > 5 per 1000 screens    Re-screen > 3 per 1000 screens


Figure 9.5: Invasive Cancer Detection Rates per 1000 Screens 2006 (by age)

There were 208 cases of invasive breast cancer detected in 2006. Shown in ten year age groups above, 132, (63)% of these were in the 50-69 age group for a cancer detection rate overall of 3.6 per 1,000 screens. Nova Scotia is lower than national targets of more than 5 per 1,000 (6.1) for first screens and higher than the 3 per 1,000 for re-screens (3.6). It may well be that with the screening program now in place, the invasive cancer rates will continue to fall as more high risk lesions are picked up in the screened population at a pre-cancerous or early stage (DCIS and atypical). The rate of invasive breast cancer increases by age group for both initial screens and re-screens. Also, many of the first time program screens have had previous mammograms in the diagnostic sector.

9.2.5  In Situ Detection Rate

Number of women detected with ductal carcinoma in situ (DCIS) cancer, rather than invasive cancer, during a screening episode per 1,000 women screened

Target: At present collected for surveillance and monitoring purposes only


Figure 9.6: In Situ Cancer Detection Rate per 1000 Screens 2006 (by age)

There were 50 cases of In Situ cancer detected in 2006. Of these, 28, (56%) were aged 50-69. The overall in situ cancer detection rate for this age group was 0.9 per 1,000 screens similar to the 1% rate at the national level. The Performance Indicator's Working Group felt it inappropriate to set targets for DCIS due to lack of evidence of the transition of DCIS to invasive cancer and increasing sensitivities of screening techniques. In 2006, there were 3 cases of LCIS, 2 of which were between 50 and 69.

9.2.6  Diagnostic Interval

Total duration from abnormal screen to resolution of abnormal screen

Target:    (1) > 90% within 5 weeks if no tissue biopsy
(2) > 90% within 7 weeks if tissue biopsy

Figure 9.7: Abnormal Screen to Diagnosis - no biopsy (all ages)

In 2006, the NSBSP overall (i.e, for all age-groups) “Diagnostic Interval” shows 65.4% of abnormal screens having had no tissue biopsy, are at case completion after five weeks from screening. This is lower than the 72% overall nationally in 2001 and 2002. (Table 9.1).
In NSBSP in 2006 the overall (i.e, for all age-groups) Diagnostic Interval for women having had a tissue biopsy was 13.4%


Figure 9.8: Abnormal Screen to Diagnosis - with biopsy (all ages)

Figures 9.8 and 9.7 demonstrate the diagnostic interval from abnormal screen to diagnosis with and without biopsy. Numbers of surgeries for which results were based are in Table 9.12 and are for screening cases only.

9.2.7  Positive Predictive Value

Proportion of abnormal cases with completed follow-up found to have breast cancer (invasive or in situ) after diagnostic work-up

Target:   1st screens  > 5% of abnormal screens are cancer
Re-screen> 6% of abnormal screens are cancer

Figure 9.9: High-Low Positive Predictive Values (ages 50-69)

Figure 9.9 demonstrates for the target age group, the individual highest and lowest as well as the average PPV for the indicated years. A downward trend of performance can be seen especially after 1994 and 2003 as new sites joined the program. The highest number of target age, first read mammograms interpreted in 2006 by a NSBSP radiologist was 4064 with a corresponding PPV of 18%. The highest PPV of the year was 18%.


Figure 9.10: High-Low Positive Predictive Values (ages 40-49)

As expected, PPV's are lower for the age 40-49 group where breast density is at times greater and can decrease the sensitivity of early detection (Figure 9.10).
One international publication has stated that Positive Predictive Values (PPVs) for initial mammograms were as high as 37.5% in the Netherlands where corresponding recall was 1.4%, and as low as 5% in the United States where the corresponding recall was 15%. Cancer detection rates did not closely follow the pattern of recall rates. These differences may be influenced by factors including prevalence of cancer in the screening population, radiologist training, quality of the mammograms and fear of malpractice and legal outcomes. Report from the International Breast Cancer Screening Network (IBSN), Draft Paper 24 September 2003.
Several radiologists in NSBSP maintain consistently high PPVs. Determinants of this trend seem to be dependent on the length of involvement in the program, level of commitment, interaction of the imaging team and frequency of multi-disciplinary team rounds reviews. PPVs for three NSBSP radiologists in 2006 were 18%, 16% and 15% with corresponding abnormal reporting rates for first reads of 2.1%, 3.9% and 3.1% respectively. Positive Predictive Values, especially in relation to abnormal reporting rates will be more meaningful when correlated with the associated interval cancer rates, which will be available for Nova Scotia by 2007.
Since the beginning of the program, all participating radiologists have received a letter detailing their individual PPV, abnormal rate and cancer detection rate for both first and subsequent screens. Specialist radiologists detect more cancers, more early stage cancers, recommend more biopsies, and have lower recall rates than general radiologists. Performance Parameters for Screening and Diagnostic Mammography: Specialists and General Radiologists; Edward A Sickles MD, Dulcy E. Wolverton MD, and Katherine E Dee MD; RSNA, 2002.


Table 9.12: 2006 NSBSP Surgical Outcomes by District Health Authority (all ages)
DHA123456789UnknAll
Screening Exams440649505914452224097311741794122686288558193
Surgical Procedures38414745144155612916405
 
Women to Surgery33384034133124510815341
B : M Ratio1:2.21:1.31:2.91:6.81:121:31:101:6.31:4.91:21:3.8
Cancer Det Rate4.54.24.9654.15.74.83.73.54.4


Table 9.13: 2006 NSBSP: Days to Diagnosis and Surgery Wait Times by District Health Authority (all ages)
DHA123456789UnknAll
Screen to first core biopsy(any result)75102574257473850345552
Screen to first core biopsy(cancer)6895514154403345284045
 
Cancer core to first surgery1231419378115668084867793
Benign core to first surgery1691451161150081144135107131
 
First core to first surgery (if multiple cores)5050504461264147603951
No core to first surgery76938317650451205611183

9.2.8  Benign to Malignant Open Biopsy Ratio

Among open biopsies, the ratio of the number of benign cases to the number of malignant cancer cases

Target:
< 2:1 for all open biopsies


Figure 9.11: Benign to Open Biopsy Ratio by District 2006 (ages 50-69)

Figure 9.11 and table 9.14 demonstrate the 2006 benign to malignant surgical ratios 1 : 4.5 (or 0.2 : 1) for women aged 50-69, indicating that overall for every one benign surgical outcome, there were 4.5 malignant outcomes. This indicator has the potential to be more significant in the future as all diagnostic facilities join with Central Mammography Booking. The important outcome is to find the greatest number of small cancers with minimum work-up, decreased wait times and decreased number of surgeries.


Figure 9.12: Malignant (M) : Benign (B) Surgical Outcomes by Year (ages 50-69)

The relationship between the number of benign surgical outcomes and number of malignant surgical outcomes not having had a core biopsy as part of their work-up remains similar from the beginning of the program. It is also apparent in figure 9.12 that the number of malignant surgical outcomes has increased substantially over the years as the program has grown. It can be seen that the number of cancers subsequently detected after having a core biopsy, remains in proportion to total number of cancers detected from open surgical outcomes. One benign or malignant surgical outcome per woman is used in Figure 9.12 indicating that benign : malignant outcome ratios of surgery have improved greatly since the start of the program. The number of core biopsies has increased, particularly as new sites joined the organized screening program in 1994, 1997, 2002 and 2005.

9.2.9  Invasive Cancer Tumor Size

Percentage of invasive cancers with tumor size of < 10mm and < 15mm and in greatest diameter as determined by the best available evidence

Targets:
> 25% <10mm and > 50% <15mm
Of 1936 cancers of all ages detected from the start of the program, 1516 (78.3%) were invasive and of these, 8.3% were less than or equal to 5mm, 36.3% were 10mm or less and 63.3% were 15 mm or less (Figure 9.13). Of all invasive cancers in the target age group, 74% were stage 1 or better.


Figure 9.13: Invasive Cancer Tumor Size 1991-2006 (all ages)

During this time 433 cases of DCIS and 13 cases of LCIS were also detected. Over 99.5% of tumor sizes were obtained from pathology reports, with film measurements needed only in cases where it was not specified in the pathology reports.
In 2006, in the target age group, 158 cancers were detected. Of these, 132 (84% were invasive and of these, (7%) were 5mm or less, 28.7% were 10mm or less and 63.6% were 15mm or less (Figure 9.14. 62% were stage 1 or better.


Figure 9.14: Invasive Cancer Tumor Size 2006 (ages 50-69)

During this time, 51 cases of DCIS were detected and there were 3 cases diagnosed as LCIS.

9.2.10  Node Negative Cancers

Proportion of invasive cancers in which the cancer has not invaded the lymph nodes

Target:
> 70% node negative
Since the beginning of the program 79% of all invasive cancers in the target age group were node negative (see figures 9.15 and 9.16).


Figure 9.15: Node Negative Cases by Year (ages 50-69)


Figure 9.16: Node Negative Cases by Year (and by age)

In addition there have been 63 cases of DCIS with nodal excisions (60 with negative nodes and 3 with positive nodes). In 2006, there were 132 invasive cancers in the target age group of which -2 (-2%) had lymph nodes excised. Of these 50% were node negative. In all age groups there were 202 lymph node dissections and of these, 14%, 30%, 36% and 20% were in the 40-49, 50-59, 60-69 and 70+ age groups respectively.


Table 9.14: 2006 Biopsy Results per woman (ages 50-69)
 B n=M n=  
   RatioRate
Benign : Malignant open biopsy ratio351580.22 : 1 
 
Benign : Malignant core biopsy ratio (atypical not included)3921552.53 : 1 
Benign : Malignant core biopsy ratio (atypical included)4191552.7 : 1 
Benign : Malignant core biopsy ratio (atypical and others included)4621552.98 : 1 
 
Benign : Malignant open biopsy ratio - direct to open biopsy (no core)1635.33 : 1 
Benign : Malignant open biopsy ratio - after core biopsy191550.12 : 1 
 
Benign open biopsy rate per 1000 screens35  1.1
Benign core biopsy rate per 1000 screens392  12.2

9.2.11  Post-Screen Detected Invasive Cancer Rate

Number of women with a diagnosis of invasive breast cancer after a negative screening episode per 10,000 person-years at risk, within 12 and 24 months of the screen date

Target:
  Canada :    < 6 per 10,000 person years (within 12 months, age 50- 69)
< 12 per 10,000 person years (within 24 months, age 50-69)
United Kingdom :12 per 10,000 screens (within 24 months)
Australia :< 6.5 per 10,000 (within 12 months)

NSBSP has identified post screen detected cancers from the start of the program, but it is known that reporting of these is of little or no use unless accurate data is available. Post screen cancers are routinely reviewed at four provincial site team rounds reviews as an ongoing quality assurance measure. Of importance is the identification of programmatic sensitivity and specificity, which may not be calculated without proper identification of these cancers. In September 2002, NSBSP had identified 141 (6/10,000) non-compliant cancers and 131 (6/10,000) interval cancers.
A provincial study funded by the Canadian Breast Cancer Foundation Atlantic Chapter, will enable the NSBSP post-screen invasive cancer rates for 2000/2001 and 2002/2003 to be included in the 2006 NSBSP Annual Report.

9.3  2006 Staff Performance/Workload Measure

Although the program philosophy for “high volume” screening is important, quality results are always the ultimate goal. Information sharing is critical for all program staff. Much has been reported about radiologist performances for the purpose of increasing cancer detection rates while keeping recalls at a reasonable level. Equally important has been to analyze booking growth for clerical and technical staff workloads over years of program expansion.

9.3.1  Radiologist

In 2006, the highest number of first reads by a single radiologist was 4064. There were in total, 73 cases reported as high suspicion and as might be expected, unofficial double reads decreased in 2006 to 294.
The percentage of unofficial double reads from all reporting sites is within the acceptable limit of 3 per 100 screens as defined by NSBSP (see figure 9.18). Provided this additional mechanism, used to increase reporting effectiveness is monitored, the practice is encouraged as an additional quality assurance initiative.


Figure 9.17: Volumes by Reporting Site (all ages)


Figure 9.18: Unofficial Double Reads by Interpretation Site (all ages)

9.3.2  Technologist and Radiologist

Screen volume increases can be seen for four out of five reporting sites in 2006. Halifax, Cape Breton, Yarmouth, Truro reporting sites have increased capacity by 10.2%, 5.9%, 2.8%, and 1.3% respectively. Numbers at the Dartmouth site have decreased due to insufficient technologist staffing.

9.3.3  Technologist

From 2005 to 2006, workloads on Mobiles 1, 2 and 3 have increased by 5.8%, 4.6% and 34% respectively, resulting in an increased capacity throughout the program (figure 9.19).


Figure 9.19: Volume by Mobile Van (all ages)

The long-range goal of the NSBSP is to have all three mobiles performing similar numbers of examinations annually. Start-up mode, portability (a drive on portable mammography unit, unlike the two self-contained mobiles), limited staffing of three days per week and possibly an excess of scheduled sites (consequently more travel time), have accounted for the lower number of screens done on Mobile 3. With vigilant scheduling following the Geographic Information Systems (GIS) Study outcomes, the gap should close.

9.3.4  Clerical

There were 135431, 123089 and 100562 procedures booked through Central Mammography Booking for the years 2006, 2005 and 2004. Of these 86041, 82392 and 70076 respectively were program screens. The maximum number of appointments booked by any one clerk was 14270, 19528 and 14188 for the same years, indicating effects of new staff and resulting in greater client satisfaction. The comparable numbers of diagnostic mammograms booked were 13106, 12853 and 13447. Also booked for the indicated years were 7646, 5531 and 2992 ultrasound examinations.
In addition for the diagnostic module there were 1321, 870 and 775 “Ineligible Screens” booked in 2006, 2005 and 2004. An “IS” is defined at CMB as a screening exam that for some reason cannot be done through NSBSP and includes cases with special needs and requests for under age mammography screening. In addition there were 913, 1270 and 1289 “Physician or Patient Demanded Screens in Diagnostic” (PDSDs) performed over the same time periods. As expected, with an increased acceptance of Centralized Mammography Booking, there is less use of these two particular categories as both women and health care givers become better educated about the difference between screening and diagnostic mammography. It can be seen however that these have increased in 2005, perhaps due to an increased number of new staff or a natural reluctance by women and physicians to comply as more sites new to NSBSP, come on line. Follow-up mammograms, 6 month Post Core Biopsy examinations and Screen Work-Up examinations are also booked by the clerical staff at CMB.


Figure 9.20: Weekly Clerical Productivity Results

Currently, a restructuring of clerical workloads is being done. Presently the highest number of abandoned phone calls is between 9:00 am and 9:30 am. The 10:00 am - 6:00 pm shift is subsequently under review and will soon be evaluated to see if it will continue. Much of the work it was intended for is now obsolete and the objective is to lower the number of abandoned calls, particularly as province-wide booking is soon anticipated. To assist in maintaining a high degree of client satisfaction despite continued program growth, graph-sharing (Figure 9.20) permits the program's booking clerks to assess their own performance activity by accessing private biweekly results. This graph is routinely posted and it is clearly seen that the busiest booking days are at the beginning of each week. Although not a new concept, these bi-weekly charts greatly assist in determining appropriate staffing complements.


Figure 9.21: CMB - Abandoned Calls

It can be seen in Figure 9.21 that the number of abandoned booking calls made to Central Mammography Booking (CMB) has improved following a steady increase in 2005 from which time these calls have been monitored. The effect of additional staffing for summer vacation relief is also noted.

Chapter 10  Former Initiatives

10.1  Database Development

From a simple flat file database available in 1991, a complete rewrite upgraded the NSBSP system to a user friendly and user developed relational database completed in 1997. A second rewrite began in 2002 and when completed in June 2004 resulted in standardized data entry procedures and outcomes for both screening and diagnostic mammography from one database. The diagnostic reporting system (DRS) is currently being used in Halifax and Cape Breton. Expansion of this Diagnostic Reporting System throughout the rest of the province is planned for 2007-2008. An interface is currently being developed with Meditech and Quadris and Star to enable all mammography results to reside in PACS. This has significant implications when a patient is required to move from one facility to another for follow-up treatment.

10.2  Central Mammography Booking (CMB) and Mammography Wait Times

A project designed to book all mammography appointments, both screening and diagnostic through one call center was completed and implemented in December 2000. Prior to this, it was only the first two mobile vans that utilized the booking center. Funding for computer interfaces and programming for this project was obtained through the federal government's Infostructure Support Program and the Canadian Breast Cancer Foundation - Atlantic Chapter. Initially the project enforced standard booking guidelines and booked appointments for two NSBSP vans, one NSBSP fixed site and one diagnostic center. Starting dates for diagnostic centers joining with CMB are seen in Table 4.1. Table 10.1 shows these sites and the resulting effect Central Mammography Booking has had on their diagnostic wait time. Core biopsies and all breast ultrasounds, with the exception of District 1 and 7, are also being booked through Central Booking. It is anticipated that all Breast MRI's will also be booked centrally and reported in the diagnostic reporting system.
There is a considerable body of evidence that an abnormal breast cancer screening precipitates acute anxiety especially upon receipt of notification of the abnormal screen. Anxiety may persist for several months after resolution of the screening episode, even after the woman has been informed that she does not have cancer. Waiting for a Diagnosis after an Abnormal Screen in Canada: Minister of Public Works and Government Services Canada, 2000. With a goal of enabling NSBSP to process the bookings for provincial diagnostic mammography departments and to assist in channeling the flow of asymptomatic women to the screening program, CMB has successfully decreased waiting times at the diagnostic sites. With appropriate integration of diagnostic and screening mammography programs through one Centralized Mammography Booking system, short wait times for diagnostics can be maintained. Urgent situation can be addressed within a few days at all sites.


Table 10.1: Impact of CMB on Diagnostic Waiting Lists
HospitalWaitWaitWaitWaitWaitWaitWaitWait
 Sep-00May 2001May-02May-03May-04May-05May-062007
         
QEII HSC (Hfx)6 mos2 mos3 wks1 wk2-4 days4 days3days4 weeks
CBHCC (Sydney)  3 months2 wks1 wk11 days3 weeks2 weeks
DGH (Dartmouth)  4 months2 wks1 wk10 wks3 weeks13 weeks
CRHCC (Truro)  3 months1 wk1 wk3 days1 week5 weeks
YRH (Yarmouth)  4 months3 months3 months2 days2 days4 weeks
SSRH (Bridgewater)1    4 months4 months2 days2 days
CCHHC (Amherst)2     1 month1 week1 week
VRH (Kentville)3     1 month1 week4 weeks
AH (New Glasgow)4       2 weeks

1
Joined CMB in July 2005
2
Joined CMB in January 2006
3
Joined CMB in January 2006
4
Joined CMB January 2007


Table 10.2: Screening Wait Times by Clinic (in weeks)
 20032004200520062007
Hfx Clinic1517273538
DGH2523344344
Truro710181817
Yarmouth 3230818
Amherst 71136
Bridgewater  392928
Kentville   813
New Glasgow    27

10.3  The Core Biopsy Program

Under auspices of NSBSP a core biopsy program was started to coincide with the program start in June 1991. Database development has permitted tracking these examinations. Since the beginning of the program in June 1991 until December 2006, a total of 7029 stereotactic core biopsies and a reported 352 ultrasound guided core biopsies have been performed on 6716 women. Results may be seen in Tables 9.10 and 9.11.
Promotion of stereotactic needle core biopsy as opposed to clinical or ultrasound guided core biopsy is preferred for the following reasons:

“Core biopsy is a superior method for the evaluation of non-palpable lesions due to increased diagnostic specificity and reduced rate of inadequate samples.” Brenner RJ, Bassett LW, Fajardo LL, Dershaw DD, Evans WP III, Hunt R, et al. Stereotactic core needle biopsy: a multi- institutional prospective trial. Radiology 2001: 218: 866-72. In reports comparing stereotactic core biopsy to surgical biopsy, the sensitivity of core biopsy for diagnosis of malignant lesions varies from 85% to 98%. However in a multi-institutional study in which the results of 1,363 image directed core biopsies were compared with the results of subsequent surgical biopsies there was 98% agreement and only 1.1% false-negative core biopsy outcome (level III evidence). Parker SH, Burbank F, Jackman RJ, Aucreman CJ, Cardenosa G, Cink TM, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology 1994; 193: 359-64. False negative core biopsy outcome from the Nova Scotia Breast Screening Program from 1991 to 2006 is also 1.1%.
Over the first 16 years of the program there have been 17 malignant core biopsies for which the corresponding surgical outcomes were benign, resulting in a false positive rate of 0.2%. The false-positive core biopsy outcome per woman is 0.3%. Atypical/suspicious and benign open surgical results are included when calculating the false positive rate.
For both stereotactic and ultrasound core biopsy to be successful there needs to be a validation process and team management.
Cancer has a significant economic impact in Canada as measured by direct and indirect costs. Direct costs refer to the value of goods and services for which payment was made and resources used in treatment, care and rehabilitation directly related to illness or injury. Indirect costs are defined as the value of economic output lost because of illness, injury-related work disability or premature death (National Cancer Institute of Canada: Canadian Cancer Statistics 2004). In 1998, in Canada, $2.5 billion were direct costs with hospital care costing $1.8 billion and representing 74% of this amount. Physician services to treat cancer cost $333 million, or 14% of direct costs. Approximately $210 million or 9% of direct cancer costs were spent on drugs for cancer treatment. The indirect cost was $11.8 billion. Economic Burden of Illness in Canada, Health Canada 2002. Although the figures above represent costs for all cancers and for all Canadian provinces, the core biopsy program in Nova Scotia has made positive impacts on reducing wait times, hospital stays and physician services. It has made a huge impact in greatly decreasing benign breast surgeries.
Published works of the Nova Scotia Breast Screening Program include:

10.4  The Pink Rose Project and Physician Assisted Navigation

The Pink Rose Project instituted the provision of “Information Packages” to newly diagnosed women at the time of imparting the diagnosis. Started and managed by a volunteer breast cancer survivor under the umbrella of NSBSP, this initiative has been adapted and introduced into most other provincial programs. Begun as a service provided by one hospital, the packages are now funded by the Canadian Breast Cancer Foundation - Atlantic Chapter, and distributed by pathology departments, NSBSP coordinators, Cancer Care personal as well as active survivors throughout the province.
With the development of NSBSP in 1991, physician assisted referral for all abnormal screens to the diagnostic work-up sites was instituted. The physician was always the first point of contact by phone, and with their approval the program would (also by phone) contact the patient with the date, time, place and nature of the work-up test or core biopsy. For even greater efficiency, the phone contact has been replaced with a faxed appointment process. As in all screening programs, results were also mailed to both the women and the physician. This fast tracking resulted in decreased times to diagnoses and overwhelming acceptance of the process. In 1997, requests from the medical community to also navigate women with abnormal reports in the diagnostic sector resulted in a full time navigation position. In addition, through personal contact with physicians and women, the navigator has promoted a heightened awareness of the clinical practice guidelines for mammography. This single NSBSP diagnostic-based navigator position has been closely tied to the largest diagnostic work-up site and is supported by the Pink Rose Project.
The NSBSP Navigator is a resource for women using diagnostic and screening facilities in the entire province, whether affiliated with NSBSP or not. Patient Navigation: Improving Timeliness in the Diagnosis of Breast Abnormalities was published in June 2004 in the Canadian Association of Radiologists Journal (CARJ Vol.55, No. 3, June 2004). This publication documents the potential to decrease waiting times related to the facilitated investigation of breast abnormalities. Other provincial breast screening programs have incorporated a similar approach for fast-tracking women to diagnosis. Influence of direct referrals on time to diagnosis after an abnormal breast screening result. Kathleen M. Decker MHSA et al: Cancer Detection and Prevention 28 (2004) 361-367. Manitoba Breast Screening Program, Winnipeg, Manitoba.
All results from the smaller diagnostic work-up sites are monitored by the NSBSP Image and Data Manager pending a status of case “completion”.
Published works of the Nova Scotia Breast Screening Program include:

Chapter 11  Current Initiatives

11.1  Using GIS as a Tool to Describe Service Provision

The Nova Scotia Breast Screening Program is currently in a period of transition and growth with a provincial plan to systematically roll-out full-field digital mammography (FFDM) and with the tentative addition of one more fixed site to create a complete province-wide program by January 2008; Nova Scotia will be the first province in Canada to have an organized breast cancer screening program that encompasses all screening activity taking place in the province. FFDM is currently being used in the Cobequid Community Health Centre in Lower Sackville, Yarmouth Regional Hospital and on the mobile van based out of Sydney; early results indicate that FFDM increases the capacity at screening sites where it is being used. Increased capacity appears to be the result of an increase in the number of screening exams that can be performed per day by technologist due to a reduction in processing and film handling time. Increased screening capacity has the potential to reduce wait times, which are on the rise because screening demand now exceeds screening capacity in many sites (see figure 11.1). An increase in screening capacity could improve retention and participation (both indicators are currently below the national target). It is now an appropriate time to develop criteria to determine how van service delivery can best compliment the fixed sites so that screening services are delivered in an equitable manner to the women of Nova Scotia.


Figure 11.1: NSBSP Volume by Site and Year (all ages)

Last year the NSBSP partnered with the Office of Public Health Practice of the Public Health Agency of Canada to explore Geographic Information Systems (GIS) as a tool to map access to and use of screening services (see last year's Annual Report). The excitement that came as a result of this partnership spawned two parallel projects this year. The first project began as a Community Health Grant Application submitted to the Canadian Breast Cancer Foundation - Atlantic Chapter by Dr. Jennifer Payne on behalf of the NSBSP. The grant request was successful and the year-long project began in May 2007; the goal of this project is to explore the use of Geographic Information Systems (GIS) to describe service provision by the NSBSP, with emphasis being placed on exploring equity in access to services. The GIS work will be carried out in collaboration with the GIS Centre at Dalhousie University. The results of this project will be used to help inform and develop criteria for planning how the fixed sites and mobile units work together to ensure equitable service delivery. It is the intent of the NSBSP to use the resultant maps and findings of this project to engage all stakeholders in discussions around service provision and the role of the mobile units. The research assistant on this project (Stephanie Lea) will also derive her thesis as a Master of Applied Health Services Research student at Dalhousie University from this work.
The second project that arose out of last year's work was a collaboration between the NSBSP and a Centre of Geographic Sciences student in the GIS for Business Advanced Diploma Program, Faye Welsh, on a project using Geographic Information Systems (GIS) to analyze the accessibility to breast screening services in Nova Scotia. In her study, Faye used data from the 2004-2006 time periods in which there were eight fixed sites and three mobile vans providing screening services (for some of the maps she included the 2 additional fixed clinics that came on-line in 2007). Using GIS, many multilayered maps were created such as figure 11.2 which shows the location of fixed screening sites, Nova Scotia road networks and the percentage of women in the target population by census division.


Figure 11.2: multilayered map created using GIS

In her project Faye used different analysis techniques to determine access to services by looking at fixed and mobile site locations, driving distances to screening sites, distribution of the target population across the province, along with the volume of visits to each site. Faye also used location-allocation analysis to determine how to optimally allocate women to a fixed site based on where they live and driving time. The map on the front cover of the Annual Report is based on how the NSBSP will look in 2008 with 10 fixed sites and it demonstrates, based on driving time, how to allocate service delivery. This approach could be used to define catchment areas for the fixed sites, which would then begin the discussions around how best to use the mobile services.
Faye's project and early GIS mapping efforts have been very promising and this tool looks to have real value for describing service provision by the NSBSP; it is also exciting to note that this is the only breast screening program in Canada currently using GIS to evaluate service delivery.

11.2  Toward a fully automated NSBSP surveillance system

Prof. Mohamed Abdolell submitted and received funding for a Canadian Breast Cancer Foundation - Atlantic Chapter Community Health Grant Application in 2007 entitled, "Automation of the NSBSP Annual Report: a first step toward developing a surveillance system". Funding for the grant started in July, 2007 and the project is expected to take one year to complete. The primary goal of this project is to fully automate the process of generating the NSBSP Annual Report. In the past, the report has taken up to twelve months to generate manually and has been a major burden on the resources of the NSBSP. Through automation of the process, the report is generated within five minutes. The current 2006 NSBSP annual report is predominantly generated using this system and serves as the basis for the evaluation of the implementation; outstanding issues will be ironed out prior to the generation of the 2007 NSBSP Annual Report. Putting into action this process is achieved by using open source software that is available under the General Public License and is therefore free. The natural consequence of developing such a system is that it can be extended to become a fully automated surveillance system that is flexible, customizable, timely, accurate, reproducible, on-demand, and low-cost. The feasibility of applying Statistical Process Control methods in the proposed surveillance system will be evaluated; such automatic flagging of emerging trends in the NSBSP would enable proactive intervention in the system to optimize resource allocation and improve access to screening for women in Nova Scotia.

11.3  Provincial Health Services Operational Review (PHSOR)

NSBSP, along with other provincial programs, participated in a review process conducted by Corpus Sanchez Inc. commissioned by the Department of Health. This “Provincial Health Services Operational Review (PHSOR)” was to conduct a value for money audit across all aspects of health services delivery in Nova Scotia. The NSBSP session with the consultant focused on the growth and development of the program, its current quality improvement initiatives, and the challenges it faces in further expanding and improving upon the care provided to the women of Nova Scotia.

11.4  NSBSP Post Screen Cancers: Report and Learning Tool

In January 2006, with funding from a Canadian Breast Cancer Foundation - Atlantic Chapter's Community Health Grant, a project was initiated with the aim to identify, assemble, classify and review the interval breast cancers diagnosed from NSBSP clients. A blitz enabled this work to be completed for the years 1991-2003 and thirty-five data charts were compiled, some results of which will be used for publication in an inter-disciplinary paper presently being written for publication by Imaging, Pathology and Oncology Departments at the QEII Health Sciences Center in collaboration with Dalhousie University.
Five NSBSP interpretation sites contributed cases for this review which resulted in 96% of all known interval cancers being reviewed in an organized fashion by a minimum of three radiologists. In addition, breast cancer pathology TNM coding was reviewed by pathology staff for accuracy and to provide feedback to the program. Data from the National Cancer Registry is also expected to contribute.
Following the review of films, a file of unique cases was compiled and will be made available in the future for review by other radiologists as a web-based learning file.
Working with the Project Manager, NSBSP staff members have been trained and future work has been organized to start review of cases identified in 2004 and 2005. Data compilation for these two years will be available by August 2008 at which time the exercise will be incorporated routinely and results compiled on a yearly basis for future analysis. A summary table of work completed to date is included.


Table 11.1: NSBSP Post Screen Detected Cancers
  Radiologists' Diagnosis 1Intervals and Other Identified Post Screen Cancers2
 Number of Women Screened1234Interval cancer Rate per 1000 screensInterval Cancer Rate per 1000 WomenRecurranceContralatteralNon-Compliant
91-925,8480000--000
93-9729,9474513991.12.11416172
98-9919,3282616951.02.97898
00-0116,192401913101.25.198106
02-0323,797392312111.03.651088
All93,1121507143351.13.23542464

1
Diagnosis is made by three Radiologists, with the coding as follows: 1:3 normal diagnoses. 2:2 normal, 1 abnormal. 3:3 abnormal. 4: 1 normal, 2 abnormal.
2
cancer cases were diagnosed in women over age 40 and include both DCIS and invasive cancers

11.5  2006 Cervical Cancer Prevention Program Update and Guideline Changes

To address site concerns about the possible deletion of the NSBSP system generated question re: pap tests, and following collaboration with Cervical Cancer Prevention Program management, the question will remain. It serves as an important reminder to women, and is one of the top reasons women give when asked “why” they are booking their pap tests. Since 1992, a reminder notice to remember to book a pap test has also been included on the screening reminder notifications. It is included as well on the “wallet sized” NSBSP promotional cards.
Effective in October 2006, guidelines for pap testing in Nova Scotia has changed. The new brochures reflecting these changes have been distributed to all NSBSP site co-ordinators to update NSBSP staff and for distribution. These brochures are available from The Cervical Cancer Prevention Program at 902-473-7438. Following are the guidelines as stated in the brochure:
When should you have a Pap Test?

11.6  Canadian Breast Cancer Foundation (CBCF) Funding

The Canadian Breast Cancer Foundation - Atlantic Chapter celebrates 10 years since its inception in 1997. The Nova Scotia Breast Screening Program has the highest percent of provincial participation in the country of women having mammograms. Meeting, achieving and maintaining high quality screening has largely been due to grants awarded over the last 10 years to NSBSP by CBCF - Atlantic. The NSBSP acknowledges and thanks CBCF for funding over the years providing the women of Nova Scotia dedicated breast screening and shares the vision of a future without breast cancer. (By 2010 it is the vision of CBCF - Atlantic to mount an advocacy campaign to raise awareness of the breast screening issue and it plans to launch an extensive public education campaign. This would include the acquisition of digital mammography units throughout the province)

Past NSBSP Funding:

1997 $36,000toward purchase of Mobile 2
1997 1,500film encoder
  15,000mammoviewer for NSBSP-Halifax
1998/99 40,000breast ultrasound equipment-Halifax
199930,000computer hardware for Infostructure Project
2000 20,000completion of Infostructure Project
  50,000x-ray equipment replacement Machine 1-Halifax
2001 50,000diagnostic database hook-up to other hospitals *
2002 150,000Mobile 3 purchase and operating costs
2003 35,000x-ray equipment replacement Machine 2-Halifax
2004 42,000purchase of two mammoviewers
2005 25,000Radiologist Learning Tool and Reports
2006 60,000purchase of three mammoviewers
2007 100,000Purchase of ultrasound machine for breast imaging in Halifax
2007 35000Access to Breast Screening Services in Nova Scotia.
  (Canadian Breast Cancer Foundation Atlantic Chapter Community Grant
  to Payne JI, Caines JS, Schaller GH, Iles S.)
 For Submission: 
   1. “Access to Breast Cancer Screening in Nova Scotia”
   - to the Community Health Grants Program Nov 06
   2. “The Nova Scotia Breast Screening Program and
   Core Biopsy: 15 Years of follow-up”
   - to be submitted in March 2008 to Canadian Breast
   Cancer Foundation Atlantic Chapter Community Grants Competition

11.7  Canadian Cancer Society Promotion

The Canadian Cancer Society (CCS) has provided large quantities of promotional brochures to NSBSP for distribution on the mobile screening vans and fixed screening sites throughout the province. These resources are also distributed by program staff during promotional activities. The brochures were titled:
Cancer Facts: what women can do
Breast Health: what you can do
Breast Self-examination: what you can do
In addition the CCS provide Breast Self-examination shower cards which are often a much needed reminder for women of the importance of timely breast health examinations and to take a proactive approach to breast health.

Chapter 12  Publications, Presentations and Posters

Conferences/Peer Reviewed

Geomatics Atlantic Conference, Wolfville, Nova Scotia, June 5-8, 2006

Annual General Meeting of the Canadian Association of Radiologists, Montreal, October 22-25, 2006

Letter to the Editor: December, re the 2005 Issue of the Canadian Association Radiology Journal on Breast Imaging. Canadian Association of Radiology Journal 2006; 57(3): 192-193

Statistical Society of Canada Annual Meeting, June 9-11, 2007, St. John's, Newfoundland

Presentations (Invited)

Chapter 13  Program Cost Trends


Table 13.1: Program Cost Trends
Cost 1 295/9697/9898/9999/0000/0101/0202/0303/0404/0505/06
          
D.S.3 cost per Screen55.2453.6242.3842.3834.8234.7240.7439.5740.0840.85
T.O.4 cost per Screen86.0372.2358.958.1551.0351.0454.7155.0554.8957.28
D.S.fn:repeatA cost per Cancer12,67310,7438,3639,2618,9579,0019,2009,7319,5168,699
T.O.fn:repeatB cost per Cancer19,36714,26311,62412,71013,12313,23412,35613,58313,03212,198

1
Screening site capital expenditures and Fees for Service are not included
2
Administration site capital expenditures, Consultant Fees and Medical Director Fees are included
3
D.S. = Direct Service
4
T.O. = Total Operating

Appendix A  Terms of Reference - Provincial Review of Mammography Units

Background

The Nova Scotia Breast Screening Program (NSBSP), a program of the Department of Health, was formed with the mandate to establish a breast screening program in Nova Scotia.

In 2005 the provincial review of all mammography units was completed and a decision was made to move to digital mammography equipment for both fixed and mobile sites throughout the province; a vendor for the equipment was selected in Fall 2005.

The Move to Digital Mammography project will plan for and implement full field digital mammography across Nova Scotia over the next 5-7 years.

The Provincial Mammography Equipment Committee has served as an advisory committee to the provincial review, procurement and planning projects. It will continue in the role as the implementation of digital mammography progresses in the province.

Mandate

The provincial mammography review will:

Responsibilities

Process

Membership


Brenda Payne (Chair)Executive Director, Acute & Tertiary Care
Rachelle O'SullivanDirector, Acute & Tertiary Care
Lynn Kilroy & Company DirectorIT Services, Department of Health
IT Representative request through Mark LeBlancHITS NS
Dr. Gerry SchallerRadiologist, DHA 9
Dr. Cupid DanielsMdeical Physicist, DHA 9
Dr. Judy CainesDirector, NSBSP
Theresa FoleyManager, NSBSP
Mike Pothier ManagerDiagnostics, DHA 2
Susan DelaneyDiagnostic Imaging Manager, DHA 9
Susan MacNeilDiagnostic Imaging DHA 8
Dr. Eric WoodsRadiologist, DHA 2
Dr. Sian IslesRadiologist, DHA 8
Allan WalshDiagnostic Imaging Manager, DHA 4
Debbie BezansonDiagnostic Imaging Manager, DHA 3

Accountability

The committee will be operational in preparation for, during, and in follow-up of implementation of digital mammography equipment. The committee is accountable to and reports directly to the Executive Director, AcuteTertiary Care.

Review

The committee may forward reports to other individuals / groups as deemed appropriate, for review and feedback.

Meetings

Meetings will take place approximately once per month or more/less frequently if required or at the call of the chair(s).

Minutes

Minutes will be taken during meetings. Minutes will record attendance, areas of concerns, decisions, action items and progress.

Distribution

Minutes will be circulated to committee members, including corresponding members.

Communication

The CEOs of all districts will be kept informed of the stages involved in the mammography equipment replacement.

Appendix B  Nova Scotia Breast Screening Mammography Guidelines - June 2006

Diagnostic Mammography (Physician Referral)

Women who are symptomatic (have new breast problems) should be checked by their family physician and possibly have a Diagnostic Mammogram arranged for them by the physician's office. A requisition must be completed. Physicians are required to fax requisitions for Diagnostic Mammograms to 473-3959 or toll free at 1-866-470-3959 and a booking time and date will be assigned. The requisition will be faxed back to the doctor's office to be issued to the woman. These requisitions must indicate specific new signs or symptoms, or other reasons for diagnostic eligibility such as:

Screening Mammography - Self-referral

The Canadian Association of Radiologists (CAR), National Standards and Guidelines for Breast Screening recommend mammography screening for asymptomatic women at least 40 years of age.

Frequency

Women aged 40-49 should have annual screening

Women aged 50-69 should have mammography screening at two year intervals unless they have a strong family history of breast cancer (mother, sister, daughter, father, brother, son), are currently on HRT or the radiologist has recommended to return sooner. Provincial/national guidelines recommended are evidence-based.

Women over the age of 70 should have screening mammography at two year intervals if they are in good health.

Ultrasound Guidelines

It is not recommended to use ultrasound as a screening tool. It may be utilized:

6 Month follow-up Mammography

If requested by the radiologist from a previous mammogram, 6 month mammogram or ultrasound procedures should be booked by the family physician. Following these short term follow-up requests, a return to routine screening is usual.

Benign Core Biopsy Protocol

6 months following a benign core biopsy a unilateral diagnostic mammogram is recommended

12 months following the benign core biopsy a bilateral diagnostic mammogram is recommended

24 months following the benign core biopsy it is recommended to resume regular guideline screening

Atypical Core Biopsy Protocol

Treatment following a core biopsy with a histological diagnosis of "atypical ductal hyperplasia" is recommended to be similar to any borderline lesion. This should involve a surgical consult and probable excisional biopsy.

Appendix C  Diagnostic Mammography Requisition




This document was translated from LATEX by HEVEA.