Nova Scotia Breast Screening Program
Annual Report 2011 (2010 Data)

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Contents


List of Tables


List of Figures

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  
breastscreening.nshealth.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 7 District 8
   
St. Martha's Hospital Cape Breton Regional Hospital
25 Bay St 1482 George St
Antigonish, NS Sydney, NS
B2G 2G5 B1P 1P3
Tel: 902-863-2830 Tel: 902-567-7788
Fax: 902-867-4724 Fax: 902-567-7812
   
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
   
District 9  
   
QEII Health Sciences Center  
1276 South Park St.  
Halifax, NS  
B3H 2Y9  
Tel: 902-473-3960  
Fax: 902-473-3959  

2. Management & Operations Teams


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OPERATIONS TEAM
Program Secretary Joanne Fraser
Promotion and Navigation Sarah McCarthy
Susan MacNeil
Marian Brine
Crystal Hilton
Data Management Theresa Foley
Data Analyst Ryan Duggan
PACS Specialist MIS/DRS Robert MacDonald
Heather Caseley
Radiologists QEII HSC Dr. Judy Caines
(Halifax) Dr. A.J. Johnson
Dr. Gordon Jones
Dr. Joy Borgaonkar
Dr. Robinette Butt
Dr. Lori McDonald
Dr. Sian Iles
Dr. Peter Brown
CBHCC Dr. Gerald Schaller
Dr. Anne Latour
YRH Dr. Eric Woods
(Yarmouth) Dr. Hubblall
CRH Dr. Nancy McNeil
(Truro and Amherst) Dr. John McNeil
SSR Dr. Arthur Marshall
Dr. C.L. Church
Dr. Chen Meng
Dr. Sangeeta Kalyan
VRH Dr. Michael Dunn
Dr. David Acton
Dr. John Bilo
Dr. Maureen Madigan
AH Dr. Dan Hoffman
Dr. Ronald MacEachern
Dr. Magdalena Biernacka
St. MH Dr. Brian Nicholson
Dr. Mike Silver
Dr. Blain MacDuff
Technical Contacts QEII HSC Bonnie Hart
CBHCC Susan MacNeil
YRH Crystal Hilton
CRH Marian Brine
DGH Sharon Hartling
CRHCC Sandra Rose
SSR Linda Roy
VRH Debbie Bezanson
AH David Quann
STMH Jodi Myles

3. Executive Summary

The Nova Scotia Department of Health & Wellness established and funded the Nova Scotia Breast Screening Program (NSBSP) as a provincial program in 1991. Nova Scotia was the 5th province in Canada to offer organized breast screening. All ten provinces and two of the three territories now have an organized breast screening program. Nova Scotia is in a unique position in that all breast imaging in the province, screening or diagnostic, is captured under the umbrella of the provincial breast screening program in a single database. This total population capture has eliminated opportunistic screening in this province and allows for population-based decision-making to be well informed and supported.

On June 15th 2011 the Nova Scotia Breast Screening Program (NSBSP) turned 20 years old. An education seminar and luncheon was held on October 6, 2011 to celebrate 20 years of organized breast screening. Over sixty people were in attendance. This included current and former clerical, technical assistants, technologists and radiologists as well as site managers and government representatives. The many successes of the program were highlighted.

As of December 31, 2010 718272 screens have been performed on 177540 women finding 3212 cancers. Cancer detection rates for this period can be seen in table 3.1. The combined screening + diagnostic participation rate in Nova Scotia for women 50-69 is currently 64%. A break down of each DHA's participation rate can be found in table 9.4.

Full Field Digital Mammography (FFDM) has been implemented in all fixed sites, screening and diagnostic, across the province. Included in the FFDM rollout was the implementation of the Diagnostic Reporting System (DRS) throughout the province. All but three districts (3, 4, & 7) are utilizing the DRS to report diagnostic breast imaging. Complete tracking of diagnostic breast imaging for women in these districts is not possible at this time. It is anticipated that all districts will be reporting all breast imaging in the new information system once implemented in 2012.

NSBSP has made some great improvements in wait time reporting along every step of the clinical trajectory. Providing the districts with these quarterly reports has resulted in a significant reduction of wait times over the past year in every district. The wait time for ``Abnormal Screen to Resolution without tissue biopsy'' is now below the Canadian target of 35 days for the first time. This value which was at 56 days one year ago has dropped to 31 days.

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. It is through this goal of standardization that the delivery of mobile mammography is being examined. Currently 3 mobiles service the province to supplement 11 fixed screening sites, 2 film-based and 1 digital. The purpose of mobile mammography is to reach rural and remote populations. It is anticipated that one FFD mobile unit can service the province ensuring that all women have equal access to screening mammography.

Through the systematic use of stereotactic needle core biopsy (a procedure perfected through the NSBSP) Nova Scotia has achieved the lowest Benign:Malignant breast surgery rate in the country. The stereotactic method accounts for 92% of all needle core biopsies performed in Nova Scotia. The remaining 8% are ultrasound-guided. The stereotactic method is performed with a regular mammographic table with an adaptable stereotactic device. This is done as an outpatient procedure, has highly reproducible results and has proven to reduce the number of unnecessary open breast surgeries.

Finally, the NSBSP is currently involved in a project with the Breast Screening Program of Newfoundland and Labrador (BSPNL) funded by the CBCF (Atlantic) and the Public Health Agency of Canada (PHAC) in developing a new comprehensive breast imaging information system. The new information system will enhance the current operations of the NSBSP and allow it to broaden its automated reporting and analytical capabilities. It will also allow for the development of interfaces with other hospital information systems. The NSBSP hopes to have the new system installed and operational by the end of 2012.


Table 3.1: Cancer Detection Rates (All Ages)
  Cancer Detection Rate per 1000 Screens   Cancer Detection Rate per 1000 Women
  1991-2008 1991-2009 1991-2010   1991-2008 1991-2009 1991-2010
  570214 645575 718272   158989 169792 177540
Age              
<50 2.3 2.3 2.3   6 6.2 6.5
50-59 4.1 4.1 4   16.7 17.6 18.5
60-69 6.2 6.3 6.4   31.1 34.4 37.9
70+ 9.6 9.5 9.6   47 50.8 56.1

4. Nova Scotia Breast Screening Program

4.1 (NSBSP) Organizational Chart - Oct 2008

4.2 Central Mammography Booking (CMB) Participants


Table 4.1: Central Mammography Booking (CMB) Participants
Screening Sites (14) 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 (11) Halifax Shopping Center Jun 1991
  Sydney - hospital May 2000
  Yarmouth - hospital Apr 2001
  Truro - hospital Jun 2002
  Dartmouth - hospital Jan 2003
  Amherst - hospital June 2004
  Bridgewater - hospital July 2005
  Kentville - hospital Jan 2006
  New Glasgow - hosptial Jan 2007
  Cobequid - Community Health Center July 2007
  Antigonish - Hospital Oct 2008
Diagnostic Sites (10) Participation date
Halifax Dec 2000
Sydney May 2001
Dartmouth Apr 2003
Truro Apr 2004
Yarmouth Apr 2005
Bridgewater July 2005
Ahmerst Jan 2006
Kentville Jan 2006
New Glasgow Jan 2007
Antigonish Oct 2008

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 & Wellness: Cancer Care Nova Scotia, Nova Scotia Diabetes Care Program, Reproductive Care Program, Nova Scotia Breast Screening Program, Cardiovascular Health, Nova Scotia Provincial Blood Coordinating Program, the Nova Scotia Hearing and Speech Program and the Legacy of Life 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

With 100% participation of provincial mammography sites, 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 & Wellness) 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 screening the 40-49 age group is beneficial providing that quality assurance aspects of the program are in place and outcomes can be monitored.

One study from Sweden compared the breast cancer mortality of women who were invited to screening at ages 40 to 49 years (study group) and women in the same age group who were not invited (control group). The results from this study, Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: Evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort, were published in Cancer: n/a. doi: 10.1002/cncr.25650.

This study took place between 1986 and 2005. Results of this comprehensive study showed that screening was an efficient resource in the reduction of breast cancer mortality for women ages 40 to 49 years old. 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.

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. Presently the CAR has increased the required number of screens from 480 to 1000 per radiologist.

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 & Wellness.

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 images be re-read following reporting sessions. Radiologist scheduling must be taken into consideration to avoid delays. 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. There is currently a study underway looking at these outcomes.

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. They also receive combined results for their site as well as the province as a whole. 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. These `report cards' also serve as a self improvement tool for radiologists.

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.


7. Provincial Advisory Committee

As the mandate for the Provincial Mammography Equipment Committee (PMEC) has been fullfilled this committee was replaced with an advisory committee in 2009.

In the interest of promoting an integrated approach to breast screening, all District Health Authorities have implemented NSBSP's screening and provincial diagnostic computer booking program. NSBSP is now 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. For purposes of uniformity and quality performance execution, one successful bid for all equipment was identified, and equipment purchases have been completed. A provincial mammography equipment committee (PMEC) for implementation of FFDM was 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.

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 2004 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 2010, it is reported that there will be an estimated 24,600 new cases of female breast cancer and 5,300 deaths in Canada. In Nova Scotia for 2010, it is estimated that there will be 740 new cases of breast cancer and 180 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, 2010.

During their lifetimes, 1 in 9 women (11%) are expected to develop breast cancer, and 1 in 28 (3.6%) are expected to die from it. Only 28% of breast cancers are diagnosed at age 70 or older, 53% between ages 50 and 69 and 19% 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, 2008/2010.

For 2010 estimated age standardized incidence rates for breast cancer in Nova Scotia are 105/100,000 with an estimated 740 new cases. In 2006, actual data reported 710 new cases for an actual age-standardized incident rate of 107/100,000. 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 mortalityx rate for Nova Scotia for 2010 is now the fourth highest in Canada at 23/100,000 based on 180 estimated deaths. Actual data for the age standardized mortality rate for breast cancer in Nova Scotia for the year 2005 was 21/100,000, a decrease from the actual rate of 25/100,000 in 2002. There were 148 deaths recorded in Nova Scotia in 2005.

In Canada in 2003 there were 95,300 Potential Years of Life Lost (PYLL) due to breast cancer (18.3% of all causes of PYLL) compared to 94,200 in 2002. With regard for the most common cancers in women and men, the PYLL from breast cancer far exceeded the PYLL from prostate cancer (33,400) reflecting the relatively young age that women die from breast cancer. Canadian Cancer Statistics 2007.

The five year relative survival ratio for breast cancer cases diagnosed 2001 to 2003 in Canada was 87%x (85% in Nova Scotia). Cancer Institute of Canada: Canadian Cancer Statistics 2007. 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, Cape Breton Regional Hospital (CBRH) in Sydney, Dartmouth General Hospital (DGH) in Dartmouth, South Shore Regional Hospital in Bridgewater, Aberdeen Hospital in New Glasgow, Yarmouth Regional Hospital in Yarmouth and Cumberland Hospital in Amherst. The remaining 3 sites, Valley Regional Hospital, St Martha's Hospital and Colchester Hospital have decided to wait for completion of interfaces before reporting in DRS. Modifications to the Diagnostic Reporting System are ongoing.

In 2012 the NSBSP is looking to implement a new breast imaging information system, developed by Dalhousie University, the Nova Scotia Breast Screening Program and the Breast Screening Program for Newfoundland & Labrador. This initiative has the support of both the Nova Scotia Department of Health & Wellness and the Public Health Agency of Canada. This collaboration is funded by the Canadian Breast Cancer Foundation Atlantic and the Public Health Agency of Canada.

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 [*].

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 2010, 5 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 68 women ``Lost to Follow-up'' and 63 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 The Nova Scotia Breast Screening Program Website

The Nova Scotia Breast Screening website, accessible at breastscreening.nshealth.ca, contains a wealth of information for the general public including background information on the program, program guidelines, various quality initiatives, and information on the screening sites that are part of the program including contact information. Also included on the site are links to the mobile van schedules (always kept current) and various statistics including Nova Scotia Annual Statistics, NSBSP Annual Reports, and Public Health Agency of Canada Biennial Reports.

The NSBSP website experienced a major update in the summer of 2011. A fresh design and an intuitive layout of content has improved the functionality and feel of the site.

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 2007, 2008, 2009 and 2010 plus the Canadian Breast Screening Database Indicators, most recently available for the combined years of 2003 and 2004 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 over a 30-month period) 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

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 over a 30-month period) as a proportion of the eligible population

Target: $ \geq$ 70% of the target population

The NSBSP participation rate for the timeframe of 2009 - 2010 was 56.86% of the target population in Nova Scotia.

Over the past year there was a biennial participation rate change of -0.74%. In the same time-frame the number of screens TRUETRUEincreaseddecreased by 2.5%, compared to a 3.9% TRUETRUEincreasedecrease one year ago. The actual number of women screen has TRUETRUEincreaseddecreased from 73278 to 75131 in the past year.


Table 9.1: Performance Indicators (ages 50-69)
    Canada Nova Scotia
Indicator Canadian Recomendations 2003+04 2007 2008 2009 2010
Number of screens N/A 1345382 35163 41781 43361 43088
Number of 1$ ^{st}$ screens N/A 321306 5065 4750 3891 2757
Number of cancers N/A 6900 155 211 223 204
Participation Rate >70% of the eligible population 36.5% 54.3% 57.55% 57.6% 56.86%
Retention Rate            
1$ ^{st}$ screen > 75% re-screened within 30 months 64.9% 61.9% 62.6% 65.2% 62.9%
Re-screen >90% re-screend within 30 months 76.8% 75.7% 76.6% 80.8% 81.8%
Abnormal Screen Rate            
1$ ^{st}$ screen < 10% of screens reported as abn 12.1% 10.6 11.1 11.6 12.9
Re-screen < 5% of screens reported as abn 6.5% 4.8 4.4 4.4 4.8
Invasive Cancer Rate            
1$ ^{st}$ screen > 5 per 1000 4.7 5.13 7.37 4.63 5.8
Re-screen > 3 per 1000 3.7 3.32 3.65 4.18 3.82
In Situ cancer Rate Surveillance and Monitoring Only          
1$ ^{st}$ screen per 1000 screens 1.3 0.59 2.74 1.03 1.81
Re-screen per 1000 screens 1 0.83 0.73 0.86 0.84
Diagnostic Interval            
No open biopsy >90% within 5 weeks (no tissue bx) 74.3% 63.4 62.5 65.8 69.5
With open biopsy >90% within 7 weeks (with tissue bx) 46.3% 16 15.9 21 20.1
Positive Predictive Rate            
1$ ^{st}$ screen > 5% of abn screens 5% 5.9% 9.2% 4.9% 6.1%
Re-screen > 6% of abn screens 7.3% 9% 10% 11.6% 9.8%
B : M open biopsy ratio < 1:1 initial screen open biopsies 2.6 : 1 0.2 : 1 0.3 : 1 0.1 : 1 0 : 1
  < 1:1 re-screen open biopsies 1.6 : 1 0.2 : 1 0.2 : 1 0.1 : 1 0.1 : 1
Invasive ca tumor size > 25% < 10mm 36.4% 35.48 32.93 33.33 36.55
  > 50% < 15mm 64.8% 69.35 60.37 67.22 63.45
Node negative cancers > 70% node negative 74.8 78 78 85 78
    Canada Nova Scotia
Indicator Canadian Recomendations 98-99 2005/2006 2007/2008 2009/2010
Post Screen Detected        
Invasive Cancer Rate 1        
within 12 months < 6 5.4 - - -
within 24 months <12 7.9 - - -
1 Funding by the Canadian Breast Cancer Foundation - Atlantic Chapter has enabled a retrospective study of Post Screen Cancer rates.


Table 9.2: Performance Indicators under review (ages 50-69)
    Canada Nova Scotia
    2003+04 2007 2008 2009 2010
             
Benign open biopsy rate Surveilance and monitoring          
1st screen per 1,000 screens 4.5 1.2 2.9 0.8 0.4
Re-screen per 1,000 screens 2.6 0.9 0.7 0.5 0.3
             
B : M ratio - direct to open bx1

Surveillance and monitoring

  9 : 1 1.2 : 1 1.7 : 1 1.7 : 1
             
Benign core biopsy rate Surveillance and monitoring          
1st screen per 1000 screens 11.6 29.4 32.2 25.2 33
re-screen per 1000 screens 4.7 10.6 9.3 7.4 7.6
             
B : M core bx ratio Surveilance and monitoring          
1st screen   2.8 : 1 4 : 1 3.3 : 1 4.9 : 1 5.4 : 1
re-screen   1.5 : 1 2.7 : 1 2.2 : 1 1.4 : 1 1.6 : 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 2009, 9.1% of women screened were over age 69. This FALSETRUEdecreasedincreased to 9.6% in 2010. 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. The NSBSP is currently reviewing its policy on reminder notices with an eye to extending this practice to women 70-74.

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 2010, 33.1% of NSBSP participants were aged 40-49.

Figure 9.1: NSBSP Biennial Participation (ages 50-69)
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The commitment of the Nova Scotia Department of Health & Wellness to the Nova Scotia Breast Screening Program has resulted in linear increases in participation rates. Support given by the Department of Health & Wellness 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 2009and 2010, there were 75131 (Table 9.3) screening mammograms performed by NSBSP on women in the target age group. The inclusion of Valley Regional Hospital in Kentville 2006, Aberdeen Hospital in New Glasgow in 2007 and Cobequid Community Health Centre later that year account for the increase in participation rates those years.


Table 9.3: NSBSP Biennial Participation Rate and Trend by District Health Authority ages 50-69
District Health Target Participation Participation Participation Participation Annual DHA Biennial Screens
Authority Population Rates Rates Rates Rates Participation 2009+2010
DHA   2006+2007 2007+2008 2008+2009 2009+2010 Trend  
            Per DHA1  
Unknown -           0
1 South Shore 9603 58.74% 60.42% 57.44% 55.44% -2% 5324
2 SW Nova 8931 59.51% 59.31% 60.65% 59.6% -1.05% 5323
3 Annapolis Valley 11988 54.28% 55.35% 55.68% 54.15% -1.53% 6491
4 Colchester E. Hants 9895 60.62% 61.38% 61.16% 61.62% 0.46% 6097
5 Cumberland 4852 54.05% 57.04% 54.61% 55.73% 1.12% 2704
6 Pictou 6890 39.67% 58.71% 58.82% 56.4% -2.42% 3886
7 Guys/Ant 6770 33.26% 46.29% 49.74% 53.4% 3.66% 3615
8 Cape Breton 19270 49.2% 53.64% 51.6% 52.06% 0.45% 10031
9 Capital 53931 57.95% 59.03% 59.94% 58.7% -1.23% 31660
Total 132130 54.3% 57.55% 57.6% 56.86% -0.74% 75131
1 Although the participate rate has dropped in the past year the number of women screened in each district has increased. New census data released in 2011 places the number of women aged 50-69 at 132130 up from the previous value of 127220

Table 9.4 contains in addition to data in Table 9.3, diagnostic data from facilities booking diagnostic mammography using the Central Mammography Booking Database. The data presented in Table 9.4 shows 83960 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 63.54% a change of -1% over 2009.

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 six 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 [*].

Figure 9.2: 2009/2010 Combined Provincial Mammography Participation Rates per DHA (ages 50-69)
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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 2010 is 63.06% (62.1% one year ago). 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: initial screen $ \geq$ 75% re-screened within 30 months
  re-screen $ \geq$ 90% re-screened within 30 months

Figure 9.3: Retention Rates by Year (ages 50-69)
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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
Diagnostic Target Biennial Biennial Combined Combined Combined
Mammography Population1 Diagnostic Screens Plus Participation Participation Participation
Facilities Mammograms Biennial Rates Rates Rates
by DHA 2009-2010 Diagnostics 2007+2008 2008+2009 2009+2010
2009+2010 Per DHA Per DHA Per DHA
Unknown - 937 937      
1 South Shore Regional 9603 598 5922 65.6% 62.7% 61.7%
3.Yarmouth Regional 8931 443 5766 63.3% 65.1% 64.6%
3 Valley Regional 11988 787 7278 61.3% 61.5% 60.7%
4 Colchester Regional 9895 531 6628 66.3% 66.3% 67%
5 Cumberland Regional 4852 234 2938 61.5% 59.3% 60.6%
6 Aberdeen 6890 358 4244 62.7% 63.3% 61.6%
7 St. Martha's 6770 373 3988 48.5% 54.1% 58.9%
8 Cape Breton Health Care 19270 1277 11308 60.6% 58.1% 58.7%
9 QEII HSC and DGH 53931 3291 34951 65.6% 66.2% 64.8%
Total 132130 8829 83960 64.43% 64.28% 63.54%
1 New census data released in 2011 places the number of women aged 50-69 at 132130 up from the previous value of 127220


Table 9.5: 30-Month Participation and Cancer Detection Rate by District ages 50-69
District Health Authority Target Women Participation Invasive In situ All Cancer Rate per 1000
(DHA) Population1 Screened rate Cancers Cancers Cancers women screened
Unknown District - 0   0 0 0  
1 South Shore 9603 5324 55.44% 21 5 26 4.9
2 South West Nova 8931 5323 59.6% 30 10 40 7.5
3 Annapolis Valley 11988 6491 54.15% 39 0 39 6
4 Colchester E. Hants 9895 6097 61.62% 41 4 45 7.4
5 Cumberland 4852 2704 55.73% 20 1 21 7.8
6 Pictou County 6890 3886 56.4% 18 6 24 6.2
7 Guysborough / Antig 6770 3615 53.4% 23 4 27 7.5
8 Cape Breton 19270 10031 52.06% 77 27 104 10.4
9 Capital 53931 31660 58.7% 189 45 234 7.4
Total 132130 75131 56.86% 458 102 560 7.5
1 New census data released in 2011 places the number of women aged 50-69 at 132130 up from the previous value of 127220


Table 9.6: Diagnostic and Screen Biennial Participation Rates ages 40-69
Diagnostic Target Biennial Biennial Combined Combined Combined
Mammography Population1 Diagnostic Screens Plus Participation Participation Participation
Facilities Mammograms Biennial Rates Rates Rates
by DHA 2009-2010 Diagnostics 2007+2008 2008+2009 2009+2010
2009+2010 Per DHA Per DHA Per DHA
Unknown - 1687 2      
1 South Shore Regional 14142 1009 8548 58.9% 60.1% 60.4%
2 Yarmouth Regional 13539 846 8629 59.9% 62.3% 63.7%
3 Valley Regional 18264 1380 10826 57.5% 59.2% 59.3%
4 Colchester Regional 15560 1016 10370 61.9% 63.3% 66.6%
5 Cumberland Regional 7083 392 4129 58% 58.1% 58.3%
6 Aberdeen 10459 648 6277 55.5% 59.7% 60%
7 St. Martha's 9802 575 5667 42.8% 52.6% 57.8%
8 Cape Breton Health Care 28177 2383 16689 57.1% 58.2% 59.2%
9 QEII HSC and DGH 88310 7877 58351 63.6% 65.3% 66.1%
Total 205336 17813 129488 61.27% 62.1% 63.06%
1 New census data released in 2011 places the number of women aged 40-69 at 205336 up from the previous value of 205194


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 1$ ^{st}$ screens and $ <5$ % of re-screens

Figure 9.4: Abnormal and PFNS Recall Rates by Reporting Group 2010 (ages 50-69)
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In 2010, 2319 screens in the target age group were reported as abnormal (Table 9.7). Abnormal reporting rates were 5.4% overall (12.9% for 1$ ^{st}$ screens and 4.8% for re-screens). An additional 41 cases (Table 9.8) were reported based on clinical findings categorized as Physical Findings Not Seen or ``PFNS''. This compares 39 a year ago and 38 in 2008. Generally 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: 2010 Abnormal call rates and cancer detection rates (50-69)
Screens n Abnormal Abnormal Cancers Cancer detection
Reports Call Rate Rate/1000
(%) Screens
1st 2757 358 12.9 21 7.6
Re-Screen 40331 1961 4.8 183 4.5
All 43088 2319 5.4 204 4.7


Table 9.8: 2010 Physical Finding Not Seen (PFNS) call rates and cancer detection rates (50-69)
Screens n PFNS PFNS Cancers Cancer detection
Reports Call Rate Rate/1000
(%) Screens
1st 2757 5 0.18 1 0.36
Re-screen 40331 36 0.09 2 0.05
All 43088 41 0.1 3 0.07


Table 9.9: 2010 Workshop Assessment (all ages)
Assessment Tests All Assessment Assessment 1$ ^{st}$ Assessment Assessment
testing per testing per testing per testing per
all abnormal all screens all abnormal all screens
screens screens
Work-up ultrasounds   1960 44.79% 2.7%   550 52.48% 7.1%
Work-up mammograms   4078 93.19% 5.61%   976 93.13% 12.6%
Core Biopsies   1171 26.76% 1.61%   291 27.77% 3.76%
MRI   42 0.96% 0.06%   6 0.57% 0.08%
Women to surgery   363 8.3% 0.5%   60 5.73% 0.77%
                 


Table 9.10: 2010 and Cumulative Core Biopsy Outcomes (all ages)
1991-2010 2010
OUTCOME Stereo U/S Guided All Stereo U/S Guided All
Benign 7495 684 8179 669 107 776
Atypical/Suspicious 587 19 606 42 1 43
Cancer 2655 331 2986 272 57 329
$ \:\:\:\:\:$Invasive 1927 318 2245 193 55 248
$ \:\:\:\:\:$DCIS 695 10 705 73 1 74
$ \:\:\:\:\:$Lymphoma 6 3 9 1 1 2
LCIS 27 0 27 5 0 5
Unsatisfactory 82 3 85 2 0 2
Others1 774 44 818 100 13 113
Total 11620 1081 12701 1090 178 1268
Benign:Malignant2 2.8:1 2.1:1 2.7:1 2.5:1 1.9:1 2.4:1
1 Includes unsuccessful and equivocal cases
2 Results of atypia and LCIS are not included to determin B : M ratios


Table 9.11: 1991-2010 Core Biopsy and Definitive Surgery Outcomes
Core Biopsy and Definitive Surgery Outcome 1991-2010 2007 2008 2009 2010
Malignant cores benign at surgery 22 3 1 2 0
Malignant cores atypical or benign at surgery 9 3 0 0 1
Malignant cores malignant at surgery 2865 230 311 328 307
Malignant cores - no definitive surgery 90 9 13 7 3
Benign cores benign at surgery 446 31 47 38 35
Benign cores atypical or suspicious at surgery 65 7 6 10 5
Benign cores malignant at surgery 148 11 15 13 10
Benign cores - no definitive surgery 7518 791 844 726 719
Atypical or suspicious cores benign at surgery 129 20 16 13 5
Atypical or suspicious cores atypical or suspicious at surgery 174 14 15 19 9
Atypical or suspicious cores malignant at surgery 230 23 27 24 21
Atypical or suspicious cores - no definitive surgery 72 8 11 9 8
Unsatisfactory or others 903 107 134 123 115

There were 11328 women having 12701 core biopsies (by screen exam date) through NSBSP from 1991 until 2010 (1228 women had more than one core biopsy at different times or bilaterally). Of the 1268 core biopsies performed in 2010, 178 were indicated as being done using ultrasound guidance for positioning of the needle. 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 2010 (by age)
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There were 263 cases of invasive breast cancer detected in 2010. Shown in ten year age groups above, 170, (65)% 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 slightly higher than national targets of more than 5 per 1,000 (5.8) for first screens and 3 per 1,000 for re-screens (3.8). It may well be that with the screening program now in place, the invasive cancer rates will remain stable 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 2010 (by age)
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There were 66 cases of In Situ cancer detected in 2010. Of these, 39, (59%) 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 2010, there were 5 cases of LCIS, 4 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)
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In 2010, the NSBSP overall (i.e, for all age-groups) ``Diagnostic Interval'' shows 70.8% of abnormal screens having had no tissue biopsy, are at case completion after five weeks from screening. This is lower than the 75% overall nationally in 2005 and 2006. (Table 9.1).

In NSBSP in 2010 the overall (i.e, for all age-groups) Diagnostic Interval for women having had a tissue biopsy was 11.5%

Figure 9.8: Abnormal Screen to Diagnosis - with biopsy (all ages)
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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: 1$ ^{st}$ 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)
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Figure 9.9 demonstrates for the target age group, the individual highest and lowest as well as the average PPV for the indicated years.

Figure 9.10: High-Low Positive Predictive Values (ages 40-49)
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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). Initial results of FFDM are showing it to be very beneficial in this age group.

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.

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: 2010 NSBSP Surgical Outcomes by District Health Authority (all ages)
DHA 1 2 3 4 5 6 7 8 9 Unkn All
Screening Exams 5010 5320 5939 6052 2480 3508 3253 9135 31999 1 72697
Surgical Procedures 14 31 23 47 12 14 11 70 207 0 429
                       
Women to Surgery 14 26 21 35 10 13 8 66 170 0 363
B : M Ratio 1:3.7 1:3 1:21 1:7.5 1:8 1:11 1:8 1:8 1:17.1 1:0 1:10.2
Cancer Det Rate 2.2 3.4 3.5 5 3.2 3.1 2.5 6.1 4.8 0 4.4


Table 9.13: 2010 NSBSP: Days to Diagnosis and Surgery Wait Times by District Health Authority (all ages)
DHA 1 2 3 4 5 6 7 8 9 Unkn All
Screen to first core biopsy(benign) 56 83 64 62 69 39 46 57 43 80 54
Screen to first core biopsy(cancer) 51 63 50 44 34 33 27 49 33 0 40
                       
Cancer core to first surgery 88 109 87 91 82 75 57 90 85 0 87
Benign core to first surgery 84 177 139 141 0 0 67 155 177 0 147
                       
First core to first surgery (if multiple cores) 57 57 39 54 45 51 38 53 52 0 51
No core to first surgery 65 150 0 114 68 0 0 212 112 0 129


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 Malignant Open Biopsy Ratio by District 2010 (ages 50-69)
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Figure 9.11 and table 9.14 demonstrate the 2010 benign to malignant surgical ratios 1 : 14.6 (or 0.1 : 1) for women aged 50-69, indicating that overall for every one benign surgical outcome, there were 14.6 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)
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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 3212 cancers of all ages detected from the start of the program, 2541 (79.1%) were invasive and of these, 9.2% were less than or equal to 5mm, 35.4% were 10mm or less and 64% were 15 mm or less (Figure 9.13). Of all invasive cancers in the target age group, 69% were stage 1 or better.

Figure 9.13: Invasive Cancer Tumor Size 1991-2010 (all ages)
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During this time 705 cases of DCIS and 27 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 2010, in the target age group, 204 cancers were detected. Of these, 170 (83% were invasive and of these, (13.2%) were 5mm or less, 36.5% were 10mm or less and 63.5% were 15mm or less (Figure 9.14. 62% were stage 1 or better.

Figure 9.14: Invasive Cancer Tumor Size 2010 (ages 50-69)
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During this time, 74 cases of DCIS were detected and there were 5 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 81% 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)
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Figure 9.16: Node Negative Cases by Year (and by age)
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In addition there have been 101 cases of DCIS with nodal excisions (99 with negative nodes and 2 with positive nodes). In 2010, there were 170 invasive cancers in the target age group of which 163 (96%) had lymph nodes excised. Of these 69% were node negative. In all age groups there were 275 lymph node dissections and of these, 15%, 25%, 40% and 21% were in the 40-49, 50-59, 60-69 and 70+ age groups respectively.


Table 9.14: 2010 Biopsy Results per woman (ages 50-69)
  B n= M n=    
      Ratio Rate
Benign : Malignant open biopsy ratio 14 204 0.07 : 1  
         
Benign : Malignant core biopsy ratio (atypical not included) 399 206 1.94 : 1  
Benign : Malignant core biopsy ratio (atypical included) 425 206 2.06 : 1  
Benign : Malignant core biopsy ratio (atypical and others included) 478 206 2.32 : 1  
         
Benign : Malignant open biopsy ratio - direct to open biopsy (no core) 5 3 1.67 : 1  
Benign : Malignant open biopsy ratio - after core biopsy 13 208 0.06 : 1  
         
Benign open biopsy rate per 1000 screens 14     0.3
Benign core biopsy rate per 1000 screens 399     9.3

10. Former Initiatives

10.1 Comparing Radiation Doses in Mammography Units Across NS

The process of replacing the mammography units with digital technology in the province started in 2007. One benefit of this strategy has been a reduction of about 37% in the radiation levels which our clients receive. In a recent study performed by Drs. Eva Barkova and Cupido Daniels, the radiation levels for average breast sizes and tissue composition, which clients received in 2006 (pre-digital era) were compared to that of 2008-2009 during which 9 digital units have already been deployed.

The graphs in figure 10.1 compare the distribution of radiation levels in 2006 for 18 non-digital, film-screen units and for 17 units in 2008-2009 consisting of 9 digital units, 1 computed radiography unit (CR), and 7 non-digital units. Important observations include:

  1. The radiation levels for non-digital units are very varied and women are exposed to different levels of radiation, albeit all below the maximum allowable amount, depending on where the imaging occurs
  2. The radiation levels for digital units are much lower (by 37%) than that of non-digital units.
  3. The radiation levels for digital units are very consistent from site to site.
Figure 10.1: Radiation doses for film and digital screening systems
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10.2 Understanding Service Delivery through the use of GIS

Over the last few years, the NSBSP has worked with the Public Health Agency of Canada as well as two students at the Centre for Geographic Sciences (NSCC) to explore the use of Geographic Information Systems (GIS) in understanding use of breast screening services by women across NS as well as to understand how services are being delivered. The province-wide transition to Full-Field Digital Mammography (FFDM) was completed in May 2010 for all 11 fixed sites and 1 mobile unit and Nova Scotia also remains the only province to encompass all screening in the province under the umbrella of an organized program.

It is within this context that a historical analysis of the use of services in the 5 years preceding the beginning of the FFDM implementation was undertaken. It was then natural that GIS be used as part of this analysis. Ms. Stephanie Lea, an x-ray technologist by background, analysed these data to form her thesis work in the Master's of Applied Health Services Research at Dalhousie University. She examined trends in participation and retention by District Health Authority (DHA) and over time. She also analysed where women accessed screening services in relation to where they lived. The final piece was to analyse how DHAs vary in their screening service delivery, including variations in capacity as well as the use of mobile versus fixed site service provision.

Participation results varied over time and place but were hard to interpret because of the addition of fixed sites over time. Retention results revealed an overall reduction over time and a greater range across DHAs over time, believed to be due in large part to increasing wait times that made it difficult for women to return to screening in the appropriate time interval. Interestingly, one of the features of Central Booking is that women are free to choose where to have their screening exam performed, but these analyses revealed that most women choose to be screened in their home DHA. The number of screens performed each year has been increasing across the province as a whole and in most DHAs but the number of screens performed for women aged 50-69 as a function of the number of women that age resident in that DHA (i.e., screens per capita) varied substantially over time within DHA and across DHA (Figure 10.2 contains most recent data for women aged 40+). Similarly there was wide variation in the provision of services through fixed vs mobile site over time within DHA and across DHA. This analysis has helped provide a solid foundation for comparison with the post-FFDM data and has produced a new way of thinking about how to analyse service provision across the DHAs, a methodology which over time will be incorporated into the NSBSP Annual Report.

Figure 10.2: Screens per 1,000 Women (Aged 50-69), by DHA
\begin{figure}\begin{center}
\epsfbox{finalReport-dhaPart}
\end{center}\end{figure}

10.3 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, Cape Breton, Dartmouth General, Bridgewater, New Glasgow, Yarmouth and Amherst. Kentville, Truro and Antigonish are waiting for completion of the interface between DRS and the hospital information system before reporting in DRS. Until this occurs patients in those 3 districts cannot be followed up and tracked in the database by Central Mammography Booking as is the practice in all other districts.

In 2012 the NSBSP is looking to implement a new breast imaging information system, developed by Dalhousie University, the Nova Scotia Breast Screening Program and the Breast Screening Program for Newfoundland & Labrador. This initiative has the support of both the Nova Scotia Department of Health & Wellness and the Public Health Agency of Canada. This collaboration is funded by the Canadian Breast Cancer Foundation and the Public Health Agency of Canada.

10.4 Central Mammography Booking (CMB)

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. Currently all breast imaging, screening and diagnostic, in the province is booked through Cental Booking. Starting dates for diagnostic centers joining with CMB are seen in Table 4.1. All guidelines are strickly followed to ensure asymptomatic women that fit the criteria for screening are booked as such. Core biopsies and all breast ultrasounds, with the exception of District 1, are also being booked through Central Booking. A breast MRI reporting module has been developed with funding from the Public Health Agency of Canada (PHAC). All breast MRI is being centrally booked and reported in the database. This process ensures that breast MRI is being utilized appropriately, guidelines developed by the Department of Health & Wellness in 2008 are being followed and recommendations are being tracked in the database and followed up in a timely manner.

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.

10.5 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 2010, a total of 11620 stereotactic core biopsies and a reported 1081 ultrasound guided core biopsies have been performed on 11328 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 2010 is also 1.1%.

Over the first 20 years of the program there have been 22 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 0.2%. 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:

10.6 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:


10.7 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 has been made available for review by of the radiologists as a web based learning file. A summary table of work completed up to the end of 2003 is included. The process is now ongoing.

The true value of screening can only be understood if a screening program is able to follow its participants for all diagnosed cancers, including those not found through screening. The NSBSP is very unusual in being able to capture these data on all of its participants. The results of this review were recently presented at the Annual Meeting of the Radiological Society of North America (RSNA) in Chicago and the results of this review are currently being summarized for publication in the RSNA scientific journal.


Table: NSBSP Post Screen Detected Cancers
    Radiologists'
    Diagnosis1 Intervals and Other Post Screen Cancers 2
            Interval Interval      
  Number         Cancer Cancer      
  of 1 2 3 4 Rate Rate Recurrence Contralateral Non-
  Women         per 1000 per 1000     Compliant
  Screened         screens Women      
91-92 5,848 0 0 0 0 - - 0 0 0
93-97 29,947 45 13 9 9 1.1 2.1 14 16 172
98-99 19,328 26 16 9 5 1.0 2.9 7 8 98
00-01 16,192 40 19 13 10 1.2 5.1 9 8 106
02-03 23,797 39 23 12 11 1.0 3.6 5 10 88
All 93,112 150 71 43 35 1.1 3.2 35 42 464
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

10.8 Interval Cancers

The review of the post-screen cancers has led to an exciting research project led by Dr. Danny Rayson, a medical oncologist at the Cancer Clinic in Halifax. The research project team is the result of a new collaboration between Dr. Jennifer Payne, Prof. Mohamed Abdolell, Dr. Penny Barnes (pathologist), Dr. Rebecca McIntosh (pathologist), Dr. Tallal Younis (medical oncologist), Dr. Judy Caines, and Ms. Theresa Foley. The project involves understanding the differences between interval cancers and screen-detected cancers and was funded by the Capital Health Research Fund. It is believed that interval cancers are more aggressive in nature (i.e., more aggressive pathology) but it is hard to show this because of a lack of follow-up data of women who have been screened. The preliminary comparison of pathology characteristics between the two groups did in fact reveal that interval cancers were more aggressive in nature than screen-detected cancers. Early results of this were presented at the Annual Meeting of the American Society of Clinical Oncology last year. This past year, the project was expanded to include a comparison of the clinical outcomes of women with interval cancers vs screen-detected cancers. With the help of a 2nd year medical student, Ms. Ariel Burns, who was funded by a Norah Stephens award, the charts of these women were reviewed at both the Halifax and Sydney cancer clinics. Ms. Burns was able to find any missing pathology data as well as collect information on breast cancer recurrence. Ms. Burns presented the completed pathology analysis at the Dalhousie Cancer Research Symposium and received an honourable mention for her poster. The analysis of the differences in clinical outcomes between the interval and screen-detected cancers is now underway with plans to submit this work in January for consideration at the upcoming Annual Meeting of the American Society of Clinical Oncology in May. At the same time, work is beginning on summarizing this work for submission to a leading medical scientific journal for publication.

10.9 Needle Core Biopsy

The NSBSP is an unusual screening program because it has incorporated the use of needle core biopsy (NCB) into its clinical practice guidelines. The use of NCB has been shown to reduce the rate of benign surgery in women. Dr. Heather Curtis, a 4th year radiology resident working on her residency research project under the guidance of Dr. Jennifer Payne and Dr. Judy Caines, conducted a review of NCB rates within the NSBSP from 1991 through to 2006. This timeframe is extremely critical in that it precedes the introduction of FFDM. The review consisted of summarizing both the rates of NCB as well as the surgery rates within the program as a whole, as well as within each program site, over time. Finally, a similar summary was compiled for the benign:malignant ratio for both NCB and surgery, the latter one being a measure to assist in minimizing the surgery rate for benign (i.e., non-cancerous) growths. What Dr. Heather Curtis found was again a confirmation that the use of NCB is associated with a decrease in the number of benign surgeries. The comparison of figures over time across the sites revealed that although sites might have differed when NCB was first introduced, the variation in rates has been greatly reduced over time. Dr. Curtis presented these results at the Annual Dalhousie Radiology Research Day. This analysis will help the NSBSP set provincial targets for these performance indicators to help ensure that women across the province receive the same high quality care, regardless at which sites they receive their care. This analysis also serves as an important benchmark for comparison once FFDM has been implemented throughout the province.

11. Current Initiatives

11.1 Mobile Breast Screening

Breast screening in NS began as 1 fixed site and 3 mobiles; currently there are 11 fixed sites across the province and three mobile units. Mobile breast screening must be coordinated across Nova Scotia to compliment the services delivered at the eleven fixed sites. It is with the intent to reach populations distanced from the fixed sites that mobile breast screening operates. In 2009, 62% of all mobile screens were performed within a 30km radius of at least one fixed site.

The objective of this initiative is to examine current mobile scheduling for the purposes of optimizing time and resources to better serve areas in the province lacking access to breast screening. Specifically, this initiative will examine current routes and booking utilization. All three mobile units currently follow routes that to some degree lack sequential scheduling of adjacent communities.

The province of NS has completed a rollout of full field digital mammography units to all eleven of the fixed sites across the province. The provision of digital mammography provides an opportunity to increase screening capacity at all fixed sites. This increased capacity at fixed sites gives rise to the opportunity to restructure mobile screening in order to provide the best service possible to those distanced from fixed sites.

Currently there are two film-based mobile units and one digital mobile. The NSBSP together with the DHW has proposed to move to a single, digital mobile screening unit for the entire province. In moving to a single, digital mobile unit, every women in Nova Scotia will be guaranteed to have her mammogram performed digitally. Access to digital mammography for all women balances the standard of care being provided in Nova Scotia. Research has also demonstrated that digital mammography decreases radiation exposure compared to film-based mammography.

Mobile stops in close proximity to fixed sites will no longer provide this duplication of service. The mobile will be focused on providing service to areas that cannot easily access fixed site service. Increased capacity at fixed sites will absorb the mobile screens that used to occur in close proximity to the 11 fixed sites. Using a single, digital mobile unit for the entire province will also make mobile screening more cost-effective. Traveling distances will be greatly reduced and mobile utilization will be maximized.

The process of transitioning from three mobiles to one is not a simple task. An assembled team from the NSBSP, the Department of Health & Wellness, and from the DHA's that coordinate the mobiles has already been working on this transition for several months.

This group is working to ensure this transition occurs as smoothly as possible. Look for more information on this initiative to become available the first half of 2012.

11.2 Evaluation of Full Field Digital Mammography (FFDM)

As mentioned earlier, the transition to FFDM was completed in May 2010. Exploratory work has been underway to understand what this transition means for the women of Nova Scotia in terms of quality of care. In Canada, the performance of breast screening programs is measured through a series of standardized performance indicators, each with its own target. Programs can use these measures to monitor their progress over time and as well as against the country as a whole. These measures have now been evaluated for the one year period prior to the FFDM transition (analog) against the first 12 months of digital mammography, allowing for a 4-month transition period. These preliminary results revealed that digital mammography appears to outperform analog mammography for women aged 40-49 years, and to a lesser extent this is also true for women aged 50-59 years. It must be noted that these data are preliminary in that not all NSBSP sites are at this point in time able to contribute 12 months of data given that some did not transition until spring of this year. It must also be noted that radiologists review screening mammograms in relation to earlier mammograms and that in this specific instance, the earlier ones were analog. Therefore the `final' analysis of the FFDM transition will not be complete until radiologists are able to review digital mammograms in relation to at least one prior digital set of mammograms. As most women in the target age range of 50-69 years are screened only once every two years, it will be a while before we can truly understand the impact of FFDM on quality of care.

11.3 Developing empirically based BI-RADS scales from FFDM

Prof. Mohamed Abdolell, with collaborators Dr. Peter Gregson, Dr. Gerry Schaller, Dr. Jennifer Payne and Dr. Judy Caines, have obtained co-funding from Capital Health Research Fund, the Department of Diagnostic Imaging, and Canadian Breast Cancer Foundation - Atlantic Region Community Health Grant for the project, "Developing empirically based BI-RADS scales using breast density measurements from full-field digital mammograms". Breast density has been associated with an increased risk of breast cancer, and is currently used by the Nova Scotia Breast Screening Program to adjust screening intervals for high-risk women (e.g., annual recall rather than biennial for women with very dense tissue). Current clinically accepted measures of breast density are based on Film Screen Mammography (FSM), and have either been determined by radiologist visual assessments or an operator dependant computer-aided mathematical assessment (algorithmic). The NSBSP will be exclusively using full-field digital mammography (FFDM) by the end of 2009, and yet no accepted standard for measuring breast density in FFDM exists. The aim of this project is to develop a fully automated algorithm to measure mammographic density based on FFDM that can be incorporated into the existing NSBSP data holdings. Preliminary results are promising and confirm a very good level of agreement between the new algorithm and the radiologist assessments of mammographic density; further efforts will be made to improve on the level of agreement. With sufficient followup, clinical outcomes will enable the use of this valid breast density measure to develop a statistical model that relates breast density to cancer risk. Such a model will be an additional tool to aid radiologists in deciding on scheduling of followup screening.

11.4 Surveillance and Reporting

In 2008, Dr. Jennifer Payne received a one-year community grant from the Canadian Breast Cancer Foundation - Atlantic Region to develop a surveillance framework for the NSBSP. Although the NSBSP reports on a series of nationally agreed upon performance indicators, the NSBSP data holdings are much broader than those of many other provinces and therefore lend themselves to calculations of other indicators, including those both in the area of quality of care as well as service provision. Although the formal grant has been completed, the framework is now being used to review other possible indicators, such as those now developed in the area of wait times (see 11.5), and those produced out of the work in health services utilization (see 11.1) and how these indicators can be used both internally by the NSBSP and externally by stakeholders and to the public at large. In addition, the NSBSP is working on various ways of presenting indicators to stakeholders - as the calculations become complex, it's important to present information to stakeholders in a format that is useful and meaningful for them. As these forms of reporting are developed, the NSBSP will be consulting with its stakeholders on ways to expand and strengthen reporting of breast screening performance in Nova Scotia.

11.5 Wait Times

As part of a province-wide initiative within the NS Department of Health & Wellness, NSBSP has been revising its measurement of wait times and has now joined other areas of diagnostic imaging in moving towards web-based reporting of these new measures. In the past, wait times were defined as the wait until the next day with 3 available appointments for a given procedure or test. The new definitions are now those being adopted by other provinces as part of a national initiative and involve measuring wait times backwards in time for all exams held in a given time period - these new measures will now accurately reflect how long people have waited to have procedures performed.

Currently NSBSP reports on the wait time for women calling in to book their first screen - there are two numbers reported: the number of days by which 50% of women were screened (median), and the number of days by which 90% (Figure 11.1) were screened (90th percentile). It should be noted that the wait time for women calling to book a re-screen is controlled by the NSBSP through one or two year recalls depending on their risk category. Therefore these re-screened women are not included in the wait time calculation.

The detail within the NSBSP database makes it very easy for these numbers to be calculated and the results are sent electronically to the Department of Health & Wellness every quarter. The NSBSP has used the same approach in calculating wait times for work-ups of women with an abnormal screen using the same indicators; the number of days by which 50% of women were screened (median), and the number of days by which 90% (Figure 11.2) were screened (90th percentile).

Figure 11.1: Screening wait times (90th percentile)

Figure 11.2: Work-up Wait Times (90th Percentile)

The NSBSP is currently exploring how these indicators can be used to measure the wait times for symptomatic women waiting for diagnostic follow-up. For more information on the provincial wait times initiative, please consult the government website (www.gov.ns.ca/health/waittimes).

11.6 NSBSP Annual Report Automation

Prof. Mohamed Abdolell, with collaborators Dr. Jennifer Payne and Dr. Judy Caines, completed a Canadian Breast Cancer Foundation - Atlantic Chapter Community Health Grant funded project, "Automation of the NSBSP Annual Report: a first step toward developing a surveillance system". The primary goal of this project was 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 now generated in 2 hours. Since 2007, the NSBSP annual report has been generated using this system. 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 has been evaluated and it has been determined that automatic flagging of emerging trends in the NSBSP to enable proactive intervention in the system to optimize resource allocation and improve access to screening for women in Nova Scotia is achievable. In the Summer of 2011 the Automated Annual Report has been re-coded in preparation for the new information system to be used by the NSBSP.

11.7 Reminder Calls

As of Jan 2008 the NSBSP began offering reminder calls to all districts of the province that were booking mammography, both screening and diagnostic, through Central Booking. This service is being provided by Voice Services through the Capital Health and has proven to be very successful. What began as a semi automated process has been upgraded in 2009 to a completely automated system. No shows have been virtually eliminated at all sites; a graph showing the effect of this service on one district is included.
\epsfbox{finalReport-023}

11.8 NSBSP Response to Canadian Task Force on Prevention Health Care's Recommendations for Breast Screening

On Nov 21, 2011 the Canadian Task Force on Preventative Health Care released recommendations for screening mammography in Canada. Although these recommendations did differ somewhat from the current recommendations, NSBSP is operating within these guidelines. In response to the Task Force recommendations the NSBSP developed an information sheet that was sent to stakeholders throughout the province. The contents of that information sheet are presented below.

There are two clinical categories of mammography: screening and diagnostic.

Screening mammography is for asymptomatic women aged 40 and over who have no breast symptoms and who do not have a personal history of breast cancer.

Diagnostic mammography is for symptomatic women, women with implants, women with a personal history of breast cancer and for workup of anyone who receives an abnormal screening mammogram report. This population should have the shortest wait time for breast imaging. Diagnostic mammograms take longer to perform, longer to be interpreted by a breast imaging radiologist and are more expensive to the health care system.

All breast imaging in Nova Scotia (screening and diagnostic) is booked through NSBSP Central Booking which has enabled Nova Scotia to eliminate opportunistic screening (screening asymptomatic women in the diagnostic sector as opposed to an organized program). This ensures that all eligible asymptomatic women requesting breast screening are screened through an organized program. All outcomes are tracked and readily available for the entire province in real time. Nova Scotia is the only province to date that manages all breast imaging through an organized program.

Although the NSBSP targets women aged 50-69, it became apparent when the program first began back in 1991 that women aged 40-49 were demanding mammography. A conscious decision was made at that time to accept them into the screening program; the cost to the health care system is less and these women can be tracked with readily available outcomes. If women 40-49 were accommodated through physician referrals in the diagnostic sector, the diagnostic sector would become overwhelmed and the true diagnostic patients would suffer increased wait times.

11.8.1 CTFPHC Recommendations vs NSBSP Clinical Practice Guidelines


Table: Comparison of NSBSP guidelines vs. recommendations by CTFPHC
\begin{table}\begin{center}
\begin{tabularx}{\textwidth}{\vert r\vert X\vert X\...
... screening &
Not recommended \\ \hline
\end{tabularx}
\end{center}\end{table}


Task Force: Does not recommend routine screening mammography for women aged 40-49 but states women may choose to screen if they place a high value on the small reduction in breast cancer mortality (demonstrated in the randomized controlled trials that they reviewed). The Task Force also notes that “access to high quality facilities with the necessary equipment and expertise in mammography is required to undergo screening.

Provincial and regional decision makers should consider whether access is adequate for people in their jurisdiction who reside outside major centers. Mobile screening units may help to increase access to screening among rural/remote dwellers.

Nova Scotia Breast Screening Program currently practices within these guidelines: NSBSP accepts women aged 40-49 into the program but does not actively recruit them. If women do opt for screening they are directed to the organized program where they can be monitored and outcomes are available. Similar to the practice for other countries that screen this age group, these women are followed with annual screening mammography. The breast tissue in this age group is generally denser, making early detection more difficult. In addition, breast cancers detected in younger women, although less frequent than older women, are generally more aggressive and grow at a (more) rapid rate.

Currently in Nova Scotia 56% of women aged 40-49 are having screening mammography through the organized program over a two-year period. An organized program ensures there is a certain standard of care across the province and outcomes are monitored and evaluated. In all of the other provinces and territories across the country, breast screening is performed both inside and outside organized programs (known as opportunistic screening) making it difficult or impossible to report on the true participation rates and outcomes. Nova Scotia has eliminated opportunistic screening.

The Task Force review did not include any studies with digital mammography. All fixed screening sites in Nova Scotia utilize digital mammography (thanks to funding from the Nova Scotia Government). Nova Scotia's initial results show digital mammography is better at picking up cancers with fewer work-ups than film mammography in almost all age groups, especially for women 40-49. This means fewer mammograms are reported as abnormal requiring further imaging and at the same time more breast cancers are being detected.

One reason the CTFPHC does not recommend screening women aged 40-49 is the chance of having a false positive mammogram is higher in this age group and can lead to further investigation including other (potentially) unnecessary procedures such as surgery. Figure 4 demonstrates the estimated rates of unnecessary procedures, according to the Task Force, for a group of women screened every 2-3 years for a period of 11 years. Figure 5 shows the actual rates in Nova Scotia using the same inclusion criteria as the Task Force for women screened in 2000 and followed through to 2011. It would normally be expected that the false positive rate decreases with increasing age however the actual false positive mammogram rate of women aged 40-49 in Nova Scotia for the most recent 11-year period is lower than that projected by the Task Force rate for women aged 70-74.


Table 11.2: NSBSP Results (women screened 2000-2011)
\begin{table}\begin{center}
\begin{tabularx}{0.65\textwidth}{\vert X\vert c\ver...
...ies & Surgical & 12 & 10 & 6 \\ \hline
\end{tabularx}
\end{center}\end{table}



Table 11.3: CTFPHC Results for 11 year screening period
\begin{table}\begin{center}
\begin{tabularx}{0.65\textwidth}{\vert X\vert c\ver...
...ign) Biopsies & 36 & 37 & 26 \\ \hline
\end{tabularx}
\end{center}\end{table}



\begin{table}\begin{tabularx}{\textwidth}{\vert X\vert X\vert}\hline
\it Provin...
...tia & \\
{\it *With physician referral} & \\ \hline
\end{tabularx}\end{table}

The last Cancer Registry report 2003-2008 for Nova Scotia showed a 4% reduction in mortality (statistically significant) compared to the previous registry report 5 years before- 1998-2003. Some will say that is because of better treatment but this same report also shows a reduction in newly diagnosed invasive disease in women aged 50-65 by 13%. This cannot be due to treatment but was likely due to early detection in screening women 40-49 for the 10 years prior.

Nova Scotia has the lowest number of benign breast surgeries in the country thanks to the use of needle core biopsy. In Nova Scotia a requirement of the breast screening program is to provide high quality standardized mammography access and care with timely assessment, informed patient navigation and appropriate follow up of women who have abnormal mammograms on screening through complete diagnostic work up including needle core biopsy in accredited work up centers before consideration of surgical intervention. Women do not proceed to breast surgery unless proper work up has been completed and surgical intervention is warranted.

Note
The Task Force states that women should be given enough information to make an informed decision in regards to screening mammography. For the past two years the NSBSP has distributed to all physicians across the province copies of the Mammography Decision Aid published by the Public Health Agency of Canada (http://www.phac-aspc.gc.ca/cd-mc/pdf/Information_on_Mammography-eng.pdfhttp://www.phac-aspc.gc.ca/cd-mc/pdf/Information_on_Mammography-eng.pdf).

11.8.2 Summary

The NSBSP is operating within the recommendations of the CTFPHC. Women 40-49 are not actively recruited, but those opting for screening are done through the organized program with high quality standardized care and real time monitoring of clinical outcomes. Women 50-69 are routinely screened every 2 years. Women 70-74 are accepted into the program but are not sent reminders to rebook; this will be reviewed by NSBSP. The NSBSP does provide a modified breast exam to all screening clients. Routine Breast Self Exam is not currently recommended by NSBSP, which is consistent with the Task Force recommendations. The NSBSP does not recommend screening with MRI.

11.9 Canadian Breast Cancer Foundation (Atlantic) Funding

The Canadian Breast Cancer Foundation - Atlantic Region 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 $36,000 toward purchase of Mobile 2
1997 1,500 film encoder
  15,000 mammoviewer for NSBSP-Halifax
1998/99 40,000 breast ultrasound equipment-Halifax
1999 30,000 computer hardware for Infostructure Project
2000 20,000 completion of Infostructure Project
  50,000 x-ray equipment replacement Machine 1-Halifax
2001 50,000 diagnostic database hook-up to other hospitals *
2002 150,000 Mobile 3 purchase and operating costs
2003 35,000 x-ray equipment replacement Machine 2-Halifax
2004 42,000 purchase of two mammoviewers
2005 25,000 Radiologist Learning Tool and Reports
2006 60,000 purchase of three mammoviewers
2007 100,000 Purchase of ultrasound machine for breast imaging in Halifax
2007 35,000 Access to Breast Screening Services in Nova Scotia.
2007 35,000 Automation of the NSBSP Annual Report: a 1st step toward a surveillance system
2008 100,000 Toward FFD rollout
2008 53,000 Extending the Surveillance Capacity of the NSBSP
2008 44,679 Developing Empirically Based BI-RADS Scales Using Breast Density Measures from FFDM - Part I
2009 52,292 Developing Empirically Based BI-RADS Scales Using Breast Density Measures from FFDM - Part II
2011 98,500 Funding for implementation of new information system
2011 100,000 Funding for digital upgrade of mainland mobile stops
Ongoing   Funding for ``Pink Rose'' Books
    (Canadian Breast Cancer Foundation Atlantic Chapter Community Grant
    to Payne JI, Caines JS, Schaller GH, Iles S.)
    Promotional Materials


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)


A. Terms of Reference - Provincial Review of Mammography Units

Background

The Nova Scotia Breast Screening Program (NSBSP), a program of the Department of Health & Wellness, 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'Sullivan Director, Acute & Tertiary Care
Lynn Kilroy & Company Director IT Services, Department of Health & Wellness
IT Representative request through Mark LeBlanc HITS NS
Dr. Gerry Schaller Radiologist, DHA 9
Dr. Cupid Daniels Mdeical Physicist, DHA 9
Dr. Judy Caines Director, NSBSP
Theresa Foley Manager, NSBSP
Mike Pothier Manager, Diagnostics, DHA 2
Susan Delaney Diagnostic Imaging Manager, DHA 9
Susan MacNeil Diagnostic Imaging DHA 8
Dr. Eric Woods Radiologist, DHA 2
Dr. Sian Isles Radiologist, DHA 8
Allan Walsh Diagnostic Imaging Manager, DHA 4
Debbie Bezanson Diagnostic 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, Acute & Tertiary 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.


B. Nova Scotia Breast Screening Mammography Guidelines - June 2010

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.

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