| 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 East Hants Health Centre |
| 150 Exhibition St | 600 Abenaki Rd |
| Kentville, NS | Truro, NS |
| B4N 5E3 | B2N 0C4 |
| 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 Regional 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 | |
| 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 | |
| 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 | ||
| Dr. N. Sharafat | ||
| YRH | Dr. Eric Woods | |
| (Yarmouth) | Dr. Hubblall | |
| CEHCC | Dr. Nancy McNeil | |
| (Truro and Amherst) | Dr. John McNeil | |
| Dr. Eric Versnick | ||
| SSR | Dr. Arthur Marshall | |
| Dr. C.L. Church | ||
| Dr. Chen Meng | ||
| Dr. Sangeeta Kalyan | ||
| VRH | Dr. Michael Dunn | |
| Dr. David Acton | ||
| Dr. Maureen Madigan | ||
| AH | Dr. Dan Hoffman | |
| Dr. Ronald MacEachern | ||
| Dr. Magdalena Biernacka | ||
| St. MH | Dr. Brian Nicholson | |
| Dr. Mike Silver | ||
| Dr. Blair MacDuff | ||
| Technical Contacts | QEII HSC | Vicki Sorhaindo |
| CBHCC | Susan MacNeil | |
| YRH | Crystal Hilton | |
| CRH | Marian Brine | |
| DGH | Sharon Hartling | |
| CRHCC | Sandra Rose | |
| SSR | Linda Roy | |
| VRH | Debbie Bezanson | |
| AH | Dona Ripoll | |
| STMH | Jodi Myles | |
As of December 31, 2011 793948 screens have been performed on 185550 women finding 3510 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 65.2%. A break down of each DHA's participation rate can be found in table 10.4.
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 2013.
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 26 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 has been changed. Three mobiles units, two film-based and one digital, have been supplementing the 11 fixed screening sites. The purpose of mobile mammography is to service remote and hard to reach populations. Beginning in 2013 mobile mammography will be delivered to 30 stops across the province using a single, digital mobile unit. This will ensure that all women in the province have equitable access to the best screening mammography services available.
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 2013.
| Cancer Detection Rate per 1000 Screens | Cancer Detection Rate per 1000 Women | ||||||
| 1991-2009 | 1991-2010 | 1991-2011 | 1991-2009 | 1991-2010 | 1991-2011 | ||
| 645571 | 718266 | 793943 | 169791 | 177538 | 185550 | ||
| Age | |||||||
| <50 | 2.3 | 2.3 | 2.3 | 6.2 | 6.5 | 6.7 | |
| 50-59 | 4.1 | 4 | 4 | 17.6 | 18.5 | 19.5 | |
| 60-69 | 6.3 | 6.4 | 6.4 | 34.4 | 38.1 | 41.5 | |
| 70+ | 9.5 | 9.6 | 9.4 | 50.9 | 56.2 | 60.2 | |
| 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 (Replaced Mobile 1) | July 2007 | |
| Fixed (11) | Halifax Shopping Centre | 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 - Hospital | Jan 2007 | |
| Cobequid - Community Health Centre | 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 | |
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.
In 2005, other measures strongly supported were:
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.
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.
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.
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.
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. A provincial mammography equipment committee (PMEC) for implementation of FFDM was established.
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.
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.
As the mandate for the Provincial Mammography Equipment Committee (PMEC) has been fulfilled this committee was replaced with the NSBSP advisory council in 2009. The membership composition and terms of reference for this council is included in this annual report as Appendix ![[*]](/usr/share/latex2html/icons/crossref.png){kind=icon}
.
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.
Central Mammography Booking Database (CMB): Includes (1) screening and (2) diagnostic booking and follow-up modules
In 2013 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 . 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 2011, 4 women were classified as ``Lost to follow-up'', and 8 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 72 women ``Lost to Follow-up'' and 71 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.
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.
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 10.1.
The NSBSP Performance Indicators for 2008, 2009, 2010 and 2011 plus the Canadian Breast Screening Database Indicators, most recently available for the combined years of 2003 and 2004 can be seen in Table 10.1. 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.
, 2) radiological, 3) clinical (Section 10.2.9)
(> 99.9% of tumor sizes input into NSBSP database are pathological)
For Nova Scotia this figure also includes node negative cases of Dcis. Although rare, surgical pathology reports of Dcis can have positive node pathology.
Table 10.1 presents both the national provincial performance indicators.
70% of the target population
The NSBSP participation rate for the timeframe of 2010 - 2011 was 58.79% of the target population in Nova Scotia.
Over the past year there was a biennial participation rate change of -1.03%. In the same time-frame the number of screens TRUETRUEincreaseddecreased by 0.8%, compared to a 2.6% TRUETRUEincreasedecrease one year ago. The actual number of women screen has TRUETRUEincreaseddecreased from 79041 to 79695 in the past year.
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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 2010, 9.6% of women screened were over age 69. This FALSETRUEdecreasedincreased to 9.8% in 2011. 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 or more. 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 2011, 32.9% of NSBSP participants were aged 40-49.
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. For the two year period of 2010and 2011, there were 79695 (Table 10.3) screening mammograms performed through the NSBSP on women in the target age group.
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Table 10.4 contains in addition to data in Table 10.3, diagnostic data from facilities booking diagnostic mammography using the Central Mammography Booking Database. The data presented in Table 10.4 shows 88383 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 65.2% a change of -1% over 2010.
Italicized numbers in column three, indicate numbers of women by DHA having had a bilateral diagnostic examination outside the screening program, 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 or order proactively. ``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 and .
Table 10.5 has in addition to data in Table 10.3 the cancer detection rate of surgically removed cancers by district.
It is important to remember that the cancer rates in Table 10.5 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 two-thirds of the annual cancer detections in this province.
Table 10.6 is similar to Table 10.4 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 10.6 it can be seen the provincial screening plus diagnostic participation rate when including the 40-49 age group for 2011 is 62.24% (63.06% one year ago). Analysis of data on women under age 50 is now possible when reporting is done through the provincial diagnostic database.
Estimated percentage of women who are re-screened within 30 months of their previous screen
Target:
initial screen
75% re-screened within 30 months
re-screen
90% re-screened within 30 months
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.
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Percentage of women screened referred for further testing because of abnormalities found within a program screen
Targets: 
10% of 1
screens and 
% of re-screens
In 2011, 2411 screens in the target age group were reported as abnormal (Table 10.7). Abnormal reporting rates were 5.4% overall (13.1% for 1 screens and 4.8% for re-screens). An additional 55 cases (Table 10.8) were reported based on clinical findings categorized as Physical Findings Not Seen or ``PFNS''. This compares 41 a year ago and 39 in 2009. 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 10.4.
| Screens | n | Abnormal | Abnormal | Cancers | Cancer detection |
| Reports | Call Rate | Rate/1000 | |||
| (%) | Screens | ||||
| 1st | 2540 | 333 | 13.1 | 21 | 8.3 |
| Re-Screen | 42465 | 2078 | 4.8 | 197 | 4.6 |
| All | 45005 | 2411 | 5.4 | 218 | 4.8 |
| Screens | n | PFNS | PFNS | Cancers | Cancer detection |
| Reports | Call Rate | Rate/1000 | |||
| (%) | Screens | ||||
| 1st | 2540 | 4 | 0.16 | 0 | 0 |
| Re-screen | 42465 | 51 | 0.12 | 1 | 0.024 |
| All | 45005 | 55 | 0.12 | 1 | 0.022 |
| Assessment Tests | All | Assessment | Assessment | 1 |
Assessment | Assessment | ||
| testing per | testing per | testing per | testing per | |||||
| all abnormal | all screens | all abnormal | all screens | |||||
| screens | screens | |||||||
| Work-up ultrasounds | 2055 | 45.16% | 2.72% | 589 | 55.41% | 7.35% | ||
| Work-up mammograms | 4290 | 94.29% | 5.67% | 1001 | 94.17% | 12.49% | ||
| Core Biopsies | 1161 | 25.52% | 1.53% | 283 | 26.62% | 3.53% | ||
| MRI | 43 | 0.95% | 0.06% | 8 | 0.75% | 0.1% | ||
| Women to surgery | 383 | 8.42% | 0.51% | 55 | 5.17% | 0.69% | ||
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There were 12380 women having 13964 core biopsies (by screen exam date) through NSBSP from 1991 until 2011 (1399 women had more than one core biopsy at different times or bilaterally). Of the 1260 core biopsies performed in 2011, 168 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 10.11.
Tables 10.12 and 10.13 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.
screen 
5 per 1000 screens Re-screen 3 per 1000 screens
There were 263 cases of invasive breast cancer detected in 2011. Shown in ten year age groups above, 169, (64)% of these were in the 50-69 age group for a cancer detection rate overall of 3.5 per 1,000 screens. Nova Scotia is slightly higher than national targets of more than 5 per 1,000 (6.3) for first screens and 3 per 1,000 for re-screens (3.6). It may well be that with the screening program now in place, the invasive cancer rates will 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.
There were 64 cases of In Situ cancer detected in 2011. Of these, 45, (70%) were aged 50-69. The overall in situ cancer detection rate for this age group was 0.8 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 2011, there were 4 cases of LCIS, 3 of which were between 50 and 69.
| Target: | (1) 90% within 5 weeks if no tissue biopsy |
| (2) 90% within 7 weeks if tissue biopsy
|
In 2011, the NSBSP overall (i.e, for all age-groups) ``Diagnostic Interval'' shows 72.5% 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 10.1).
In 2011 the overall (i.e, for all age-groups) Diagnostic Interval for women having had a tissue biopsy was 10.9%
Figures 10.8 and 10.7 demonstrate the diagnostic interval from abnormal screen to diagnosis with and without biopsy. Numbers of surgeries for which results were based are in Table 10.12 and are for screening cases only.
| Target: | 1 screens |
5% of abnormal screens are cancer |
| Re-screen | 6% of abnormal screens are cancer
|
Figure 10.9 demonstrates for the target age group, the individual highest and lowest as well as the average PPV for the indicated years.
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 10.10). 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.
| DHA | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | Unkn | All |
| Screening Exams | 5047 | 5456 | 5872 | 6197 | 2395 | 3283 | 3602 | 9508 | 34025 | 285 | 75677 |
| Surgical Procedures | 45 | 30 | 24 | 33 | 16 | 19 | 26 | 62 | 204 | 0 | 459 |
| Women to Surgery | 37 | 26 | 21 | 27 | 12 | 16 | 25 | 56 | 163 | 0 | 383 |
| B : M Ratio | 1:7.5 | 1:2.2 | 1:9.5 | 1:5.5 | 1:3 | 1:14 | 1:23 | 1:16.3 | 1:12.2 | 1:0 | 1:8.7 |
| Cancer Det Rate | 5.9 | 3.3 | 3.2 | 3.6 | 3.8 | 4.3 | 6.4 | 5.2 | 4.3 | 0 | 4.4 |
| DHA | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | Unkn | All |
| Screen to first core biopsy(benign) | 47 | 75 | 64 | 57 | 45 | 28 | 24 | 51 | 51 | 47 | 53 |
| Screen to first core biopsy(cancer) | 41 | 51 | 42 | 52 | 49 | 28 | 22 | 39 | 38 | 0 | 39 |
| Cancer core to first surgery | 84 | 111 | 92 | 103 | 90 | 64 | 60 | 83 | 89 | 0 | 87 |
| Benign core to first surgery | 92 | 142 | 118 | 202 | 132 | 95 | 51 | 169 | 179 | 0 | 148 |
| First core to first surgery (if multiple cores) | 57 | 57 | 43 | 69 | 64 | 56 | 37 | 47 | 55 | 0 | 52 |
| No core to first surgery | 71 | 100 | 54 | 101 | 39 | 0 | 0 | 69 | 97 | 0 | 76 |
2
1 for all open biopsies
Figure 10.11 and table 10.14 demonstrate the 2011 benign to malignant surgical ratios 1 : 10.9 (or 0.1 : 1) for women aged 50-69, indicating that overall for every one benign surgical outcome, there were 10.9 malignant outcomes. The important outcome is to find the greatest number of small cancers with minimum work-up, decreased wait times and decreased number of surgeries.
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 10.12 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 10.12 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 see table 5.1.
10mm and 15mm and in greatest diameter as determined by the best available evidence
25% 10mm and 50% 15mm
Of 3545 cancers of all ages detected from the start of the program, 2807 (79.2%) were invasive and of these, 10.9% were less than or equal to 5mm, 37.1% were 10mm or less and 64.7% were 15 mm or less (Figure 10.13). Of all invasive cancers in the target age group, 45% were stage 1 or better.
During this time 786 cases of DCIS and 34 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 2011, in the target age group, 218 cancers were detected. Of these, 169 (78% were invasive and of these, (12.2%) were 5mm or less, 40.4% were 10mm or less and 62.9% were 15mm or less (Figure 10.14. 62% were stage 1 or better.
During this time, 79 cases of DCIS were detected and there were 4 cases diagnosed as LCIS.
70% node negative
Since the beginning of the program 81% of all invasive cancers in the target age group were node negative (see figures 10.15 and 10.16).
In addition there have been 127 cases of DCIS with nodal excisions (125 with negative nodes and 2 with positive nodes). In 2011, there were 169 invasive cancers in the target age group of which 160 (95%) had lymph nodes excised. Of these 78% were node negative. In all age groups there were 281 lymph node dissections and of these, 17%, 26%, 39% and 18% were in the 40-49, 50-59, 60-69 and 70+ age groups respectively.
| B n= | M n= | |||
| Ratio | Rate | |||
| Benign : Malignant open biopsy ratio | 20 | 218 | 0.09 : 1 | |
| Benign : Malignant core biopsy ratio (atypical not included) | 398 | 227 | 1.75 : 1 | |
| Benign : Malignant core biopsy ratio (atypical included) | 417 | 227 | 1.84 : 1 | |
| Benign : Malignant core biopsy ratio (atypical and others included) | 464 | 227 | 2.04 : 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 | 14 | 215 | 0.07 : 1 | |
| Benign open biopsy rate per 1000 screens | 20 | 0.4 | ||
| Benign core biopsy rate per 1000 screens | 398 | 8.8 |
The graphs in figure 11.1 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:
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 11.2 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.
In 2013 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.
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.
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 2011 is also 1.1%.
Over the first 21 years of the program there have been 24 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:
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:
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.
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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 was recoded in preparation for the new information system to be used by the NSBSP.
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 Nova Scotia 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.
The NSBSP, together with the DHW and the 3 district operators, has proposed to move to a single, digital mobile screening unit for the entire province, effect January 2013. In moving to a single, digital mobile unit, every woman 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.
The mobile will be focused on providing service to areas that cannot easily access fixed site service. Criteria for mobile stop service include: Distance from a fixed site/other mobile stop(s), hard to reach populations, and utilization.
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.
In total, 30 stops will be part of the provincial, digital mobile route (see table 12.1 and figure 12.1).
The NSBSP now reports eight wait time indicators to the DHW and all DHAs: Screening Wait Time (Figure ); Screen to Work-up (Figure ); Screen to Report; Report to Work-up; Diagnostic Wait Time; Image to Core; Screen to Core; and Work-up to Core. A ninth indicator, Core to Surgery, will be reported as well, beginning in 2013.
The data elements within the NSBSP database makes it easy for these indicators to be calculated. The statistical values with wait times are median (i.e. the number of days 5 out of 10 women waited) and 90th percentile (i.e. the number of days 9 out of 10 women waited). The results are sent electronically every quarter to the Department of Health & Wellness and every breast imaging manager, radiologist and lead technologist in the province.
For more information on the provincial wait times initiative, please consult the government website (http://waittimes.novascotia.cahttp://waittimes.novascotia.ca).
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.
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.
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).
Using specialized mailing software the NSBSP is now able to apply the National Change of Address (NCOA) database to its postcard mailouts. This has drastically reduced the number of pieces returned to the program and, more importantly, insures more clients receive their reminder postcard.
In the redesign process, the NSBSP worked in collaboration with Canada Post to have the postcard designated as Addressed Admail. As a result of this designation the cost of postage for each postcard has been reduced approximately 33%. The cost savings from this has dramatically helped offset the cost of the new envelope inserter and postcard printer.
In 2004, the Department of Health approved a Provincial Program Model and accountability framework to guide the operations and governance of ``provincial programs''. The approved model identified three criteria for identification as a ``provincial program'':
The review resulted in the following direction regarding the NSBSP: NSBSP will have dual reporting to both the IWK Women's Health and the Department of Health and Wellness. Initial discussions between the NSBSP, DHW, IWK, and CDHA have started to begin the process of transitioning the governance.
An update on this governance restructuring will be provided in next year's annual report.
Looking toward having a means for all cancer screening programs to collaborate with each other, a Cancer Screening Working Group was established in 2012 to develop membership and Terms of Reference for a Screening Advisory Committee. It is anticipated that this advisory committee will be functional in 2013. The Terms of Reference and an update on its activities will be included in next year's annual report.
Quality assurance is an integral component of organized breast cancer screening programs in Canada. The Nova Scotia Breast Screening Program (NSBSP) requires double reading of every tenth screening mammogram. The double reads are performed blindly in real-time, with discrepant reads resolved by a third, blinded radiologist. The NSBSP is reconsidering criteria for selecting mammograms for double reading therefore Megan McInnis, a 4th year radiology resident working on her residency project under the direction of Dr Judy Caines and DR Jennifer Payne conducted a review of all double reads conducted at QE11 Health Science Center in Halifax from Jan 2001- Dec 2010. The objective of the project was to describe outcomes of the review process for screening mammograms selected for double-reading by age group, order of screen, and technology.
Analyses were conducted to identify the proportion of results that changed as a function of second and third reads. Analyses were carried out for the full sample, as well as by 10-year age group, order of screen (first, subsequent), and technology(analog, digital).
Of the 14927 mammograms included in the audit, 14767 (98.9%) were normal on first read. Of these, 14382 (97.4%) remained normal on second read. In contrast, of the 160 abnormals on first read, only 79(49.4%) remained abnormal on second read. A total of 464 (3.1%) triple reads were required. Triple read rates were highest for abnormal on first read, youngest age group, and first screen.
Megan's findings were presented at Radiology Research Day and were chosen to represent the Radiology Department at Faculty of Medicine Residents' Research Day. Megan also completed a poster for Capital District Health Authority (CDHA) Quality Week and her findings were also presented by Dr Sian Iles at the ICSN in Australia.
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 |
The NSBSPAC members shall be appointed by the Department of Health and Wellness. Each member will be expected to participate in the majority of the meetings and participate in working groups or committees as requested.
NSBSPAC members will be appointed starting January 2013.
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.
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.
It is not recommended to use ultrasound as a screening tool. It may be utilized:
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.
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
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