| NSBSP Administration Site and Central Mammography Booking | |
| 7001 Mumford Rd | |
| Unit 603L | |
| Halifax, Nova Scotia | |
| B3L 2H8 | |
| Toll Free: 1-800-565-0548 (Mobile van, fixed site and diagnostic mammography bookings) | |
| Halifax: 902-473-3960 (District 9 fixed sites and diagnostic mammography bookings) | |
| Fax: 902-473-3959 | |
| Toll-Free Fax: 1-866-470-3959 | |
| www.breastscreening.ns.ca | |
| NSBSP NAVIGATION | |
| Toll Free: 1-877-738-9898 | |
| Halifax: 902-473-3680 | |
| CENTRAL MAMMOGRAPHY BOOKING AFFILIATES | |
| District 1 | District 2 |
|---|---|
| South Shore Regional Hospital | Yarmouth Regional Hospital |
| 90 Glen Allen Dr | 60 Vancouver St |
| Bridgewater, NS | Yarmouth, NS |
| B4V 3S2 | B5A 2P3 |
| Tel: 902-527-5246 | Tel: 902-742-3541 |
| Fax: 902-543-9793 | Fax: 902-742-5320 |
| District 3 | District 4 |
| Valley Regional Hospital | Colchester Regional Hospital |
| 150 Exhibition St | 207 Willow St |
| Kentville, NS | Truro, NS |
| B4N 5E3 | B2N 5A1 |
| Tel: 902-678-7381 (2720) | Tel: 902-893-5554 |
| Fax: 902-678-0098 | Fax: 902-893-5534 |
| District 5 | District 6 |
| Cumberland Regional Health Care Complex | Aberdeen Hospital |
| 110 East Pleasant St | 835 East River Rd |
| Amherst, NS | New Glasgow N.S |
| B4H 1N6 | B2H 3S6 |
| Tel: 902-667-5400 (6155) | Tel: 902-752-7600 |
| Fax: 902-667-6307 | Fax: 902-755-2541 |
| District 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 | |
| MANAGEMENT TEAM | ||
| Medical Director | Dr. Judy Caines | |
| Program Manager | Theresa Foley | |
| Department of Health Advisors | Cheryl Doiron, Deputy Minister of Health | |
| Abram J. Almeda, Interim Executive Director, Acute & Tertiary Care | ||
| Rachelle O'Sullivan, Director, Acute & Tertiary Care | ||
| Sandra Cascadden, Chief Information Officer for Department of Health Promotion & Protection | ||
| Manager, PACS Operations & Applications | Rick Nickerson | |
| Consultant Epidemiologist | Dr. Jennifer Payne, Dept of Radiology, Dalhousie University | |
| Consultant Statistician | Prof. Mohamed Abdolell, Diagnostic Radiology, Dalhousie University | |
| Chief Medical Physicist | Dr. Cupido Daniels | |
| OPERATIONS TEAM | ||
| Program Secretary | Joanne Fraser | |
| Promotion and Navigation | Sarah McCarthy | |
| Susan MacNeil | ||
| Marian Brine | ||
| Crystal Hilton | ||
| Data Management | Theresa Foley | |
| PACS Specialist MIS/DRS | Robert MacDonald | |
| Heather Caseley | ||
| Radiologists | QEII HSC | Dr. Judy Caines |
| (Halifax) | Dr. A.J. Johnson | |
| Dr. Gerald Schaller | ||
| Dr. Gordon Jones | ||
| Dr. Joy Borgaonkar | ||
| Dr. Robinette Butt | ||
| Dr. Lori McDonald | ||
| Dr. Peter Brown | ||
| CBHCC | Dr. Sian Iles | |
| (Sydney) | Dr. John Chadwick | |
| Dr. Anne Latour | ||
| YRH | Dr. Eric Woods | |
| (Yarmouth) | Dr. Matthew Brookes | |
| CRH | Dr. Nancy McNeil | |
| (Truro and | Dr. John McNeil | |
| Amherst) | Dr. Dave Gordon | |
| DGH | Dr. Andrew Ingham | |
| (Dartmouth) | Dr. Carla Pittman | |
| Dr. Kim Colter | ||
| Dr. Susan Delaney | ||
| SSR | Dr. Peter Jeffrey | |
| Dr. Arthur Marshall | ||
| Dr. C.L. Church | ||
| Dr. Chen Meng | ||
| VRH | Dr. Michael Dunn | |
| Dr. David Acton | ||
| Dr. John Bilo | ||
| Dr. Maureen Madigan | ||
| AH | Dr. Dan Hoffman | |
| Dr. Ronald MacEachern | ||
| Dr. Magdalena Biernacka | ||
| St. MH | Dr. Brian Nicholson | |
| Dr. Mike Silver | ||
| Dr. Blair 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 | Peter Lush | |
| STMH | Jodi Myles | |
The Nova Scotia Department of Health established and funded the NSBSP as a provincial program in 1991. All ten provinces and two territories now have breast screening programs. Evidence from randomized controlled projects has demonstrated that organized breast screening mammography maximizes the early detection of breast cancer.
On June 
2008 the Nova Scotia Breast Screening Program (NSBSP) celebrated the 
year of providing an outcome driven, client oriented program to women in Nova Scotia. As of December 31, 2008 570214 screens have been performed on 159010 women finding 2534 cancers. Cancer detection rates for this period can be seen in table 3.1
NSBSP offers modified clinical breast examinations and breast health information at all sites. Currently there are fourteen screening sites and ten diagnostic sites booking procedures and contributing real-time data through the provincial Central Mammography Booking Database (CMB).
Central Mammography Booking (CMB) in both screening and diagnostic mammography is present in all sites across Nova Scotia. CMB had initially decreased wait times in all diagnostic sites dramatically; however screen wait times have since increased, predominantly due to decreased capacity. To increase capacity and provide a standardized approach to breast imaging, the NSBSP, with the support of the Nova Scotia Department of Health, has moved forward with a planned approach toward complete provincial Full Field Digital Mammography (FFDM) in both the screening and diagnostic sector.
Presently five FFDM sites, 9 units, are operational. The first FFDM mobile in Canada opened in Cape Breton (District 8) in July, 2007. This was followed by a fixed FFDM unit in the Cobequid Community Health Center (District 9) and a combined diagnostic and screening site at Yarmouth Regional Hospital (District 2). Included in the FFDM approach is the implementation of the diagnostic mammography reporting system throughout the province. In the spring of 2008 five additional FFDM units were installed across the province: Two at the QEII, one at the Halifax Clinic, Halifax Shopping Centre, one at the Valley Regional Hospital and one in Sydney at CB Regional Hospital.
One main goal of the NSBSP is to standardize the mammography process throughout the entire province. ``Lack of full organization may result in sub-optimal program operation, performance and resource efficiency.'' Progress in Cancer Control: Screening: Canadian Cancer Society/National Cancer Institute of Canada: Canadian Cancer Statistics 2006.
There are still many challenges for the Nova Scotia Breast Screening Program which include:
The Nova Scotia Breast Screening Program's goal is to reduce the mortality from breast cancer in Nova Scotia women aged 50-69 years of age by 30% within ten years following development of a province wide screening program. As of 2008 there is now a provincewide program. All mammography in the province is being done under the umbrella of the NSBSP.
The Nova Scotia Breast Screening Program's vision is to provide quality standardized mammography access with timely assessment, informed patient navigation and appropriate follow-up of women who have abnormal mammograms on screening, through diagnostic work-ups in accredited work-up centers, before consideration of surgical alternatives.
The NSBSP works closely with other provincial and national committees and organizations in the fulfillment of its mandate. These include:
The program enjoys close ties with all DHA coordinators and is well-networked into other provincial programs. The NSBSP adheres to all of the current provincial program mandates.
| Cancer Detection Rate per 1000 Screens | Cancer Detection Rate per 1000 Women | ||||||
| 1991-2006 | 1991-2007 | 1991-2008 | 1991-2006 | 1991-2007 | 1991-2008 | ||
| 433830 | 496569 | 570214 | 133940 | 146590 | 159010 | ||
| Age | |||||||
| <50 | 2.3 | 2.2 | 2.3 | 5.6 | 5.6 | 6 | |
| 50-59 | 4.2 | 4.1 | 4.1 | 15.3 | 15.7 | 16.7 | |
| 60-69 | 6.2 | 6.2 | 6.2 | 26.6 | 28.3 | 30.9 | |
| 70+ | 9.8 | 9.7 | 9.6 | 40.7 | 43.4 | 47.1 | |
| Screening Sites (13) | Participation date | |
| Mobiles (3) | Mobile 1 (Cape Breton) | Sept 1994 |
| Mobile 2 (Western) | July 1997 | |
| Mobile 3 (Northern) | Jun 2003 | |
| Mobile 4 (Replacing Mobile 1) | July 2007 | |
| Fixed (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 | |
Within the Acute and Tertiary Care Branch the following provincial programs are currently funded by the Department of Health: Cancer Care Nova Scotia, Nova Scotia Diabetes Care Program, Reproductive Care Program, Nova Scotia Breast Screening Program, 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:
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.
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.
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.
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. This review process is now in the implementation stage. For purposes of uniformity and quality performance execution, one successful bid for all equipment was identified, and equipment purchases have begun. A provincial mammography equipment committee (PMEC) for implementation of FFDM has been established.
Although a number of new technologies are on the horizon, they are unlikely to replace mammography in the near future for screening the general population. Mammography remains the only breast cancer screening tool proven to reduce mortality from breast cancer in the population. Public Health Agency of Canada, 2006.
As the mandate for the Provincial Mammography Equipment Committee (PMEC) has been fullfilled this committee was replaced with an advisory committee in 2009.
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 2008, it is reported that there will be an estimated 22,400 new cases of female breast cancer and 5,300 deaths in Canada. In Nova Scotia for 2008, it is estimated that there will be 690 new cases of breast cancer and 190 deaths. Breast cancer is the most common cancer and most common cause of death among females aged 20-49, accounting for 40% of cancer diagnoses and 25% of cancer deaths. Cancer Institute of Canada: Canadian Cancer Statistics, 2008.
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, 52% between ages 50 and 69 and 20% under age 50. Presently 1.0% of females are survivors of breast cancer diagnosed within the previous 15 years. Canadian Cancer Society/National Cancer Institute of Canada: Canadian Cancer Statistics, 2008.
For 2008 estimated age standardized incidence rates for breast cancer in Nova Scotia are 101/100,000 with an estimated 690 new cases. In 2003, actual data reported 590 new cases for an actual age-standardized incident rate of 92/100,000 third lowest among all Canadian provinces. Incidence is increasing due to the implementation of breast screening programs and greatly improved methods of data collection both of which NSBSP has as been active in developing and promoting.
The estimated age standardized mortality rate for Nova Scotia for 2008 is now the third highest in Canada at 25/100,000 based on 190 estimated deaths. Actual data for the age standardized mortality rate for breast cancer in Nova Scotia for the year 2002 was 25/100,000, a decrease from the actual rate of 26/100,000 in 2001. There were 170 deaths recorded in Nova Scotia in both 2001 and 2002.
In Canada in 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% (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
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 2008, 4 women were classified as ``Lost to follow-up'', and 10 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 60 women ``Lost to Follow-up'' and 51 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.
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 2005, 2006, 2007 and 2008 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.
, 2) radiological, 3) clinical (Section 9.2.9)
(> 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 9.1 presents both the national provincial performance indicators.
70% of the target population
The NSBSP participation rate for the biennial timeframe of 2007 and 2008 was 53.37% of the targeted age population in Nova Scotia.
Over one year there was a biennial participation rate change of 5.34%, with an actual change of 10% in women screened. For the same time-frame the number of screens increased by 10%, compared to a 9% increase one year ago. The actual number of women screen has increased from 57046 to 63386 in the past year. The low participation rate of 36.72%, seen in DHA 7 (Guysborough/Antigonish) reflects the lack of database information from this site which began booking mammography through Central Booking and submitting data to the province in October 2008. This is not an accurate representation of the breast screening participation rate in this district.
Minimal changes can be seen in the Capital Health District (DHA 9) and Cape Breton (DHA 8), both requiring much needed additional capacity in mammography services.
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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 2007, 10.2% of women screened were over age 69. This remained constant at 10.2% in 2008. In 1997, 4% of NSBSP's clientele were over the age of 69. Following policy change in 1998 to accept these women into the program (but not send them reminder letters) these figures have been watched carefully for the resulting affect on program capacity, as it increasingly affects available bookings for the target age group of 50-69. However, many in this group had started with the program when in the target age group and if still asymptomatic, should not need to have examinations in and tie up the diagnostic system. After age 70, screening mammography is recommended if a women's life expectancy is anticipated to be ten years.
In the initial six months of the program the policy to not accept the 40-49s was clearly not enforced and 20% of women attending were in this age group. However, physicians and women in their 40s lobbied strongly in an effort for them to officially become part of the program. Following a relatively high cancer detection rate and a high number of node positive cases seen in this group in 1992, it was decided to change policy and accept these women in order to provide organized outcomes for this younger group for whom surveillance and monitoring should also occur. If this had not been done, they also would have continued to have screening mammography in the diagnostic mode, resulting in unnecessary appointments in the diagnostic sector and no tracking of outcomes. In 1995, it officially became policy to send recall letters to these younger women using the annual screen protocol.
In 2008, 33.4% of NSBSP participants were aged 40-49.
The commitment of the Nova Scotia Department of Health to the Nova Scotia Breast Screening Program has resulted in linear increases in participation rates. Support given by the Department of Health toward provision of a truly comprehensive, provincial mammography program continues to be apparent. Increases in 2004/2005 mainly represent the addition of the screening program from Bridgewater and additional NSBSP screening appointments from the fixed site at the Yarmouth Regional Hospital. For the two year period of 2007and 2008, there were 63386 (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.
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Table 9.4 contains in addition to data in Table 9.3, diagnostic data from facilities now booking diagnostic mammography using the Central Mammography Booking Database. The data presented in Table 9.4 shows 71652 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 60.33% a change of 6% over 2007.
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 C
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 2008 is 54.02% (49.46% 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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| Diagnostic | Target | Biennial | Biennial | Combined | Combined | Combined |
| Mammography | Population | Diagnostic | Screens Plus | Participation | Participation | Participation |
| Facilities | Mammograms | Biennial | Rates | Rates | Rates | |
| by DHA | 2007-2008 | Diagnostics | 2005+2006 | 2006+2007 | 2007+2008 | |
| 2007+2008 | Per DHA | Per DHA | Per DHA | |||
| Unknown | - | 6556 | 283 | |||
| 1 South Shore Regional | 13805 | 117 | 7139 | 38.8% | 45.5% | 51.7% |
| 2 Yarmouth Regional | 13235 | 78 | 6971 | 49.9% | 51.4% | 52.7% |
| 3 Valley Regional | 17805 | 70 | 8590 | 36.6% | 45.7% | 48.2% |
| 4 Colchester Regional | 14839 | 265 | 8097 | 47% | 49.5% | 54.6% |
| 5 Cumberland Regional | 7155 | 32 | 3513 | 44% | 46.9% | 49.1% |
| 6 Aberdeen | 10240 | 26 | 4747 | 10.2% | 27.4% | 46.4% |
| 7 St. Martha's | 9920 | 80 | 3321 | 27.5% | 28.6% | 33.5% |
| 8 Cape Breton Health Care | 28610 | 2187 | 14242 | 43.7% | 45.4% | 49.8% |
| 9 QEII HSC and DGH | 82006 | 6734 | 49850 | 47.9% | 53.4% | 60.8% |
| Total | 197615 | 16145 | 106753 | 50.39% | 49.46% | 54.02% |
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 2008, 2168 screens in the target age group were reported as abnormal (Table 9.7). Abnormal reporting rates were 5.2% overall (11.1% for 1
screens and 4.4% for re-screens). An additional 38 cases (Table 9.8) were reported based on clinical findings categorized as Physical Findings Not Seen or ``PFNS''. This compares 35 a year ago and 44 in 2006. 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.
| Screens | n | Abnormal | Abnormal | Cancers | Cancer detection |
| Reports | Call Rate | Rate/1000 | |||
| (%) | Screens | ||||
| 1st | 4750 | 531 | 11.1 | 48 | 10.1 |
| Re-Screen | 37031 | 1637 | 4.4 | 163 | 4.4 |
| All | 41781 | 2168 | 5.2 | 211 | 5.1 |
| Screens | n | PFNS | PFNS | Cancers | Cancer detection |
| Reports | Call Rate | Rate/1000 | |||
| (%) | Screens | ||||
| 1st | 4750 | 3 | 0.06 | 0 | 0 |
| Re-screen | 37031 | 35 | 0.09 | 0 | 0 |
| All | 41781 | 38 | 0.09 | 0 | 0 |
| 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 | 1755 | 41.19% | 2.38% | 659 | 47.41% | 5.31% | ||
| Work-up mammograms | 3988 | 93.59% | 5.42% | 1291 | 92.88% | 10.39% | ||
| Core Biopsies | 1339 | 31.42% | 1.82% | 516 | 37.12% | 4.15% | ||
| MRI | 19 | 0.45% | 0.03% | 4 | 0.29% | 0.03% | ||
| Women to surgery | 438 | 10.28% | 0.59% | 117 | 8.42% | 0.94% | ||
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| Core Biopsy and Definitive Surgery Outcome | 1991-2008 | 2005 | 2006 | 2007 | 2008 |
| Malignant cores benign at surgery | 23 | 2 | 4 | 3 | 1 |
| Malignant cores atypical or benign at surgery | 10 | 0 | 0 | 3 | 0 |
| Malignant cores malignant at surgery | 2219 | 222 | 228 | 230 | 311 |
| Malignant cores - no definitive surgery | 65 | 7 | 10 | 9 | 13 |
| Benign cores benign at surgery | 362 | 27 | 45 | 31 | 47 |
| Benign cores atypical or suspicious at surgery | 49 | 4 | 9 | 7 | 6 |
| Benign cores malignant at surgery | 111 | 14 | 11 | 11 | 15 |
| Benign cores - no definitive surgery | 6070 | 606 | 676 | 791 | 844 |
| Atypical or suspicious cores benign at surgery | 111 | 2 | 9 | 20 | 16 |
| Atypical or suspicious cores atypical or suspicious at surgery | 143 | 10 | 12 | 14 | 15 |
| Atypical or suspicious cores malignant at surgery | 183 | 10 | 16 | 23 | 27 |
| Atypical or suspicious cores - no definitive surgery | 58 | 4 | 8 | 8 | 11 |
| Unsatisfactory or others | 670 | 52 | 81 | 107 | 134 |
There were 9091 women having 10096 core biopsies (by screen exam date) through NSBSP from 1991 until 2008 (913 women had more than one core biopsy at different times or bilaterally). Of the 1445 core biopsies performed in 2008, 192 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.
screen 
5 per 1000 screens Re-screen 
3 per 1000 screens
There were 273 cases of invasive breast cancer detected in 2008. Shown in ten year age groups above, 170, (62)% of these were in the 50-69 age group for a cancer detection rate overall of 3.7 per 1,000 screens. Nova Scotia is higher than national targets of more than 5 per 1,000 (7.4) for first screens and higher than the 3 per 1,000 for re-screens (3.6). It may well be that with the screening program now in place, the invasive cancer rates will continue to fall as more high risk lesions are picked up in the screened population at a pre-cancerous or early stage (DCIS and atypical). The rate of invasive breast cancer increases by age group for both initial screens and re-screens. Also, many of the first time program screens have had previous mammograms in the diagnostic sector.
There were 69 cases of In Situ cancer detected in 2008. Of these, 40, (58%) 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 2008, there were 3 cases of LCIS, 2 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 2008, the NSBSP overall (i.e, for all age-groups) ``Diagnostic Interval'' shows 65.1% of abnormal screens having had no tissue biopsy, are at case completion after five weeks from screening. This is lower than the 74.3% overall nationally in 2003 and 2004. (Table 9.1).
In NSBSP in 2008 the overall (i.e, for all age-groups) Diagnostic Interval for women having had a tissue biopsy was 16.1%
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.
| Target: | 1 screens |
 5% of abnormal screens are cancer |
| Re-screen |  6% of abnormal screens are cancer
|
Figure 9.9 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 9.10).
One international publication has stated that Positive Predictive Values (PPVs) for initial mammograms were as high as 37.5% in the Netherlands where corresponding recall was 1.4%, and as low as 5% in the United States where the corresponding recall was 15%. Cancer detection rates did not closely follow the pattern of recall rates. These differences may be influenced by factors including prevalence of cancer in the screening population, radiologist training, quality of the mammograms and fear of malpractice and legal outcomes. Report from the International Breast Cancer Screening Network (IBSN), Draft Paper 24 September 2003.
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 | 5480 | 5099 | 6466 | 5601 | 2631 | 3687 | 2449 | 9241 | 32824 | 157 | 73645 |
| Surgical Procedures | 32 | 35 | 47 | 44 | 17 | 38 | 9 | 62 | 242 | 1 | 527 |
| Women to Surgery | 26 | 29 | 36 | 37 | 15 | 34 | 9 | 52 | 199 | 1 | 438 |
| B : M Ratio | 1:0.8 | 1:6.2 | 1:17 | 1:2.1 | 1:14 | 1:3.2 | 1:7 | 1:14.7 | 1:6.1 | 1:0 | 1:4.8 |
| Cancer Det Rate | 2 | 4.9 | 5.3 | 4.5 | 5.3 | 7.1 | 2.9 | 4.8 | 4.8 | 0 | 4.7 |
| DHA | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | Unkn | All |
| Screen to first core biopsy(benign) | 71 | 78 | 62 | 51 | 59 | 43 | 33 | 55 | 45 | 53 | 51 |
| Screen to first core biopsy(cancer) | 62 | 62 | 62 | 39 | 59 | 38 | 39 | 51 | 38 | 0 | 45 |
| Cancer core to first surgery | 98 | 103 | 101 | 90 | 96 | 74 | 81 | 92 | 88 | 0 | 90 |
| Benign core to first surgery | 110 | 239 | 218 | 114 | 127 | 109 | 134 | 108 | 140 | 0 | 135 |
| First core to first surgery (if multiple cores) | 53 | 53 | 46 | 54 | 38 | 38 | 58 | 46 | 54 | 143 | 51 |
| No core to first surgery | 90 | 85 | 82 | 94 | 118 | 42 | 43 | 197 | 100 | 0 | 87 |
2
1 for all open biopsies
Figure 9.11 and table 9.14 demonstrate the 2008 benign to malignant surgical ratios 1 : 5.4 (or 0.2 : 1) for women aged 50-69, indicating that overall for every one benign surgical outcome, there were 5.4 malignant outcomes. This indicator has the potential to be more significant in the future as all diagnostic facilities have now joined 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.
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.
10mm and 
15mm and in greatest diameter as determined by the best available evidence
25% 
10mm and 
50% 
15mm
Of 2534 cancers of all ages detected from the start of the program, 1992 (78.6%) were invasive and of these, 8.7% were less than or equal to 5mm, 35.8% were 10mm or less and 63.7% were 15 mm or less (Figure 9.13). Of all invasive cancers in the target age group, 74% were stage 1 or better.
During this time 563 cases of DCIS and 19 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 2008, in the target age group, 211 cancers were detected. Of these, 170 (81% were invasive and of these, (9.8%) were 5mm or less, 32.9% were 10mm or less and 60.4% were 15mm or less (Figure ![[*]](/usr/share/latex2html/icons/crossref.png){kind=icon}
. 62% were stage 1 or better.
During this time, 73 cases of DCIS were detected and there were 3 cases diagnosed as LCIS.
70% node negative
Since the beginning of the program 79% of all invasive cancers in the target age group were node negative (see figures 9.15 and 9.16).
In addition there have been 80 cases of DCIS with nodal excisions (77 with negative nodes and 3 with positive nodes). In 2008, there were 170 invasive cancers in the target age group of which 165 (97%) had lymph nodes excised. Of these 78% were node negative. In all age groups there were 276 lymph node dissections and of these, 18%, 28%, 34% and 19% 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 | 39 | 211 | 0.18 : 1 | |
| Benign : Malignant core biopsy ratio (atypical not included) | 497 | 205 | 2.42 : 1 | |
| Benign : Malignant core biopsy ratio (atypical included) | 535 | 205 | 2.61 : 1 | |
| Benign : Malignant core biopsy ratio (atypical and others included) | 605 | 205 | 2.95 : 1 | |
| Benign : Malignant open biopsy ratio - direct to open biopsy (no core) | 6 | 5 | 1.2 : 1 | |
| Benign : Malignant open biopsy ratio - after core biopsy | 33 | 206 | 0.16 : 1 | |
| Benign open biopsy rate per 1000 screens | 39 | 0.9 | ||
| Benign core biopsy rate per 1000 screens | 497 | 11.9 |
At the Queen Elizabeth II Health Sciences Centre, the largest diagnostic mammography centre in Nova Scotia, synoptic reporting for breast imaging has been utilized for over 15 years. It has since been expanded to include Cape Breton Regional Hospital, Dartmouth General Hospital, South Shore Regional Hospital, Aberdeen Hospital and Yarmouth Regional Hospital. Completion of the rollout of this reporting system is anticipated by the end of 2009.
A synoptic report contains a summary of essential information in a checklist format and utilizes standard language, descriptions and classification system. Synoptic reporting distills reports that can often be subjective, wordy, obscure, and difficult to interpret into reports that are clear, consistent and easy to understand. Synoptic reporting may improve the content and completeness of reports, reduce the risk of misinterpretation of findings, improve communication between referring clinicians and radiologists, and facilitate the transfer of information to databases for quality improvement activities and audit.
A breast imaging synoptic report helps clinicians and patients by assisting in tracking individual lesions, ensuring the inclusion of mammographic and ultrasound characteristics of lesions, offering one classification per lesion and a combined imaging diagnosis. As patient information is captured in the database, there is increased confidence that no one will fall through the cracks of the health care system since patients are captured, placed on a "to do" list for synoptic reporting, and held until their case is resolved.
The goals of synoptic reporting for breast imaging within the Nova Scotia Breast Screening Program are to: a) be as comprehensive as possible in the range of circumstances for which a computer generated report is possible; b) include all the relevant and necessary descriptors and parameters in every report; and, c) be as user-friendly as possible. A corollary goal is to maximize data capture by keeping typed and dictated notes to a minimum.
The Diagnostic Reporting System (DRS) attempts to address these issues by enforcing a common, terse format with clear, concise findings, impressions and recommendations. Dictated and typed notes, addenda and reports cannot be tracked by the DRS and are essentially excluded from the database. When there is the need to expand or clarify a point, the DRS provides a typed note block that will accept up to 250 characters.
Time, or lack thereof, in today's health care climate requires such clarity to enable clinicians to quickly read, understand and deal with reports that require additional action for their patients. Patients also benefit from synoptic reporting as clarity and consistency enables further testing to occur promptly.
There is a learning curve with synoptic reporting and many of the questions and observations stem from a lack of familiarity with it and its versatility, a familiarity that can only be achieved by frequent and committed use. Reporting with synoptic reporting is quite a different experience when compared to a dictated narrative. The user is forced to be much more concise and definite.
Currently, 80% of all breast imaging in Nova Scotia is reported using synoptic reporting. By the end of 2009, all breast imaging in the province will be reported in a single database using synoptic reporting.
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.
| Hospital | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 |
| Halifax CLinic | 15 | 17 | 27 | 35 | 38 | 33 | 22 |
| DGH | 25 | 23 | 34 | 43 | 44 | 48 | 26 |
| Truro | 7 | 10 | 18 | 18 | 17 | 26 | 18 |
| Yarmouth | 32 | 30 | 8 | 18 | 8 | 0.4 | |
| Amherst | 7 | 11 | 3 | 6 | 3 | 0.2 | |
| Bridgewater | 39 | 29 | 28 | 23 | 7 | ||
| Kentville | 8 | 13 | 12 | 5 | |||
| New Glasgow | 27 | 37 | 18 | ||||
| Cobequid | 12 | 10 | |||||
| Antigonish | 10 |
| Hospital | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 |
| QE2 | 24 | 8 | 3 | 1 | 0.5 | 0.5 | 0.4 | 4 | 11 | 3 |
| CB | 12 | 2 | 1 | 1.5 | 3 | 2 | 3 | 4 | ||
| DGH | 16 | 2 | 1 | 40 | 3 | 13 | 15 | 2 | ||
| CRHCC | 12 | 1 | 1 | 0.4 | 1 | 5 | 4 | 0.5 | ||
| YRH | 16 | 12 | 12 | 0.3 | 0.3 | 4 | 1.5 | 1 | ||
| SSH | 16 | 12 | 0.3 | 0.3 | 4 | 0.5 | ||||
| CCHHC | 4 | 1 | 1 | 4 | 1 | |||||
| VRH | 4 | 1 | 4 | 2 | 2 | |||||
| AH | 2 | 1 | 0.5 | |||||||
| St. MH | 0.5 |
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 2008 is also 1.1%.
Over the first 18 years of the program there have been 23 malignant core biopsies for which the corresponding surgical outcomes were benign, resulting in a false positive rate of 0.2%. The false-positive core biopsy outcome per woman is 0.3%. Atypical/suspicious and benign open surgical results are included when calculating the false positive rate.
For both stereotactic and ultrasound core biopsy to be successful there needs to be a validation process and team management.
Cancer has a significant economic impact in Canada as measured by direct and indirect costs. Direct costs refer to the value of goods and services for which payment was made and resources used in treatment, care and rehabilitation directly related to illness or injury. Indirect costs are defined as the value of economic output lost because of illness, injury-related work disability or premature death (National Cancer Institute of Canada: Canadian Cancer Statistics 2004). In 1998, in Canada, $2.5 billion were direct costs with hospital care costing $1.8 billion and representing 74% of this amount. Physician services to treat cancer cost $333 million, or 14% of direct costs. Approximately $210 million or 9% of direct cancer costs were spent on drugs for cancer treatment. The indirect cost was $11.8 billion. Economic Burden of Illness in Canada, Health Canada 2002. Although the figures above represent costs for all cancers and for all Canadian provinces, the core biopsy program in Nova Scotia has made positive impacts on reducing wait times, hospital stays and physician services. It has made a huge impact in greatly decreasing benign breast surgeries.
Published works of the Nova Scotia Breast Screening Program include:
The Pink Rose Program is a component of the Nova Scotia Breast Screening Program
and is a system of information and guided support developed to aid the patient
diagnosed with breast cancer. It also provides information and assistance to family,
friends and physicians involved. It is confidential and comprehensive and enables
information and support to be initiated with a positive diagnosis of breast cancer.
The Pink Rose was started in 1994 as a result of a registered medical technologist,
Dianna Schreuer, being diagnosed with breast cancer for the first time in 1989 at age
43 and again in 1994. Through personal experience, she became aware of just how little
information and support there was for a newly diagnosed patient.
Dr. Judy Caines, Medical Director of the Nova Scotia Breast Screening Program, together with Dianna Schreuer developed a pilot program for providing information to women newly diagnosed with breast cancer.
The Pink Rose now rests comfortably under the umbrella of the Nova Scotia Breast
Screening Program. The book, The Intelligent Patient Guide to Breast Cancer (now Edition 4), by Dr. Ivo Olivotto, is provided to all women newly diagnosed with breast cancer in Nova Scotia, funded by the Canadian Breast Cancer Foundation (Atlantic Region)
This ``process'' has since been replicated in many other jurisdictions throughout the country.
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. 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:
In 2005 the NSBSP partnered with the Office of Public Health Practice of the Public Health Agency of Canada to explore Geographic Information Systems (GIS) as a tool to map access to and use of screening services. The excitement that came as a result of this partnership spawned three projects using GIS. The first project began as a Community Health Grant Application submitted to the Canadian Breast Cancer Foundation - Atlantic Chapter by Dr. Jennifer Payne on behalf of the NSBSP. The grant request was successful and the year-long project began in May 2007; the goal of this project was to explore the use of Geographic Information Systems (GIS) to describe service provision by the NSBSP, with emphasis being placed on exploring equity in access to services. The GIS work was carried out in collaboration with the GIS Centre at Dalhousie University. The results of this project will be used to help inform and develop criteria for planning how the fixed sites and mobile units work together to ensure equitable service delivery. It is the intent of the NSBSP to use the resultant maps and findings of this project to engage all stakeholders in discussions around service provision and the role of the mobile units. The research assistant on this project (Stephanie Lea) will also derive her thesis as a Master of Applied Health Services Research student at Dalhousie University from this work.
The second project that arose was a collaboration between the NSBSP and a Centre of Geographic Sciences student in the GIS for Business Advanced Diploma Program, Faye Welsh, on a project using Geographic Information Systems (GIS) to analyze the accessibility to breast screening services in Nova Scotia. In her study, Faye used data from the 2004-2006 time periods in which there were eight fixed sites and three mobile vans providing screening services (for some of the maps she included the 2 additional fixed clinics that came on-line in 2007). Using GIS, many multilayered maps were created such as figure 11.2 which shows the location of fixed screening sites, Nova Scotia road networks and the percentage of women in the target population by census division.
In her project Faye used different analysis techniques to determine access to services by looking at fixed and mobile site locations, driving distances to screening sites, distribution of the target population across the province, along with the volume of visits to each site. Faye also used location-allocation analysis to determine how to optimally allocate women to a fixed site based on where they live and driving time. This approach could be used to define catchment areas for the fixed sites, which would then begin the discussions around how best to use the mobile services to support the fixed sites. This is the concept used to inform the third GIS project.
The third project, which was completed in May 2009, was another collaboration between the NSBSP and the Centre of Geographic Sciences, GIS for Business Advanced Diploma Program. The student, David Crawford, did his project on the spatial optimization of a mobile breast screening unit for Nova Scotia. In his project David analyzed the current provision of screening services via the 11 fixed sites along with the need for breast screening services across the province (derived from census data). He used this information to create service (catchment) areas for each of the fixed sites. He then created an optimal province-wide tour for a mobile screening van to provide screening to women who are not able to be serviced by one of the fixed facilities (Figure 11.3).
The three projects and early GIS mapping efforts have been very promising and this tool looks to have real value for describing service provision by the NSBSP; it is also exciting to note that this is the only breast screening program in Canada currently using GIS to evaluate service delivery.
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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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, Ms. Theresa Foley and Stephanie Lea. 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. Dr. Penny Barnes presented the pathology findings at the United States and Canadian Academy of Pathology (USCAP). The analysis of the differences in clinical outcomes between the interval and screen-detected cancers is now complete and was presented as a poster at the American Society for Clinical Oncology meeting in May and a manuscript has been submitted for consideration to the journal Lancet.
Effective in October 2006, guidelines for pap testing in Nova Scotia has changed. The new brochures reflecting these changes have been distributed to all NSBSP site co-ordinators to update NSBSP staff and for distribution. These brochures are available from The Cervical Cancer Prevention Program at 902-473-7438. Following are the guidelines as stated in the brochure:
When should you have a Pap Test?
In 2008-2009, two Dalhousie University industrial engineering students, Eric Giacomin and Jennipher Langille, under the direction of Dr. John Blake, project faculty advisor, undertook a project of looking at the call volume at Central Booking at the NSBSP.
In December 2000, the NSBSP began to book all mammography appointments in the Central Mammography Booking database for sites affiliated with the NSBSP. As of October 1, 2008 all mammography for the province is now centrally booked. Screening appointments are booked when the woman, asymptomatic, call the 1-800 # to book at a site of their choice. All appointments with the NSBSP are handled by central booking. Each day there are between 4-8 booking clerks scheduled for the phones. History has shown that certain times, certain days and certain months are busier than others: Mondays and Tuesdays tend to be busier than the rest of the week, and the month of October has shown itself to be busier, as it is breast awareness month. As well some sites book sooner than others, particularly for mobile visits. The number of incoming calls as well as the number of abandoned calls is recorded daily; logs are sent from Aliant with this information along with weekly and monthly logs per booking clerk.
Central booking accepts calls from 8:00 AM until 5:00 PM, Monday through Friday, with the exception of holidays. Over the last nine years, the number of participants, and thus the call volume, has increased. Determining a staff schedule for call representatives to meet the increased demand is problematic. Calls that cannot be answered immediately accumulate in a queue, producing long wait times and in turn, an increased likelihood of abandonment. The current schedule was determined from the program manager's past experience. The NSBSP has requested a tool that would accurately predict call volumes and determine how many representatives should be scheduled.
The final product was presented to the NSBSP in the form of a Microsoft Excel workbook. It contains the forecast data and queueing model to determine the number of representatives on a given day. The forecast will adjust to actual monthly call volumes, as they are entered into the workbook to keep seasonal factors and trends accurate.
The forecast and queueing model provides a strong foundation for scheduling representatives. The deliverable allows the program manager to create schedules and potentially reduce the wait time in the queue and the number of abandoned calls.
As accurate as a model can be, it cannot predict the future. There will be days when the average wait is above the time specified, however, procedures at the NSBSP which allow for an increase in call capacity for a period of time will no doubt be beneficial in managing fluctuations in the call volume.
Based on the information received from this project the schedules of the booking clerks has been modified with the result of a significant reduction in abandoned calls.
The graphs in figure 11.5 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:
| 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 FFDM 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 | ||
| 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 | ||
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.
| Brenda Payne (Chair) | Executive Director, Acute & Tertiary Care |
| Rachelle O'Sullivan | Director, Acute & Tertiary Care |
| Lynn Kilroy & Company Director | IT Services, Department of Health |
| IT Representative request through Mark LeBlanc | HITS NS |
| Dr. Gerry Schaller | Radiologist, DHA 9 |
| Dr. Cupid Daniels | Medical Physicist, DHA 9 |
| Dr. Judy Caines | Director, NSBSP |
| Theresa Foley | Manager, NSBSP |
| Mike Pothier | Director of Clinical Support, 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 |
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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