Certifications and training for mammography screening services and professionals in Norway

Transcription

1 Certifications and training for mammography screening services and professionals in Norway Solveig Hofvind Cancer Registry of Norway Thursday May 31, 2018, 15:40-16:00 Rome, Italy

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3 Health costs per inhabitants, selected OECD countries, 2013 (*2012) purchase adjusted USD purchase adjusted USD Governmental costs Private costs

4 BreastScreen Norway Started as a pilot in 1995 Nationwide in years of organized breast cancer screening in Norway

5 The Norwegian Breast Cancer Screening Program BreastScreen Norway Administered by the Cancer Registry of Norway

6 The Cancer Registry of Norway Established in 1953 Mandatory by law to notify new cancer cases to the CRN (MD, hospitals and labs) Cancer information comes from several independent sources Annually notifications related to cancer illness of these, almost new cancer cases Cancer incidence annual report National quality register for breast cancer

7 The Cancer Registry of Norway Established in 1953 Mandatory by law to notify new cancer cases to the CRN (MD, hospitals and labs) Cancer information comes from several independent sources Annually notifications related to cancer illness of these, almost new cancer cases Cancer incidence annual report National quality register for breast cancer About 160 persons employed Administration Registry IT Research Screening (breast cancer = 9 employees) Screening Breast Cancer Screening Program Cervical Cancer Screening Program Pilot: Colorectal cancer screening

8 BreastScreen Norway Administered by the Cancer Registry of Norway Steering group, Advisory board and professional groups

9 BreastScreen Norway Steering group headed by the Health Directorate Advisory board advices to the CRN Professional groups Radiology Pathology Radiography Medical Physicists Epidemiologists (will be established in 2018) Structure and strategy for national screening programs in Norway Guidelines for diagnostics, treatment and follow-up

10 BreastScreen Norway Screening unit at Danmarksplass, Bergen Administered by the Cancer Registry of Norway Steering group, Advisory board and professional groups Targets women aged 50-69, invited every two years Own fee for screening: 25 Euro Independent double reading with consensus/arbitation Screening and recall assessment, treatment and follow up is performed by the breast centers (local health trusts) 30 screening units and 16 breast centers Based on European guidelines (2006) and EUSOMA Own quality assurance manual for all professionals Mobile screening unit in Finnmark

11 A national coordination center ensures similar screening for all the women National guidelines for Screening Treatment and follow-up All women are offered same screening, treatment and follow-up regardless of where the screening exam is performed and where they live One quality assurance manual The same guidelines and quality assurance are performed for all labs/breast centers Common rules for implementation of new techniques One common IT network

12 A national coordination center ensures similar screening for all the women A PIN given to all inhabitants in Norway allow us to link data- Within the Cancer Registry (interval cancer) Statistics Norway Birth Registry Death Registry +++

13 National level (Cancer Registry) Administration Managing/running the program Invitations Identification of the women targeted by the screening program Letters IT systems and support At the Cancer Registry To / from the screening units To /from the breast centers Collection, coding and quality assurance of the data Ensure high quality and completeness

14 National level (Cancer Registry) Information To the women targeted by the screening program To the general population To media Quality assurance and - improvements According to the quality assurance manual Reporting to the breast centers and to the professionals Meetings, site visits and work-shops Research Initiate and perform

15 Regional / county level Staff to do: Screening According to the guidelines Ensure and maintain high attendance rate Interpretation of the screening tests According to the guidelines (volume, time etc) Additional/recall exams, treatment and follow up According to the guidelines Quality assurance Related to the regional activity According to the guidelines Report deviations Research Regional and national projects

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18 Not shown... Not detected

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20 Results

21 Conclusions: High compression force and low compression pressure were associated with more favorable early performance measures in the screening program.

22 Warranted: Closer collaboration with the medical physisists

23 Our goal is to: Ensure standardized imaging stepwise potitioning? Ensure optimal image quality Find evidence for the optimal compression force/pressure Find evidence for the optimal screening volume for the radiographers to perform excellent

24 Radiographers Requirements Bachelor in radiography Course in mammography during the first two years of practice During 2018: Speciality in breast radiography Reqirements regarding performance of a particular volume of screening and clinical examinations, education (points) and academics (scientific/research work)

25 Attendance rate: 75%

26 Attendance rate among those invited 2016 and % of the invited women have requested that data about their negative screening examinations should not be used for quality assurance or research 3.8% of the women have opted out the majority due to breast cancer Breast Center Participation Rogaland 80 % Hordaland 75 % Oslo 66 % Telemark 74 % Agder 78 % Troms og F 76 % Østfold 73 % Nordland 80 % Trøndelag 78 % Oppland 76 % Møre og R 75 % Sogn og F 79 % Vestfold 74 % Hedmark 75 % Akershus Øst 73 % Vestre Viken 74 % Total 75 %

27 Participation rate % Immigrants in the target All women Non-immigrants Immigrants group of BreastScreen Norway (%) Oslo Østfold Akershus Hedmark Oppland Vestfold Telemark Agder Rogaland Hordaland Sogn og Fjordane Møre og Romsdal Trøndelag Nordland Troms og Finnmark Vestre Viken Total

28 Participation rate % Immigrants in the target All women Non-immigrants Immigrants group of BreastScreen Norway (%) Oslo Østfold Akershus Hedmark Oppland Vestfold Telemark Agder Rogaland Hordaland Sogn og Fjordane Møre og Romsdal Trøndelag Nordland Troms og Finnmark Vestre Viken Total

29 Participation rate % Immigrants in the target All women Non-immigrants Immigrants group of BreastScreen Norway (%) Oslo Østfold Akershus Hedmark Oppland Vestfold Telemark Agder Rogaland Hordaland Sogn og Fjordane Møre og Romsdal Trøndelag Nordland Troms og Finnmark Vestre Viken Total

30 Early performance measures Radiologists

31 Time spent on initial interpretation DM Center X; January October 2016 Radiologist n Time used per screen read A :41 B :49 C :38 D :39 E :14 F :45 G :47 H :59 All :39

32 Interpretation score and consensus Interpretation score Radiologists 1 2+ B ,8 % C ,4 % D ,3 % E ,7 % G ,7 % H ,2 % All ,7 % Consensus Selected for recall Deselected % % % % % % % % % % % % % % Further analyses long time follow up and reviews - are needed to ensure that the correct cases are selected and deselected

33 Working days from screening to final interpretation: 8 days Breast Center Number of working days Rogaland 3.6 Hordaland 8.0 Oslo 6.3 Telemark 6.8 Agder 5.8 Troms og F 5.4 Østfold 1.5 Nordland 5.0 Trøndelag 31.5 Oppland 11.7 Møre og R 4.0 Sogn og F 5.6 Vestfold 4.0 Hedmark 3.0 Akershus Øst 4.3 Vestre Viken 4.8 Total 7.6

34 Recall rate due to abnormal mammography, Recall rate: 3.3% Prevalently screened: 5.5% Subsequently screened: 2.6% Breast Center Total Rogaland 2.1 %. Hordaland 4.0 % Oslo 3.6 % Telemark 1.4 % Agder 2.6 % Troms og F 2.7 % Østfold 2.4 % Nordland 2.4 % Trøndelag 3.1 % Oppland 2.8 % Møre og R 3.3 % Sogn og F 6.2 % Vestfold 3.1 % Hedmark 4.1 % Akershus Øst 4.0 % Vestre Viken 5.1 % Total 3.3 %

35 Rate of screen-detected breast cancer Rate of screen-detected breast cancer: 0.56 Prevalently screened: 0.64% Subsequently screened: 0.53%

36 Rate of screen-detected breast cancer Rate of screen-detected breast cancer: 0.56% Prevalently screened: 0.64% Subsequently screened: 0.53%

37 Recalls and cancer detection (Site ) R1 Screen reads (n) Total (n) Recalled R1 Score 1 (n) R1 score 1 (%) A % B % C % D % E % F % G % H % Total %

38 Recalls and cancer detection (Site ) R1 Screen reads (n) Total (n) Recalled R1 Score 1 (n) R1 score 1 (%) SDC R1 Score 1 SDC % R2 = 2 R2 = 3 R2 = 4/5 A % B % C % D % E % F % G % H % Total % % % % % % ,0 % ,0 % % %

39 Rate of interval breast cancer Rate of interval breast cancer: 0.18% IC=24% of the breast cancers detected among screened women

40 Histologic Tumor Diameter Screen-detected breast cancer Mean/median (mm) 15, , , , , ,4 12,5 15,0 13 Interval breast cancer 22, , ,5 19,5 21, , , ,8 18

41 Breast cancer survival by detection mode and tumor size, diagnosed SDC IBC Outside BreastScreen Norway

42 Informed review of screen-detected and interval breast cancers Radiologists Missed Minimal sign actionavble Minimal sign not actionable True Occult Radiographers Missed due to positioning errors

43 Informed review of screen-detected and interval breast cancers 16 breast centers 8 pairs, 16 review sessions Consensus panel 5 breast radiologists Aim: 75 IC and 75 SDC from each center 1258 screen-detected 1062 intervals In total: 2320 cases reviewed Approx. 15 hours of work at each center

44 Study design - deliberations Feasibility Involve and engage all breast centers Reasonable time consumption Quality assurance Research based evaluation Stimulate uniform screening process across centers Educational perspective How can we perform better in the future? Radiographers/radiologists with less experience observed the review process

45 Classification according to visibility on prior mammograms TRUE Not visible on prior mammograms MISSED MINIMAL SIGN ACTIONABLE MINIMAL SIGN NON ACTIONABLE Obvious abnormalities visible on priors Minor abnormalities visible on priors, not necessarily requiring a recall Very subtle findings on priors at the site of the upcoming cancer; not suspicious for malignancy OCCULT Visible neither on prior nor diagnostic mammograms

46 Classification Missed True Minimal sign actionable Minimal sign non actionable Occult Total SDC % 45.5 % 15.6 % 16.5 % 0.2 %

47 Classification Missed True Minimal sign actionable Minimal sign non actionable Occult Total SDC % 45.5 % 15.6 % 16.5 % 0.2 % IC % 34.9 % 15.2 % 13.2 % 12.2 % 47.1% true + occult IC

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51 Early performance measures in mammographic screening by mammographic density Automated measurements of breast density Two screening sites Accepted for publication in Radiology

52 VDG1 n=84,991 (37%) VDG2 n=80,333 (35%) VDG3 n=55,629 (24%) VDG4 n= 11,045 (5%) Total n=231,998 Recall rate Biopsy rate

53 VDG1 n=84,991 (37%) VDG2 n=80,333 (35%) VDG3 n=55,629 (24%) VDG4 n= 11,045 (5%) Total n=231,998 Recall rate Biopsy rate Rate of screen-detected breast cancer (per 1,000 screening examinations) DCIS Invasive DCIS + Invasive

54 VDG1 n=84,991 (37%) VDG2 n=80,333 (35%) VDG3 n=55,629 (24%) VDG4 n= 11,045 (5%) Total n=231,998 Recall rate Biopsy rate Rate of screen-detected breast cancer (per 1,000 screening examinations) DCIS Invasive DCIS + Invasive Rate of interval breast cancer (per 1,000 screening examinations) DCIS Invasive DCIS + invasive

55 VDG1 n=84,991 (37%) VDG2 n=80,333 (35%) VDG3 n=55,629 (24%) VDG4 n= 11,045 (5%) Total n=231,998 Recall rate Biopsy rate Rate of screen-detected breast cancer (per 1,000 screening examinations) DCIS Invasive DCIS + Invasive Rate of interval breast cancer (per 1,000 screening examinations) DCIS Invasive DCIS + invasive Sensitivity Specificity

56 28% reducion in breast cancer mortality among the invited women 37%reduction in breast cancer mortality among those screened 43% reduction in breast cancer mortality among those screened

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59 Radiologists Which qualifications need to be met to start working in BreastScreen Norway? supervised 500 clinical mx examinations trained in clinical examination shadow read 1500 screening examinations participated at 500 consensus decisions 15 multidispilinary meetings knowledge about the content in dedicated docuemtation about screening, diagnostics, treatment and follow up of bc patients, including the QA manual course in general aspects of screening

60 Radiologists Which qualifications need to be met to continue working in BreastScreen Norway? screen 3000 scr ex annually regularly take part in consensus and multidisplinary meetings do clinical mx and further assessment describe MR keep updated about data regarding clincal and histopathologcal aspects participate at national and international conferences every two years keep updated by reading professional literature and articles

61 What happens if the QA parameters are not met?

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64 Summary Certifications and training for mammography screening services and professionals in Norway Challenges Founded on European and Norwegian guidelines National guidelines for Screening Diagnostics Treatment Follow-up QA for screening, Q-improvement projects, research Feedback, but no real action is taken if recommendations are not met

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67 Radiologists Interpretation scores Recalls Rate of screen-detected breast cancer Interval breast cancer Mammographic features Histopathologic findings A program for analyzing the data is available at each site Mini-Reports (4-6/year) Reports Site visits Meetings A board of radiologists Quality improvements projects Research

68 Reports number of screen reads

69 Percentage of recalls where one of the two readers have given a score of 1

70 Percentage of recalls where one reader scored 1 Reader A

71 Percentage of screen-detected breast cancer where one reader scored 1 and the other 2+ («Missed» by Reader A) Reader A

72 Percentage of screen-detected breast cancer where Reader A one reader scored 1 and the other 2+ («Saved» by Reader A)

73 Percentage of screen-detected breast cancer where both readers scored 2+ Reader A