First National Digital Mammography Survey in Portugal - Findings and Recommendations - A.Pascoal * , C.Reis, M.Oliveira, T.Sakellaris, J.Alves, M.Koutalonis (*afiliated to FEUCP when the survey was performed. Currently afiliated to King’s College Hospital) 1 Proteção Radiológica na Saúde, 18-20 Sep 2013, Lisbon Portugal
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First National Digital Mammography Survey in Portugal
(*afiliated to FEUCP when the survey was performed.
Currently afiliated to King’s College Hospital)
1
Proteção Radiológica na Saúde, 18-20 Sep 2013, Lisbon Portugal
Introduction
2
Some facts about breast cancer
“…is the top cancer in women worldwide and is increasing particularly in developing countries”
WHO, 2011
3
Some facts about breast cancer
• 1500 breast deaths/year
• 4500 new cases/year
• 1% ♂ (male)
• 10% women will develop breast cancer
• 90% curable if diagnosed early
LPCC, 2011
4
Some facts about mammography
“the only screening method that has proven to be effective (…) can reduce mortality by 20 to 30% in women over 50 yrs old when screening coverage is over 70% (IARC, 2008).
1. How many mammography systems are installed in the country? What type of technology is available?
2. How is staff (radiographers and radiologists) being
trained in mammography? 3. How is the performance of DM systems in clinical use?
4. How do practice in mammography comply with international guidelines of best practice?
Is there room for improvement?
14
Methods
15
Phase 1 – characterisation of technology
• Literature search
• Information request – healthcare authorities: DGS; 7 ARS – Manufacturers and distributors
• Questionnaires
16
Phase 2 – characterisation of practice
• Targeted questionnaires – breast radiographers – chief radiographer – breast radiologists
• Data collected – Type of institution – Education and training – Mammography technique in use – Radiology practice (reading and interpretation) – Quality control – Views on impact of DM
17
Phase 3 – technical performance
• Selection criteria – Type of technology (CR, DR) – Manufacturer – Geographical location – Type of provider (public, private, cooperative) – Practical issues (time and resources available)
• Exposure data collected from – 38 mammography systems
• 25 CR • 13 DR
– 2121 exams/patients
– 8484 exposures (= images)
44
MGD (from clinical exposure data)
45 45
0
5
10
15
20
25
30
35
0-‐0,5
0,6-‐1
1,1-‐1,5
1,6-‐2
2,1-‐2,5
2,6-‐3
3,1-‐3,5
3,6-‐4
4,1-‐4,5
4,6-‐5
5,1-‐5,5
5,6-‐6
6,1-‐6,5
6,6-‐7
7,1-‐7,5
7,6-‐8
8,1-‐8,5
8,6-‐9
9,1-‐9,5
9,6-‐10
10,1-‐10,5
10,6-‐11
11,1-‐11,5
Rela2ve Freq
uency (%
)
DR:1,54 mGy (CC)
CR: 1,85 mGy (CC)
MGD, mGy
DR:1,68 mGy (MLO)
CR: 2,10 mGy (MLO)
Dose reference levels
• MGD (from clinical exposure data) • Exposure data of MLO projections
46
0
5
10
15
20
25
30
35
Rel
ativ
e Fr
eque
nce
[%]
Thickness [mm]
CR DR
Ref. establishment of DRL, IPEM
Dose reference levels
47
Dose Reference Levels CR
2.2 mGy
Dose Reference Levels DR
1.5 mGy
UK - 3.5 mGy (SFM) Young et al proposes 2.2 mGy (CR) and 1.5 mGy (DR)
Conclusions
48
Mammography equipment
• Limited peer review data
• No national equipment registry with updated information and relevant technical detail
• The majority (76%) of mammography systems are CR technology
• Number of DR systems more than doubled in 2 years (31…67)
49
Organisational matters
• Workload is higher in private & screening centres
• Use of equipment is based on manufacturers’ guidance
• Training needs identified by radiologists and and radiographers (dosimetry, artefact recognition, tomosynthesis)
• 33% of radiologists still report on hardcopy format
50
Organisational matters
• QC not performed in 30% of the participant centres
– Reject analysis is not implemented in the majority of centres
– Lack of clarity regarding servicing (manufacturer) and QC (independent)
51
Equipment performance
• Mean Glandular Dose (MGD) – Higher MGD for CR systems compared to DR – MGDPMMA< 2.5 mGy (EUREF acceptable ref.) for vast majority of
systems
• SdNR lower than expected (AEC calibration?) particularly for CR systems
• Image quality – Wide range of image quality
• CR systems (score 30 to 100) • DR system (score 61 to 91)
52
Recommendations
53
Recommendations
To be discussed and formulated in collaboration
with you - the stakeholders.
54
Aknowledgments
55
Projecto financiado pela Fundação para a Ciência e Tecnologia (2010-2013) PTDC/SAU-BEB/100745/2008
Thank you
56
HOSPITAL DE SÃO JOÃO, E.P.E. INSTITUTO PORTUGUÊS DE ONCOLOGIA DO PORTO FRANCISCO GENTIL KRUG DE NORONHA, LDA. - PORTO SMIC - SERV. MÉD. DE IMAGEM COMPUTORIZADA GRUPO EUROMEDIC _C. MED. C. BRANCO - DUARTE JOAO & J CEDILE - C. DIAG. POR IMAGEM DE LEIRIA DIAGNOSTICUM - CLÍNICA DE DIAGNÓSTO HOSPITAIS UNIVERSITÁRIOS DE COIMBRA HOSPITAL STº ANDRÉ - LEIRIA INSTITUTO PORTUGUÊS DE ONCOLOGIA DE COIMBRA FRANCISCO GENTIL LPCC-NÚCLEO REGIONAL DO CENTRO PINHO E MELO STA CASA MISERICORDIA MEALHADA CEDIMA-CENTRO IMAGIOL.MEDICA, LDA CLIDIRAL - CLÍNICA DE DIAGNÓSTICO CUFBELÉM - CLÍNICA STA MARIA BELÉM CONS. RADIOLOGICO DR. SENA BATISTA GRUPO EUROMEDIC _MANUEL ESTEVES & LUIS FRAZAO LDA GRUPO EUROMEDIC_CRT - CENTRO DE RADIOLOGIA DE TOMAR GRUPO EUROMEDIC_DR.MESQUITA G.(FILHO)& A.-C.R.E.AV.REPUB.S.A GRUPO IMAG_CDRE - CENTRO DIAGNOSTICO RADIO ECOG ALGUEIRAO MEM MARTINS HOSPITAL DA LUZ, S.A. HOSPITAL FERNANDO FONSECA QUADRANTES-CLIN.MEDIC.DIAGNOST.,LDA SINDICATO DOS BANCÁRIOS DO SUL E ILHAS – CC E HOSPITAL UNIÃO MUTUALISTA N.SRA. DA CONCEIÇÃO - MONTEPIO BARREIRO LPCC - NÚCLEO REGIONAL DO SUL IRE-IMAGEM RADIOLOGICA ECOGRAFICA, LDA – LISBOA MATERNIDADE DR.ALFREDO DA COSTA C. HOSP. BAIXO ALENTEJO CENTRO DE RADIOLOGIA DE BEJA, LDA. GRUPO EUROMEDIC_CDI-CLINICA MANUFACTURERS AND DISTRIBUTORS OF MA
DIAGNOST.IMAGEM,LDA. HOSPITAL DO LITORAL ALENTEJANO CENTRO HOSPITALAR DO BARLAVENTO ALGARVIO IMAG-FERNANDO SANCHO, LDA HPP - HOSPITAL PRIVADO SÃO GONÇALO DE LAGOS LAGOA CENTRO _ M. CARMO A. CASTRO J. MAURICIO R A RADIOLOGIA ALBUFEIRA LDA MADEIRA MEDICAL CENTER HOSPITAL ESPIRITO SANTO GRUPO DR.CAMPOS COSTA CLÍNICA DR.PASSOS ANGELO HOSPITAL DO FUNCHAL CENTRO MÉDICO DR. VERÍSSIMO DE JESUS CLÍNIA- CLÍNICA MÉDICA DA LINHA HOSPITAL PARTICULAR DO ALGARVE ASSOCIAÇÃO ONCOLÓGICA DO ALGARVE HPP - HOSPITAL SANTA MARIA DE FARO HPP - LUSÍADAS CUF - INFANTE SANTO HOSPITAL S. TEOTÓNIO DE VISEU CUF-DESCOBERTAS CENTRO HOSPITALAR DE COIMBRA ESS-HOSPITAL DE SANTIAGO GRUPO ESFERA SAÚDE HOSPITAL ST ANTÓNIO CAPUCHOS INSTITUTO PORTUÊS DE ONCOLOGIA DE LISBOA FRANCISCO GENTIL CENTRO HOSPITALAR DO PORTO- HOSPITAL GERAL DE STO ANTONIO DR. JOAO CARLOS COSTA GABINETE DE RADIOLOGIA DE ESPINHO, DR KRUG DE NORONHA GINOECO-SERVIÇOS MÉDICOS DE IMAGEM GRUPO ESS _HOSPITAL DA ARRÁBIDA - VN GAIA