Question

Which conditions for the transfer of information should be met?

Recommendation

The national guideline development group is of the opinion that:

  • objective information should be available to women to help them in their decision to participate in the national breast cancer screening programme;
  • the screening organisation should notify area hospitals promptly of scheduling, so that the hospitals can adjust their breast clinic's capacity accordingly;
  • the application of BI-RADS in screening aids communication between the screening radiologist, the primary care physician and the breast care team;
  • the general practitioner should refer the referred woman to a breast clinic or breast care team;
  • the mammogram should be repeated if the screening mammogram she brings is not of diagnostic quality;
  • if a screening mammogram is not feasible, the woman should be advised to have the test conducted in the radiology unit of a hospital;
  • if, after evaluation by the breast care team, there seems to be a false-positive referral, the woman should be referred back actively to the national breast cancer screening programme.

Conclusions

The screening radiologist's performance improves with a good balance between screening radiology and diagnostic radiology. The relationship between performance and the volume of exams to be screened is complex; there is no straightforward correlation.

Level 3: A2 Buist

Literature summary

What conditions must be met for the transfer of information to the clinic?

Everyone involved in the screening and follow-up process must fully realise that screening is a way of reducing breast cancer mortality and is not a perfect and comprehensive way to protect women against breast cancer. Only a small proportion of participants have breast cancer, and false-negative and false-positive results are unavoidable but constantly cause debate.

Jørgensen (2006) states that this can at least partly be traced back to the educational information given to women who are invited. The picture sketched is often too rosy and creates unrealistic expectations. Possibly because this information serves a double purpose: national breast cancer screening greatly benefits from a large turnout and makes an effort to do so in an inviting manner, influencing the balance between benefit and harm. It is of utmost importance that attention is paid to providing this information in an objective manner [BVN, 2003]. Specifically, it should be pointed out that women who have a palpable abnormality or other symptom do not belong in the screening program. The nationwide coordination is the job of the RIVM, which is responsible for distribution of information in the Netherlands. The invitation brochure and the standard invitation letter is updated annually, to enable women to make their dicisions on current information.

In addition, the national breast cancer screening programme must strive for the highest level of communication with the follow-up care path, for planning purposes as well as to mitigate negative effects of screening, in particular extra tests due to false-positive findings.

 

The screening mammogram: Is it still necessary to repeat the digital mammogram?

The screening radiologist's annotations are saved digitally using the Dutch IT/DigiBOB software. At present, the key information (the abnormality on the mammogram) with the data transfer information from the screening radiologist, as described below, is usually delivered on a CD. There are various reasons to send the screening mammogram to the breast clinic in the hospital to which the woman is being referred:

  1. The quality of images on a CD is often not diagnostic; differences between image processing systems complicate the interpretation and processing.
  2. Repeating the test is of practical value for additional magnification views or tomosynthesis. But it also increases the final sensitivity (up to 30%) by repeat imaging of the same pathology [Bick, 2006].
  3. It can also be considered the system's own quality control: abnormalities that are cause for referral are sometimes not detectable on the mammogram made in the clinic. That is      especially true of abnormalities that are small, found at the edge of the image, or based on incidental overprojection of normal structures. The radiation exposure is negligible.

Creation of a broadband connection between screening organisations and hospitals is in progress.

When the hospital has the same image processing system as the screening organisation, so that the image quality is equivalent, or if the hospital has access to the images via broadband technology, repeating the image is not necessary.

The screening radiologist

A large cohort study of the performance of 120 screening radiologists in the United States found that it is mainly radiologists doing both diagnostic breast radiology and screening who achieve the best results. The sensitivity in this study was 85.2% (95% CI 83.7-86.6%). There were no significant differences between large and small volume screens; the relationship between the number of screens and performance proved to be complex [Buist, 2011]. A minimum of 3,000 screens per years was set; in the Netherlands the average volume handled by a screening radiologist is 7,000. This and the other standards that must be met by screening radiologists in the Netherlands are described in the Quality Registry of the LRCB. It also states the requirement that screening radiologists must be involved in diagnostic breast radiology. The LRCB registers the licensed screening radiologists in the Quality Registry.

Screening radiologists provide the patient's general practitioner with all the information necessary for referral. At a minimum this information must include: the side, localisation, nature and size of the abnormality and the number of abnormalities. This must be recorded in a standard sketch annotated on the mammogram.

The following BI-RADS categories may be assigned to a screening mammogram used for referral (a "positive screening result") (see section 2.22) [ACR, 2003]:

  • BI-RADS 0, incomplete exam; need additional imaging evaluation and/or prior mammograms for comparison
  • BI-RADS 4, probably malignant, suspicious laesion
  • BI-RADS 5, highly suggestive of malignancy

 

For instance, BI-RADS 0 may imply there is reason to take a magnification view or do an ultrasound, or to compare the mammogram with previous mammograms that are not available at the national breast cancer screening centre, in order to differentiate between a real laesion and a composition image. If the final assessment category assigned is BI-RADS 4 or 5, the emphasis is on the degree to which the laesion is suspected of malignancy; whether needle biopsy is needed will be determined in the hospital. BI-RADS final assessment category 3 (probably benign) does not belong in a routine screening setting. This category can be assigned only after the necessary additional imaging has taken place, thus in the hospital. This is because in the follow-up rounds the Dutch screening programme confines to MLO (mediolateral oblique) views The remaining categories (BI-RADS 1 and 2) are considered negative screening results, and therefore meet the criteria for routine screening, not for referral.

Applying the BI-RADS categories with some explanatory text helps general practitioners, giving them more understanding of the level of suspicion. If the woman has been referred with a BI-RADS 0, her general practitioner can explain to her that an irregularity was indeed seen on the mammogram, but that more imaging is needed for confirmation. The chance of cancer is about 10%. Also within the breast clinicthe BI-RADS final assessment category will influence the referral routine. ZonMw (The Netherlands Organisation for Health Research and Development) has subsidised a prospective, epidemiological study by the University Medical Centre Sint Radboud and the LRCB, investigating various different scenarios including the possibility of whether BI-RADS 0 referrals can be held entirely outside the breast clinic and can be evaluated within the screening setting.

The screening organisation

The five regional screening organisations are responsible for the screening programme. Job descriptions and responsibilities of screening technicians can be viewed at www.lrcb.nl. The organisations must ensure that all women who participate in national breast cancer screening are notified of their results by mail as soon as the organisation can do so – preferably within 10 workdays [Harmonisatie Kwaliteitsbeoordeling in de Zorgsector, 2006]. Mailing of results should not be timed so that the message arrives on a Friday or right before holidays. If the results are positive, the woman's general practitioner will be notified before the woman herself. The woman will then receive a letter advising her to contact her general practitioner. She will also receive the folder "When Further Testing is Needed." Often general practitioners contact the woman before she receives the letter. This is preferable.

The screening organisation is in charge of sending a letter of referral and for making the digital images available. The screening organisation communicates promptly with hospitals in the area about the local screening schedule, so that the hospitals can adjust their breast clinic's capacity accordingly.

The general practitioner

If a woman is referred for further diagnostic testing, her general practitioner is responsible for:

  • giving her information on the procedure of referral, to add to the information in the results letter the woman received.
  • referring the patient to a breast clinic or breast care team, taking into account the woman's preference. In most areas referral is done using a set of forms. In this set, the form for the specialist contains the same information and has a space for the primary care physician to provide additional information, such as relevant patient history. These forms must be given to the woman.
  • contacting the woman herself, if she does not contact her doctor.
  • reporting the referral (which specialist, which hospital) to the screening organisation. In many regions a "return mail form" in the set of forms can be used for this purpose.

The breast care team

The specialists (the breast care team) involved in the process of further diagnostic testing of the referred woman are responsible for ensuring that:

  • diagnostics and treatment take place within a recognisable organisational structure (see Chapter 13);
  • the general practitioner is notified promptly of follow-up diagnostic findings, the treatment plan and its results;
  • the screening organisation is notified (preferably within three months) of the results of diagnostic tests.

The woman brings the records (forms and CD) she received to her breast clinic appointment. The surgeon or breast care nurse specialist sees to it that the radiologist has access to the mammograms and the additional information. The pathologist must also have access to this information.

 

Relaying information to the patient

Well-informed patients are more able to process stress. The further diagnostic test results must be relayed to the patient at each moment in the diagnostic process, though she will mainly receive this information at the breast clinic directly from the attending surgeon and nurse specialist.

 

Mammograms that are difficult to perform

Under the terms of the Equal Treatment Act, in 2008 the RIVM established that every woman in the Netherlands must have access to one of the national breast cancer screening centres. For women with a physical disability, each screening unit has an elevator. In exceptional cases they can rely on the radiological department of an associated hospital.

Another group is made up of women for whom mammograms may not be technically feasible, such as women who have had breast-conserving therapy (see also 12.4) or have silicone breast implants (see also 2.2.5). If both the first and second radiologists reading the mammogram find it hard to interpret, they advise the individual women to have their screening examination performed in the radiology department of a hospital, because there more options for imaging are available. The decision to give the woman this advice must be based on the RIVM protocol. Given the improved contrast ratios in digital mammography, these would be exceptions to the rule: the vast majority will be able to be screened normally.

Authorization date and validity

Last review : 13-02-2012

Last authorization : 13-02-2012

Initiative and authorization

Initiative : Nationaal Borstkanker Overleg Nederland

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie