Quality Determinants of Organized Breast Cancer Screening Programs

Introduction

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Background

In March 1988, a national workshop on the early detection of breast cancer was held in Ottawa. The report from the workshop, which was presented to the Conference of Deputy Ministers of Health in December 1988, had an underlying theme:

"Screening mammography is here to stay and it is urgent for governments to move quickly to develop strategies for dealing with it and for guiding its implementation in a way which is most cost-effective and most likely to benefit women."

To facilitate the introduction and operation of breast cancer screening programs in Canada, it was felt to be important to promote ongoing dialogue between the provinces/territories, the federal government and national organizations. As a first step, Health Canada, in collaboration with the Canadian Cancer Society and the National Cancer Institute of Canada, organized Interchange '90, a Canadian forum to collaborate on the development of breast cancer screening programs. One of the conclusions from Interchange '90 was that the establishment of quality assurance (QA) programs would be aided by the development, revision, and updating of national guidelines in such areas as participation, film interpretation, follow-up processes, and other issues related to screening.

This commitment to the promotion of QA in breast cancer screening was renewed under the Canadian Breast Cancer Screening Initiative. In 1995, a Working Group on the Quality Determinants of Organized Breast Cancer Screening Programs was established, and the first report, Quality Determinants of Organized Breast Cancer Screening Programs, was published in 1998. In 2001, the working group's new mandate was to:

• identify the key indicators and key activities of QA for breast cancer screening programs and translate these indicators and activities into written policies or statements for the National Committee of the Canadian Breast Cancer Screening Initiative;
• promote the adoption of QA in breast cancer screening programs;
• link with international activities with respect to QA in breast cancer screening.

Purposes and Scope

Population screening for breast cancer is a major public health intervention, and experience in other countries shows that suitable performance parameters can be achieved only through strict adherence to QA guidelines. Since screening is targeted essentially at asymptomatic women, the fine balance between benefits and undesirable effects is completely dependent on program quality.

This document identifies the requirements and conditions for high-quality screening through an organized approach, an approach that relies on adoption of best practices for all aspects of a breast cancer screening program, evidence-based decision making and, if necessary, expert opinion. Furthermore, continual assessment of the screening process and outcome is an integral part of the organized approach to breast cancer screening. To reduce mortality from breast cancer in the population, a screening program must be able to provide mammography procedures of sufficient sensitivity to detect the disease in the early stages, and it must have effective strategies to ensure that the target population accepts and uses the services offered. A high quality screening program must also try to avoid any adverse effects, such as a false sense of security for some, unnecessary anxiety and suffering for others, unnecessary biopsies, unnecessary radiation exposure, and missed breast cancers.

The success of screening is a shared responsibility best assumed with a team approach. Many groups of people contribute to the delivery of a high quality breast cancer screening program: health promoters and communicators; program managers; primary care physicians and other health professionals who advise women on screening; community organizations and the media, which inform the public about screening; radiologists; technologists; medical physicists; nurses; pathologists; surgeons; counsellors; and support staff such as receptionists. Also important is the need for a client-centred approach and a prompt, effective and sensitive means of communicating results. A clear understanding of the information collected at all stages of mammography is not only vital to women's peace of mind but may also increase the likelihood of compliance with regular screening or recommended follow-up.

The chain of events in a screening program is illustrated in Figure 1.

This document addresses the issues related to the client-centred approach, promotion of and recruitment into the program, retention, quality of mammography, reporting of results, communication of results, follow-up and diagnostic workup, and program evaluation. Also presented, as special projects, are the results of a survey on quality assurance in Canadian breast screening programs, and details of a proposed study on radiologists' performance in Canada.

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