first national digital mammography survey in portugal ... 2/room a/2 mammography/4...
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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
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).
“Mammography screening is very complex
and resource intensive.”
WHO, 2011
5
What may go wrong?
Missed breast cancers
• Breast: dense, thick • Tumor: subtle, masked, multicentric, multifocal • Technique: positioning, exp factors, processing
• Observer: perception issues, lack of experience
Kamal et al, 2007
6
What may go wrong?
Missed breast cancers? How can be reduced?
“(…) be strict about positioning and technical requirements to optimize image quality”
Annesa et al, 2003
7
Technological advances in mammography
8 8
Screen-Film Mammography
(SFM)
Computed Radiography
(CR)
Direct Radiography
(DR)
1960’s 1980’s 1990’s
International guidance on QA in mammography
9
EU Guidelines 2006
IAEA 2011
ACR Guidelines 1999
Manual de Boas Práticas em Radiologia
Minist. Saúde Desp. 258/2003
Objectives
10
How is mammography in Portugal?
11
?
Focus: digital mammography
How is mammography in Portugal?
12
People
Technology
Results Processes &
Methods
Goals
A broad perspective
Literature survey – peer review
• Carvalho AF et al, Radiation Doses from Mammography in Portugal, Radiation Prot. Dosimetry 36 (2-4), 261-263 (1991)
• Carvalho AF et al, Qualidade dos Aspectos Técnicos em Mamografia em Portugal, Acta Rad. Portuguesa, 35-38 (1995)
• N. Machado et al, Results of radiation protection programs on mammography, Rad Prot Dos Vol. 116, No. 1–4, pp. 624–626 (2005)
• Pascoal et al, Mamografia digital vs analógica: fundamentações da escolha, ARP, vol XVIII, 69, 21-22 (2006)
Curso Imagiologia Mamária, IPOFG, Lisboa 22.03.2012 A. Pascoal
([email protected]) 13
Questions to be answered
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)
18
19
CR Tube & generator - Caracterização - Exactidao - Repetibilidade
X-ray beam dosimetry - Caracterização - Output - HVL - Dosimetria
Detector tests - Aligment - Uniformity - Ghosting (DR) - Image quality
(TORMAM, TORMAX) - Detector response - MTF, NPS, DQE - AEC - Interplate variability (CR) - Fading (CR)
Compression device - Thickness - Pressure
Duration ~4h/unit
Phase 3 – technical performance
DR
Duration ~ 3h/unit
Results – fase 1 (technology)
20
Installed base of mammography systems
21
Private Public Screening Other Total
CR 211 33 28 15 287 (64%) DR 47 16 3 1 67 (15%) SFM 23 4 1 28 (6%) Not known 57 3 3 63 (14%) In transition 1 1 (0.3%)
Total 339
(76.0%) 56
(12.6%) 31
(7.0%) 20
(4.4%) 446
(100%)
* *
* number of DR systems more than doubled (31…76) in 2 years (2010-12)
Distribution of mammography systems
22
Computed Radiography
Direct Radiography
Portugal
Results – phase 2 (practice & organisational matters)
23
Response rate
• Questionnaires sent to 269 hospitals & clinics • Response rate: 24%
24
Norte Centro LVT Alent Algar Mad Total #
centers
Radiolo 15 11 30 3 8 2 69 53
Radiog 26 13 50 10 15 4 118 65
Chief Radiog 10 9 27 4 7 2 59 59
Sample characteristics
25 25 North Centre LVT Alentejo Algarve Madeira
1.7% 1.7% 1.7%
10.0% 8.5%
32.2%
1.7% 6.8%
1.7%
6.8% 5.1%
6.8%
3.4%
1.7%
1.7%
6.8%
1.7%
Other Private Public Screening
• Profile of the institutions that ?
Mammography workload
26
Shifts/week Hours/Shift Exams/Shift Mammography/Hour
Public 5.8 ± 1.6 6.0 ± 0.2 17.7 ± 6.4 2.9 ± 1.1
Private 8.3 ± 2.3 4.8 ± 0.5 19.7 ± 2.1 4.4 ± 0.5
Screening 5.6 ± 2.3 7.0 ± 1.3 55.0 ± 3.2 8.1 ± 1.5
Other 2.3 ± 0.7 3.3 ± 1.8 11.7 ± 6.4 3.6 ± 1.1
Mammography guidance in use
27
Manufacturer 63%
Local protocol 29%
National Guideline
2%
International Guideline
6%
Training in mammography
28 23% 33%
77% 67%
Radiologists Radiographers
Training in DM
No Training in DM
~ 61% : Courses (PT and abroad) Manufacturer
Sessions 1w (93%)
~ 42% : Manufacturer Workshops
Short-term sessions 1-2d (73%)
Self-assessed training needs
No answer
Yes
No
Radiographers Radiologists
7% 1%
38% 48%
55% 51%
29
• QC • Intervention • Optimisation • Dosimetry
• Artifact recognition • Dosimetry • Tomosynthesis
Radiologists practice (image viewing/reporting)
Hardcopy or softcopy?
Reporting time (digital compared to analogue)?
30
Both 14%
Hardcopy 33%
Electronic display 53%
Comparable 52% Less time
19%
More time 29%
Use of post processing tools (radiologists)
31
19.0% 18.6% 18.6%
10.2% 7.8% 5.7% 5.2% 4.8% 3.9% 3.3% 1.7% 1.3%
Quality assurance practice
32
Yes 71%
No 29%
0 2 4 6 8
10 12 14 16 18 20
Daily Weekly Monthly Quarterly 6-month. Annual Radiographer 7 6 8 0 4 0 Manufacturer 0 2 0 5 20 6 Eng. Hosp. 0 0 1 0 0 0 Med Physicist Hosp 0 1 0 0 4 1 Outsourcing 0 0 1 10 12 5
Reject analysis
• Performed in 35% of institutions only – Various causes for rejects
33
12.7% 8.6%
18.2% 17.8% 21.0% 20.4%
1.3%
Technical parameters
Image processing
Artifacts Patient motion Skin folds No pectoral muscle
Other
Results – phase 3 (technical performance)
34
Technical performance assessment
35 35
52 Equipments (15% of total) • 18 DR (27%) • 34 CR (12%)
Alignment of light field to X-ray field
36
Alignment CR DR Total Pass 14% (4) 64% (9) 30% N=13 Fail 86% (25) 36% (5) 70% N=30
Chest wall Chest wall
1/10/13 37
Expected
Causes • Overuse of image plates
• CR reader mechanical issues
Observed
Artefacts
MGD (PMMA phantom; AEC)
38
38
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
M13
M
18
M11
M
44
M50
M
24
M46
M
9 M
23
M15
M
40
M51
M
49
M17
M
42
M1
M10
M
41
M48
M
2 M
19
M26
M
39
MG
D [m
Gy]
EUREF Acceptable EUREF Achievable This study
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
M35 M31 M16 M36 M8 M12 M70 M6 M45 M25
MG
D [m
Gy]
Mamography unit ID
DR
CR
SdNR (PMMA phantom; AEC)
39 39
Mammography equipment
CR
Agfa
Fuji
Carestream/ Kodak
DR
GE 2000
GE DS
Fuji Amulet
Siemens Inspiration
Small breast Medium breast Large breast
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR < Accep/ Achiev Accep < SdNR <Achiev SdNR > Accep/ Achiev
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR (PMMA phantom; AEC)
40
Mammography equipment
CR
Agfa
Fuji
Carestream/ Kodak
DR
GE 2000
GE DS
Fuji Amulet
Siemens Inspiration
Small breast Medium breast Large breast
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
SdNR
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD
MGD > Accep/ Achiev Accep < MGD <Achiev MGD <Accep/ Achiev
Image Quality (TORMAM)
• Image quality
• 200 images (under AEC) • 4 trained observers
41
CR - Image Quality & MGD (PMMA)
42
0
20
40
60
80
100
0.0
1.0
2.0
3.0
4.0
5.0
M13
M
11
M9
M22
M
24
M49
M
51
M20
M
15
M40
M
30
M50
M
43
M46
M
38
M34
M
17
M42
M
1 M
48
M27
M
19
M26
M
2 M
41
M29
M
5 M
39
Imag
e Q
ualit
y S
core
MG
D [m
Gy]
Mammography unit ID
MGD [mGy] TORMAM Score
DR - Image Quality & MGD (PMMA)
43
0
20
40
60
80
100
0.0
1.0
2.0
3.0
4.0
5.0
M35
M7
M3
M12
M45
M31
M6
M28
M36
M16
M47
M2
M33
M14
M32
M71
M25
M8
Imag
e Q
ualit
y S
core
MG
D [m
Gy]
Mammography Units (DR systems)
MGD [mGy] TORMAM Score
MGD (from clinical exposure data)
• 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
Collaborative work
57