To evaluate national screening mammography, we tracked abnormal screening results in 2011 for health outcomes. Data were pooled from mammogram registries, and the performance of the screening program was examined using a two-year follow-up window from the time of the mammography. Findings show a shortage of films and physicians and inconsistency in the program in different terms.
Globally, more women are being diagnosed with and dying from breast cancer. To combat breast cancer, WHO recommends earlier detection and access to treatment at an early stage. The Ministry of Health (MoH) introduced free mammogram screening for breast cancer for women aged 40 and above and for younger women at high risk of breast cancer in 2008-2009 in the West Bank and in 2010 in the Gaza Strip. To evaluate national screening mammography, we tracked abnormal screening results in 2011 for health outcomes. Data were pooled from mammogram registries in the 12 district primary health care clinics in the West Bank; the MoH clinic in the Gaza Strip; Cancer and Death registries at the Palestinian Health Information Center (PHIC); the Referral Department of MoH; interviews with all mammography technicians and supervisors; MoH doctors/radiologists who read the mammogram films; and follow up calls to all women with abnormal screening results not found in either registry.
Using a two year follow-up window from the time of the mammography, we examined the performance of the screening program in several ways:
- The challenges faced by mammography technicians;
- The rates of cancer detection (number of cancers detected per 1000 screening mammographs);
- False-positive rates (number of women with abnormal screening results without breast cancer divided by the total number of cases with abnormal screening results);
- The timeliness of abnormal screening and diagnostic follow up (time to read the mammogram films);
- The types of cancer detected;
- The completeness of cancer registries of notified cancer cases in the West Bank and the Gaza Strip.
In the West Bank, there was shortage of films, especially of the larger size. There was also a shortage of physicians/radiologists that led to delays in reading mammography films; the service varied between 1-60 days. There was inconsistency in the screening mammography program in the twelve districts in terms of outreach; clinical breast examinations; referrals; time taken to read the mammogram films; giving the mammogram films back to the screened women; the follow-up of screened women; the existence of screening mammography guidelines and guidelines for referrals of suspected cancer cases; and storage of patients’ files. Only two clinics kept patient files (own initiative); the others kept the mammography reports for normal cases in one file, and suspected cases in another file.
Four out of the 12 mammography clinics are located in old buildings with poor ventilation and lacks hygiene: in Nablus, Salfit, Tulkarem and Tubas. A lack of preventive maintenance resulted in frequent breakdowns of mammography machines in many clinics and interrupts the screening program. In most districts, the follow up of women with abnormal screening results was inadequate, primarily due to poor communication between primary and secondary health care providers as there was no feedback on women referred for diagnosis.
Of the 6746 women screened, 6.2% (417/6746) cases of cancer were suspected. About one third (136/417) of the suspected cases were diagnostic (for women with signs and symptoms). Of the remaining women with suspected cancer (281 screening cases), 14.6% (41/281) were diagnosed with breast cancer. Assuming the remaining 6610 (6746 total screened subtracting the 136 diagnostic cases) screened women were asymptomatic, the rate of detection by mammography was 6.2 per 1000 (41/6610). Of the 41 diagnosed cases, only 21(21/41=51%) were found in the cancer registry, with the stage of the cancer stated in only one case. The absence of stage of cancer in 20 out of the 21 diagnosed cases found at the Cancer Registry prevented us from examining the impact of screening on women’s morbidity.
In the Gaza Strip, there is only one mammography machine. They maintained patient files and the mammogram films were read the following day. Guidelines existed for screening mammography and for referrals of suspected breast cancer cases. Of the 699 women screened, 2.4% (17/699) were suspected cases. Four of the 17 suspected cases were confirmed to have breast cancer. The rate of detection by mammography was 5.7 per 1000 (4/699). Of the four confirmed cases, three were found at the cancer registry and one case was found in the referral department.
In conclusion, this is an important initiative despite its very limited resources. Further support is required in the following areas:
• To develop screening mammography protocols for referrals of suspected cancer cases;
• To improve infrastructure;
• To review medical records and mammography registry;
• To train existing practitioners and additional physicians/radiologists to speed up the process of reading results;
• To extract diagnostic cases from primary health care for timely referral to secondary health care facilities;
• To improve the completeness and quality of the Cancer Registry by better communications between surgeons, oncologists and pathologists to determine the stage of cancer;
• To ensure that cases of cancer are notified;
• To improve the public education component in the current national screening program in line with WHO recommendations on appropriate widespread coverage of high-risk groups.