A Survey on Mammography Utilization in the Philippines with Focus on Certain Quality Parameters
A Multi-center Cooperative and Collaborative Action Research Study
Catherine S. Co, MD
Melvin Tan-Paredes, MD
Orlino C. Bisquera, MD
Edgardo Penserga, MD, FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Reprint requests: Reynaldo O. Joson, MD, Ospital ng Maynila
Medical Center, Quirino Avenue, Malate, Manila, Philippines. Email:ommcsurgery@yahoo.com
Mammography Utilization
Background: There is a quality concern on the utilization of
mammography in the Philippines.
Objectives: To determine the pattern and outcome of utilization of
mammography in selected hospitals in terms of frequency of requests; requesting
specialties; age distribution of patients; results of findings whether normal,
benign, and suspicious for cancer; frequency and outcome of needle-localization
biopsy; and overall cancer detection rate.
Methods:
In
three hospitals, record review was done. Sources of records came from the
departments of radiology, pathology, and surgery. The published data from one local hospital was incorporated into
the pool.
Results:
The frequency varied from 94 to 2117 per year. Taking 50 years old as the recommended age for screening mammography, 56 per cent were done in younger patients and therefore considered unnecessary. The most common requesting physicians were the surgeons and the gynecologists. Overall, 64 per cent had normal findings; 27 per cent, benign readings; and the remainder, suspicious for malignancy without palpable mass, 1 per cent, with mass, 5 per cent. Two selected hospitals with mammography-guided needle localization breast biopsy facilities reported a malignancy rate of 11 and 20 per cent respectively.
Conclusion: There is a need to improve the quality of mammography
utilization in the country which
should start with the physicians following the evidence-based indications of
the procedure. The Philippine College
of Surgeons or the Philippine Society of General Surgeons should take the lead.
Mammography started in the Philippines in the early
1990s. Over the past 10 years, it has
progressively and rapidly become very popular, and in the public perception, it
has become synonymous with breast cancer screening. Noting that it is being
widely used, the authors raised a concern on the quality of mammography
utilization in the country, in which there is a scarcity of data. As of 2003,
there is only one published paper on the patterns of mammogram utilization and
this was done in Cebu City (1). This paper showed evidences of irrational use
of the procedure with 11 patients aged 10-19 years and 71 patients aged 20 to
29 undergoing mammography. It also
showed a very low cancer yield, only about 5% had suspicious for
malignancy. The authors felt there was
a need to get more data and investigate on the quality aspect of the procedure,
whether it was being properly utilized and what is the cancer yield.
Thus,
the objective of this study was to determine the pattern and outcome of
utilization of mammography in selected hospitals in terms of frequency of
requests; specialty of requesting physicians; age distribution of persons
undergoing mammography; results of findings whether normal, benign, and
suspicious for cancer; frequency and outcome of needle localization biopsy; and
overall cancer detection rate.
Methods
In
the three hospitals which responded to contribute data to the survey, record
review was done to gather the data on frequency of requests; specialty of
requesting physicians; age distribution of persons undergoing mammography;
results in terms of normal, benign, and suspicious for cancer; frequency of
needle localization biopsy and its results; and overall cancer detection rate
of mammography. The sources of the
records were from the departments of radiology, pathology, and surgery. The data gathered underwent statistical
analysis using average and percentage.
Frequency of mammography done
The frequency of mammography done varied from one hospital to another (Table 1). The lowest frequency was 94 per year in one of the private hospitals while the highest was 2117 per year in the university hospital.
Table 2 shows the age distribution of patients undergoing
mammography. Overall, taking 50 years
old as the recommended age for screening mammography, 56 per cent were done in
younger patients. If 40 years old was used as the cut-off age, the frequency in
the younger patients was 19 per cent.
In terms of absolute number, there were 59 patients aged 19 years and
below, 596 aged 21-30 years old, and 2732 aged 31-40, a total of 3387 patients,
who underwent what was strictly considered unnecessary mammography.
The most common requesting physicians were the surgeons and
the gynecologists (Table 3). In the
private hospitals, the gynecologists were almost twice as frequent in
requesting for mammography. In the
university hospital, because of the presence of a protocol in the department of
surgery for all established breast cancers to have preoperative mammography to
screen the contralateral breast, the frequency of requesting mammography was
almost the same between the surgeons and gynecologists.
Overall,
64 per cent had normal findings, 27 per cent had benign readings, and the
remainder, 9 per cent, suspicious for malignancy inclusive of presence or
absence of palpable mass (Table 4). The
frequency of reading of suspicious for malignancy in the absence of palpable
mass ranged from less than 1 to 4 per cent.
Results of mammography-guided
needle localization breast biopsy
Of
the three selected hospitals participating in the survey, only two had
mammography-guided needle localization breast biopsy facility. The reported malignancy rate was 11 per cent
in the university hospital and 20 per cent in a private hospital (Table 5).
This
paper attempts to give a picture on the utilization of mammography and its
outcome in the country. Initially,
requests were made to several hospitals in Luzon, Metro Manila, the Visayas,
and Mindanao. However, only three
hospitals responded, all in Metro Manila.
Mammography is most commonly done in private hospitals. Rarely is it done in government hospitals
which usually do not the machine.
The
information derived from the 4 sets of data coming from three private and one
university hospital could safely be said to give a representative picture of
utilization of mammography in the country.
The authors included the data from a Cebu private hospital to represent
the hospitals outside Metro Manila and in the provincial setting. The private hospital with more than 7000
cases and with facilities for needle-localized biopsy could represent the sophisticated
hospitals in Metro Manila. The other
private hospital with 1000 cases could represent the run of the mill private
hospitals in an urban center. The
university hospital is one of each kind, it being the largest teaching
government hospital in the country.
Although it would not represent any tertiary government hospital,
because of its caseload, it offered important information particularly in the
outcome of mammography utilization.
Although this survey may strictly not be representative of the entire
country, it is the best that could be done at present. Even abroad, there is difficulty in doing
such a study, especially in exchanging performance-related mammography data from
health providers (2,3). Furthermore,
there are few studies that have examined the outcomes of screening mammography
in community practice (4).
Although
there is still some controversy on the benefit on mammography screening (5),
the prevailing thinking is that it is beneficial in reducing breast cancer
mortality by about 30 per cent (6-8).
The predominant question raised these days is the judicious use of the
procedure. There is a frequent clamor
for quality assurance studies to make mammography more effective and efficient
(9-10).
Quality
utilization of mammography can be evaluated using several parameters such as whether
done according to proper indications, accuracy of interpretations of films,
quality of films, cancer yield or malignancy rate, quality of life,
cost-effectiveness, and utility. With
so many parameters to contend with, doing a quality assurance study on
mammography is not easy. Thus, for the
purpose of this study, the quality parameters will just be limited to whether
the mammography is being done as recommended by established societies and the
malignancy rate.
Based
on the most recent pronouncement of the Philippine College of Surgeons on
October, 2003, which states that “scientific data and several cancer
organizations support a recommendation for annual screening mammography for women
aged 50-74. For high risk women,
mammography may be done starting aged 40.”
In this survey, if 50 years old will be used as the cut-off for
mammography utilization, then 56 per cent would be considered not following the
guidelines. What was glaring in this
series, more than 3000 persons less than 40 years old underwent unnecessary mammography.
Looking
at the malignancy rate, the overall rate for suspicion for malignancy was only
one per cent on mammography. The
actual cancer yield was difficult to determine as not all the patients with
suspicion for breast cancer on mammography underwent needle-localized
biopsy. However, extrapolation from
those with needle-localized biopsy would tend to show a less than one per cent
cancer yield .
Evidently,
from the data obtained, there is a need to improve the quality of utilization
of mammography in the country which should start with the physician following
the evidence-based or data-driven indication of mammography. The Philippine College of Surgeons or the
Philippine Society of General Surgeons should take the lead. Definite guidelines on the indications of
mammography should be formulated for the health professionals and the public to
follow. For example, the routine
mammography prior to hormonal replacement therapy as well as in patients with
established breast cancer just for screening the contralateral breast need to
be reviewed. In the latter, there was zero
synchronous cancer yield in the contralateral breast.
Besides
setting definite guidelines on the use of mammography, enforcement of guideline
implementation should be effective. Based on its track record in promoting and
enforcing rational drug prescription and other quality care practices, PhilHealth
may be of help. The health maintenance
organizations and the utilization review committee of a hospital may also be
helpful. Hopefully, with mammography
being done under a well-established, the malignancy yield will increase and
there will a reduction of unnecessary mammography which is associated not only with
anxiety of the reports and recall, but also pain, inconvenience, expenses, and
most important of all, unnecessary surgery in false positive cases. For the university government hospital, the
2000 mammography per year with a yield of less than one per cent breast cancer
is a significant drain in its resources.
References
10. Bulliard JL, De Landtsheer JP, Levi F. Results from the Swiss mammography screening pilot programme. Eur J Cancer. 2003;39(12):1761-9.
Table 1. Frequency of mammography done in
selected hospitals.
|
PH1 1994-2001 (8 yrs) |
PH2 1998-2002 (5 yrs) |
PH3 1997-2001 (5 yrs) |
UH 1999-2002 (4 yrs) |
Total |
Total
no. |
7323 |
1673 |
468 |
8468 |
17932 |
No.
per year |
915 |
335 |
94 |
2117 |
|
Table
2. Age distribution of persons undergoing mammography in selected hospitals.
Age
group |
PH1 (n=7323) |
PH2 (n=1663) |
PH3 (n=468) |
UH (n=8302) |
Total (n=17288) |
|
10-19 |
0 |
35 (2%) |
15 (3%) |
9 (<1%) |
19% |
56% |
20-29 |
192 (3%) |
151 (9%) |
67 (14%) |
186 (2%) |
||
30-39 |
966 (13%) |
332 (20%) |
94 (20%) |
1340 (16%) |
||
40-49 |
2708 (37%) |
627 (38%) |
144 (31%) |
3117 (38%) |
81% |
|
50-59 |
2410(33%) |
375 (23%) |
105 (22%) |
2500 (30%) |
44% |
|
>60 |
1047 (14%) |
143 (6%) |
43 (9%) |
1150 (14%) |
Table
3. Types of physicians requesting for mammography in selected hospitals.
|
PH1 (n=7323) |
PH2 (n=1673) |
PH3 (n=468) |
UH (n=8468) |
Surgeons |
1348 (18%) |
197 (12%) |
134 (29%) |
3446 (41%) |
Gynecologists |
2337 (32%) |
989 (59%) |
186 (40%) |
3530 (42%) |
Others
/ unknown |
3638 (50%) |
487 (29%) |
148 (32%) |
1492 (7%) |
Table
4. Results of mammography in selected hospitals.
|
PH1 (n=7323) |
PH2 (n=1650) |
PH3 (n=468) |
UH (n=8402) |
Total (n=17843) |
Normal |
4449 (61%) |
1266 (77%) |
373 (80%) |
5293 (63%) |
11381 (64%) |
Benign |
2721 (37%) |
254 (15%) |
58 (12%) |
1801 (21%) |
4834 (27%) |
Suspicious
without palpable mass |
99 (1%) |
64 (4%) |
|
49 (<1%) |
212 (1%) |
Suspicious
with palpable mass |
54 (<1%) |
66 (4%) |
|
1259 (15%)** |
|
Suspicious
(+/- mass ) |
|
|
23 (5%) |
|
|
|
|
|
BI-RADS 0 =2; BI-RADS 3 = 12; BI-RADS
5 = 0 |
|
|
**
majority of these patients were diagnosed to have breast cancer and prior to
operation, underwent mammography to
study the contralateral breast.
Table
5. Mammography-guided needle location biopsy of non-palpable lesions in
selected hospitals.
|
PH1 (n=50) |
PH2 (no data) |
PH3 (no data) |
UH (n=27) |
Benign |
35 (70%) |
|
|
24 (89%) |
Malignant |
10 (20%) |
|
|
3 (11%) |
Indefinite |
5 (10%) |
|
|
|