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

 

 

Abstract

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.

 

 

                                    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                 

Introduction

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

Request for data on mammography from about 10 hospitals distributed in the major islands of the country was done initially.  However, only three hospitals responded, two private hospitals (PH1, PH2) and one university hospital (UH).  Since there was already a published study in a private hospital in Cebu (1), the data from this hospital were incorporated into the pool.  Thus, the survey in this study consisted of data from three private hospitals (PH1, PH2, PH3) and one university hospital (UH).

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.

Results

 

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. 

 

Age distribution of persons undergoing mammography

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.

 

Type of physicians requesting for 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.

 

Results of mammography

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).

 

 

 

 

 

 

 

 

 

Discussion

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

  1. Siguan SS, Atilano AA, Medalle ER.  Patterns of mammogram utilization andclinical profile of patients who underwent mammography at Cebu (Velez) General Hospital. Philipp J Surg Spec 2003; 58(1) 22-26.
  2. Fairbrother G, Luciano J, Park HL. Improving the process through which health plans and providers exchange performance-related mammography data. J Urban Health. 2002;79(4):617-27.
  3. Klabunde CN, Sancho-Garnier H, Broeders M, Thoresen S, Rodrigues VJ, Ballard-Barbash R. Quality assurance for screening mammography data collection systems in 22 countries. Int J Technol Assess Health Care. 2001;17(4):528-41.
  4. Freeman JL, Goodwin JS, Zhang D, Nattinger AB, Freeman DH Jr.  Measuring the performance of screening mammography in community practice with Medicare claims data. Women Health. 2003;37(2):1-15.
  5. Olsen O, Gotzsche PC.  Cochrane review on screening for breast cancer with mammography.  Lancet 2001; 358: 1340-1342.
  6. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S.  Report of the International Workshop on Screening of Breast Cancer.  J Natl Ca Inst 1993; 85:1644.
  7. Smart CR. Highlights of the evidence of benefit for women aged 40-49 years from the 14-year follow-up of the Breast Cancer Detection Demonstration Project. Cancer 1994;74:296.
  8. Shapiro S, Venet W, Strax P, Venet L.  Periodic Screening for Breast Cancer: The Health Insurance Plan Project and its Sequelae.  Baltimore: Johns Hopkins Press. 1988.
  9. Klabunde CN, Sancho-Garnier H, Taplin S, Thoresen S, Ohuchi N, Ballard-Barbash R; Quality assurance in follow-up and initial treatment for screening mammography programs in 22 countries. Int J Qual Health Care. 2002;14(6):449-61.

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%)