Clinical quality assurance in breast cancer screening and diagnosis: a warning regarding mammographic positioning

This study aimed to evaluate the clinical image quality of mammograms performed in users of the Brazilian Unified Health System (SUS) referred to a tertiary hospital. Methods: A prospective study assessed mammograms from women referred to a specialist breast center in Goiânia, Goiás, Brazil, between May and October 2017. Scans performed in the preceding 6 months, either screening or diagnostic, were included in the study. Clinical quality was determined from 40 variables related to patient identification, technical performance, the equipment, radiological findings, reporting of results, and breast positioning. Scans performed in the public and private healthcare networks were compared regarding mammographic positioning. Results: Overall, 4,560 variables associated with the clinical quality of the images were evaluated in scans from 114 women with a mean age of 50.6 years. A total of 660 (14.47%) inadequacies were found, 443 (67.12%) of which were related to breast positioning. The most common errors were as follows: pectoral muscle could not be seen in 86.8% of scans in the craniocaudal view and inframammary angle could not be seen in 79.8% of scans in the mediolateral oblique view. Considering the breast-positioning criteria evaluated in the mediolateral oblique view, there was a greater risk of the breast not being centrally positioned with the nipple in profile (RR 4.66; 95%CI 1.05−20.62; p=0.02) and of nonvisualization of the retro-areolar area (RR 4.14; 95%CI 0.92−18.66; p=0.04) in the exams performed in the private compared to the public network.

Knowledge of basic attention professionals about prevention and early detection of breast cancer in the state of Goiás

The role of Basic Health Care (BHC) professionals is essential in the primary and secondary prevention of breast cancer. The aim of this study was to characterize BHC professionals in the Health Regions of a federative unit and to assess their knowledge about breast cancer. This was a prospective study carried out with BHC professionals from the state of Goiás. Phase 1 ­ Preparation of material and training of the team. Phase 2 ­ Agreement of actions between executing team and coordination of health regions. Phase 3 ­ Presentation of project at the collegiate meeting. Phase 4 ­ Qualification of BHC professionals with different learning methods and application of questionnaires, evaluating the contribution of the action. A total of 1,133 professionals were included; mean age was 36.3 years, and they were predominantly women (87.6%), working as community health agents (59.2%) and at public service (76.3%). Only 53.8% of professionals identified the female sex as a risk factor for breast cancer, while 90% identified family history as an important factor for the development of the disease. Important changes in physical examination that can occur in patients with the disease, such as skin retraction, skin bulging and nipple injury, were mentioned as a risk factor only by 35.3%, 31.3% and 39.7%, respectively. BHC professionals who participated in the project had less than ten years of professional experience and significant restrictions of knowledge about primary and secondary prevention of breast cancer. They still experience difficulties in accessing mammography and specialized care.

Opportunistic mammography screening by the Brazilian Unified Health System in 2019

Introduction: Mammography screening has been the best method for detecting early tumors and reducing breast cancer mortality according to different studies. In Brazil, the number of women who undergo mammography tests by the Brazilian Unified Health System (SUS) has been far below international recommendations. Objective: To describe the number of mammographies, mammography coverage, and the amount spent on this exam during 2019 by SUS, in Brazil. Method: Ecological study with data from the Department of Informatics of the Brazilian Unified Health System and the Brazilian Institute for Geography and Statistics in order to verify the number of mammographies performed by the SUS concerning the Brazilian female population in Brazil, in the age group of 50 to 69 years, in the states and in macro-regions during 2019. Results: In 2019, 2,660,469 mammographies were performed in the country out of the expected total of 12,154,979, accounting for a 21.9% mammography coverage by SUS at the cost of BRL 117,841,231.97. The lowest coverage rates were verified in the states of Amapá (0.6%) and the Federal District (4.9%), whereas the best rates were found in the states of Paraná (29.7%) and Alagoas (29.6%). Conclusions: The number of mammographies performed in Brazil in 2019 by SUS corresponded to almost » of the country's need, with mammography coverage far below the target and being widely different among the many Brazilian states.

Contribution of the Unified Health Care System to mammography screening in Brazil, 2013 / Contribuição do Sistema Único de Saúde no rastreamento mamográfico no Brasil, 2013

Abstract Objective: To estimate the coverage of opportunistic mammography screening performed via the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System), at the state and regional level, in 2013. Materials and Methods: This was an ecological study in which coverage was estimated by determining the ratio between the number of mammograms performed and the expected number of mammograms among the population of females between 50 and 69 years of age. The number of mammograms performed in the target population was obtained from the Outpatient Database of the Information Technology Department of the SUS. To calculate the expected number of mammograms, we considered 58.9% of the target population, the proportion that would be expected on the basis of the recommendations of the Brazilian National Cancer Institute. Results: In 2013, the estimated national coverage of mammography screening via the SUS was 24.8%. The mammography rate ranged from 12.0% in the northern region to 31.3% in the southern region. When stratified by state, coverage was lowest in the state of Pará and highest in the state of Santa Catarina (7.5% and 35.7%, respectively). Conclusion: The coverage of mammography screening performed via the SUS is low. There is a significant disparity among the Brazilian states (including the Federal District of Brasília) and among regions, being higher in the south/southeast and lower in the north/northeast.

Resumo Objetivo: Estimar a cobertura mamográfica em rastreamento oportunista realizado pelo Sistema Único de Saúde (SUS) no Brasil, nas suas regiões e nas Unidades da Federação, no ano de 2013. Materiais e Métodos: Estudo ecológico, em que a estimativa da cobertura foi a proporção entre o número de exames realizados e o número de exames esperados na população feminina na faixa etária de 50 a 69 anos. O número de exames realizados refere-se aos dados da produção mamográfica da população alvo, disponíveis no Sistema de Informações Ambulatoriais do Departamento de Informática do SUS. Para o cálculo do número de exames esperados considerou-se 58,9% da população alvo, tendo em vista as recomendações do Instituto Nacional de Câncer. Resultados: A estimativa da cobertura mamográfica no rastreamento realizado pelo SUS no Brasil, em 2013, foi 24,8%. A prevalência de mamografias variou de 12,0% na Região Norte a 31,3% na Região Sul. Ao estratificar por Unidades da Federação, a menor cobertura foi no Pará (7,5%) e a maior cobertura foi em Santa Catarina (35,7%). Conclusão: A cobertura mamográfica do SUS no Brasil é baixa. Existe uma desigualdade significativa entre as Unidades da Federação, sendo maior nas regiões Sul e Sudeste e menor nas regiões Norte e Nordeste do país.

Performance of diagnostic centers in the classification of opportunistic screening mammograms from the Brazilian public health system (SUS) / Avaliação do desempenho dos centros de diagnóstico na classificação dos laudos mamográficos em rastreamento oportunista do Sistema Único de Saúde (SUS)

Objective To evaluate the performance of diagnostic centers in the classification of mammography reports from an opportunistic screening undertaken by the Brazilian public health system (SUS) in the municipality of Goiânia, GO, Brazil in 2010. Materials and Methods The present ecological study analyzed data reported to the Sistema de Informação do Controle do Câncer de Mama (SISMAMA) (Breast Cancer Management Information System) by diagnostic centers involved in the mammographic screening developed by the SUS. Based on the frequency of mammograms per BI-RADS® category and on the limits established for the present study, the authors have calculated the rate of conformity for each diagnostic center. Diagnostic centers with equal rates of conformity were considered as having equal performance. Results Fifteen diagnostic centers performed mammographic studies for SUS and reported 31,198 screening mammograms. The performance of the diagnostic centers concerning BI-RADS classification has demonstrated that none of them was in conformity for all categories, one center presented conformity in five categories, two centers, in four categories, three centers, in three categories, two centers, in two categories, four centers, in one category, and three centers with no conformity. Conclusion The results of the present study demonstrate unevenness in the diagnostic centers performance in the classification of mammograms reported to SISMAMA from the opportunistic screening undertaken by SUS. .

Objetivo Avaliar o desempenho dos centros de diagnóstico na classificação dos laudos dos exames de mamografia em rastreamento oportunista do Sistema Único de Saúde (SUS), no município de Goiânia, em 2010. Materiais e Métodos Trata-se de estudo ecológico, em que foram analisadas informações reportadas ao Sistema de Informação do Controle do Câncer de Mama (SISMAMA) pelos centros de diagnóstico que realizavam mamografia de rastreamento para o SUS. A partir da frequência de exames por categoria BI-RADS® e os limites estabelecidos para este estudo, foram calculados os percentuais de conformidade de cada centro de diagnóstico. Consideraram-se como centros de desempenho iguais os que apresentaram percentuais de conformidade iguais. Resultados Quinze centros de diagnóstico realizavam mamografia para o SUS, e estes reportaram 31.198 exames de rastreamento. O desempenho dos centros de diagnóstico com relação às categorias BI-RADS mostrou que nenhum centro apresentou conformidade para todas as categorias, um apresentou conformidade em cinco categorias, dois em quatro categorias, três em três categorias, dois em duas categorias, quatro em uma categoria e três não apresentaram conformidade. Conclusão Os resultados deste trabalho mostraram que houve desigualdade no desempenho dos centros de diagnóstico no que se refere à classificação dos laudos dos exames de mamografia reportados ao SISMAMA do rastreamento oportunista realizado pelo SUS. .

Efetividade de programa de controle de qualidade em mamografia para o Sistema Único de Saúde / Effectiveness of a quality control program in mammography for the Brazilian National Health System / Efectividad de programa de control de calidad en mamografía para el Sistema Nacional de Salud de Brasil

OBJETIVO: Avaliar a efetividade de um programa de controle de qualidade de imagem nos serviços de mamografia da rede do Sistema Único de Saúde. MÉTODOS: Estudo prospectivo com análise temporal do tipo "antes e depois" de uma ação de vigilância em saúde. Participaram do estudo 35 serviços que tinham mamógrafos em operação e realizavam exames regularmente em Goiás entre 2007 e 2009. Foram avaliados os serviços, por testes de desempenho de mamógrafos, processadoras e demais materiais em três visitas técnicas, a qualidade da imagem e a dose de entrada no simulador radiográfico de mama. Cada serviço recebeu uma pontuação correspondente ao percentual dos testes em conformidade com os padrões. RESULTADOS: Os percentuais médios de conformidade dos serviços foram de 64,1% (± 13,3%) na primeira visita, 68,4% (± 15,9%) na segunda e 77,1% (± 13,3%) na terceira (p < 0,001). As principais melhorias foram decorrentes dos ajustes da força de compressão da mama, do controle automático de exposição e do alinhamento da bandeja de compressão. As doses medidas estavam dentro da faixa de conformidade em 80% dos serviços avaliados. CONCLUSÕES: A implantação do programa nos serviços foi efetiva para a melhoria dos parâmetros de operação do mamógrafo, embora 40% dos serviços não tenham alcançado o nível aceitável de 70%. Este resultado indica a necessidade de haver continuidade na vigilância em saúde.

OBJECTIVE: To assess the effectiveness of a quality control program in mammography services of the Brazilian National Health System (SUS). METHODS: A prospective study using temporal analysis of a health surveillance action was conducted. A total of 35 service providers that had mammography equipment in operation and regularly performed exams between 2007 and 2009 in the state of Goiás, Central-Western Brazil, participated in this study. Services were assessed during three site visits by performance testing of mammography equipment, film processors, and other materials, and image quality and entrance surface dose in a phantom were also assessed. Each service was scored according to the percentage of tests that conformed to standards. RESULTS: The mean percentage for compliance among the participating service providers were 64.1% (± 13.3%) in the first visit, 68.4% (± 15.9%) in the second, and 77.1% (± 13.3%) in the third (p < 0.001). The main improvements resulted from adjustments to the breast compression force, the automatic exposure control system, and the alignment of the compression paddle. The doses measured were within the conformity range in 80% of the services assessed. CONCLUSIONS: The implementation of this program in the mammography services was effective at improving the operational parameters of the mammography machines, although 40% of the services did not reach the acceptable level of 70%. This result indicates the need to continue this health surveillance action.

OBJETIVO: Evaluar la efectividad de un programa de control de calidad de imagen en los servicios de mamografía de la red del Sistema Único de Salud. MÉTODOS: Estudio prospectivo con análisis temporal de tipo "antes" y "después" de una acción de vigilancia en salud. Participaron del estudio 35 servicios que tenían mamógrafos operativos y que realizaban exámenes regularmente en el estado de Goiás, Brasil, entre 2007 y 2009. Se evaluaron los servicios, por pruebas de desempeño de mamógrafos , procesadoras y demás materiales en tres visitas técnicas, la calidad de la imagen y la dosis de entrada en el simulador radiográfico de mama. Cada servicio recibió una puntuación correspondiente al porcentaje de las pruebas en conformidad con los patrones. RESULTADOS: Los porcentajes promedio de conformidad de los servicios fueron de 64,1% (+/-13,3%) en la primera visita, 68,4% (+/-15,9%) en la segunda y 77,1% (+/-13,3%) en la tercera (p < 0,001). Las principales mejoras fueron decurrentes de los ajustes de la fuerza de compresión de la mama, del control automático de exposición y del alineamiento de la bandeja de compresión. Las dosis medidas estaban dentro del intervalo de conformidad en 80% de los servicios evaluados. CONCLUSIONES: La implantación del programa en los servicios fue efectiva para la mejora de los parámetros de operación del mamógrafo, a pesar de que 40% de los servicios no hayan alcanzado el nivel aceptable de 70%. Este resultado indica la necesidad de darle continuidad a la vigilancia en salud.

Estimativas da cobertura mamográfica no Estado de Goiás, Brasil / Estimated mammogram coverage in Goiás State, Brazil

Este estudo transversal objetivou estimar a cobertura da mamografia no Estado de Goiás, Brasil, descrevendo sua oferta, demanda e variações para as diversas faixas etárias, tendo como unidades de observação 98 serviços de mamografia. Foram estimados as frequências de realização da mamografia por faixa etária e tipo de sistema de saúde, bem como o número de exames necessários para a cobertura de 70 por cento e 100 por cento da população-alvo. Foi avaliada a associação entre a realização da mamografia, a distribuição geográfica dos mamógrafos, o tipo de atendimento e a faixa etária. As estimativas de cobertura total para 100 por cento das mulheres nas faixas etárias de 40-69 anos e de 50-69 anos foram de 61 por cento e 66 por cento, tendo o Sistema Único de Saúde contribuído com 13 por cento e 14 por cento, respectivamente. Para atingir 70 por cento de cobertura, seria necessário realizar 43.424 mamografias adicionais. Todas as associações apresentaram diferença estatística significativa (p < 0,001). Conclui-se que a cobertura da mamografia está distribuída de maneira desigual no Estado de Goiás e o número de exames realizados é inferior ao necessário.

This cross-sectional study aimed to estimate mammogram coverage in the State of Goiás, Brazil, describing the supply, demand, and variations in different age groups, evaluating 98 mammography services as observational units. We estimated the mammogram rates by age group and type of health service, as well as the number of tests required to cover 70 percent and 100 percent of the target population. We assessed the association between mammograms, geographical distribution of mammography machines, type of service, and age group. Full coverage estimates, considering 100 percent of women in the 40-69 and 50-69-year age brackets, were 61 percent and 66 percent, of which the Brazilian Unified National Health System provided 13 percent and 14 percent, respectively. To achieve 70 percent coverage, 43,424 additional mammograms would be needed. All the associations showed statistically significant differences (p < 0.001). We conclude that mammogram coverage is unevenly distributed in the State of Goiás and that fewer tests are performed than required.