Mammography ASSIGNMENT
National Health Service Breast Screening Programme,
(NHSBSP)
Faculty of Health and Social Care Sciences
KINGSTON UNIVERSITY-ST. GEORGE’S,
UNIVERSITY OF LONDON
Professional Practice in Mammography
Post Graduate Certificate (RAM031 & RAM 032)
The college of Radiographers
Post Graduate Award in Mammography Practice
Student No. 0853594
Word Count: 4000
CONTENTS
PAGE NO.

Introduction
3

Breast Screening Unit
4

1st Stage Screening
6

Assessment Clinic
7

Multi Disciplinary Team Meeting (MDM)
8

Radiotherapy
11

Conclusion
15

Annex - 1
16

Annex - 2
17

References
18

Bibliography
22
2
Introduction
‘Breast cancer is the second most common cancer overall worldwide and remains a
major public health problem among women with more than 1.5 million new cases
diagnosed each year’, (Hass et al., 2007), ‘Cancer screening is synonymous with
secondary prevention, in which earlier therapeutic intervention is possible in an
asymptomatic population to identify cancer at an earlier stage than it would have
been diagnosed in the absence of screening’ (De Vita et al., 2008). As stated in
NHSCSP (2010), a greater number of smaller cancers (15mm or less), which are not
detectable by hand, have been found through screening. Hence, I will take this
opportunity to explore the NHSBSP-UK by the experience and knowledge gained
through my visits to the Breast screening unit, Assessment clinic, Multi-Disciplinary
Team Meeting (MDM) and Radiotherapy department according to the Module guide
(2009).
3
Breast Screening Unit
Breast screening is a method of detecting breast cancer at a very early stage,
(NHSBSP, 2009). The expectation is that early diagnosis and treatment lead to a
reduction in mortality from the disease and /or reduction in the severity of the
disease, (De Vita et al., 2008). The routine mammographic screening is an accepted
standard for the early detection of breast cancer and nearly 90% of women diagnosed
with breast cancer will survive their disease at least 5 years, (National Cancer
Institute, NCI, 2010). Screening is distinguished from case detection which occurs
when the woman presents to a General Practitioner (GP) with symptomatic disease.
According to the NHSBSP (2009), in 1986, Professor Sir Patrick Forrest published a
report, ‘Forrest Report’ saying that ‘In the UK, two thirds of women treated for
breast cancer would eventually die from the disease’. This report further states that
‘Screening by mammography can lead to prolongation of life for women aged 50 and
over’. In response to this, in 1988 NHSBSP was set up by the Department of Health
providing free screening to all women aged 50-65 in the UK and this was the first
breast screening programme in the world and national coverage was achieved by the
by the mid 1990s,(ibid). In 2006/2007, statistics showed that for every 1000 woman
aged 50-70 screened, 13.2 cancers were detected and the standardized detection ratio
was 1.41, (NHSBSP, 2008).
The Cancer Reform Strategy (2007), recommended the extension of breast screening
to include women between 47 and 73 years old, guaranteeing that all women will be
screened at least once before the age of 50, and then receives 8 further invitations.
According to this, NHSBSP (2009), the programme is phasing in this extension
screening women aged 47 to 73 starting in 2010 and with the intention to complete
by 2012. At present, 5 breast screening units in the UK have started to implement the
age extension scheme and more women can be diagnosed and treated earlier because
of the changes made. This will be a big challenge for all the breast screening units in
the UK because it means 400,000 more women will be screened every year,
(NHSBSP,
Annual
review,
2009).
‘Digital
Mammography,
another
key
4
recommendation of the cancer reform strategy (2007), is being introduced across the
NHSBSP’, (op.cit).
Clinical trials have found that digital mammography systems are superior for the
detection of cancers in younger women and women with relatively dense breasts,
(Turnbull, 2009). Furthermore, Professor Young explains the advantages of going
digital which include better workflow and possibly more rapid imaging due to
cassette-less operation. Storage, retrieval, copying and transmission of images should
be simplified by computer storage, (ibid). In addition, breast screening units can link
up with NHS’s Picture Archiving Communication Systems, (PACS). According to
my experience, we can immediately see our images both on the mobile and in the
department improving job satisfaction. Mammographers will get less strain on joints
and hands, (Breast screening study day, 2010). I disagree with this, as they will be
expected to go quicker and handle more women per day resulting in possibly more
strain to their joints and hands.
With digital imaging, women will benefit because of the low recall rate, (NCI, 2010)
and further reducing the radiation dose, (Peart, 2005). Cassette-less operation will be
quicker and should reduce women waiting times and increase the daily throughput of
women. But conversely, Peart (2005) further emphasizes the loss of ability to control
radiation dose to the woman and to adjust for density and contrast. The author is
concerned that mammographers will lose the experience of manipulating individual
technical factors working with film processing and perhaps lack of awareness of
radiation protection. The author is aware that mammographers will need their IT
skills improved to operate computers accurately to minimize trouble shooting with
busy clinics. Thankfully, however, Quality control tests will still need to be
accurately performed to enhance image quality and performance, therefore, planned
well thought out training is essential for mammographers, (Breast screening study
day, 2010).
5
1st Stage Screening
Women are invited once in every three years for screening. Their details are obtained
from the GP’s patients list. ‘Breast Screening – the facts’ leaflet in NHSBSP (2009)
will be sent with the invitation letter to help the women to make an informed
decision as to whether they would like to accept their screening invitation or not.
This leaflet further states,’ Mammography is the most reliable way of detecting
breast cancer early, but like other screening tests, it is not perfect’. There is no
guarantee that screening is 100% effective and this is what women need to
understand when deciding whether or not to attend, (NHSBSP, Annual review,
2009). Dr. Joan Austoker recently presented her new draft for the breast screening
leaflet at a breast experts meeting on the morning of 19th January 2010, but sadly
died on the same day in the evening, (The Guardian, 2010 p.41).
Each year thousands of women have their first mammogram. Peart (2005), states that
they come with preconceived notions about the mammogram-stories that they have
heard from friends, relatives or co-workers. They seek compassion, reassurance,
professionalism, education and for some even counseling, (ibid). Every step of the
way, from the time they walk into the department or mobile van to the time the
woman heads for home, both the mammographer and the department is under
assessment. The mammography examination in fact presents a unique opportunity
for us to educate our women.
Women are more likely to return for a routine mammogram and comply with followup requests after a pleasant experience with a mammographer. I think, if the
woman’s first experience with mammography is painful and the mammographer is
unsympathetic, there is a greater chance that the woman will not return for future
mammograms. Woman will also be reluctant to recommend a mammogram to their
friends or family or will perpetuate the myths of mammography being a painful
study, if their first experience is unpleasant.
I understand through my experience, the best way to combat the misconception of
mammography is good communication. We should communicate effectively with
our women throughout the mammogram. This communication should not just be
6
questions and answers. We should always invite questions from the woman, then
listen and encourage further comments. We are able to identify concerns and answer
questions before the woman leaves. We should communicate with women clearly
using eye contact so that woman can reveal any fears or misconceptions. When going
through routine mammographic questioning, we should explain the procedure
helping the woman to feel comfortable and relaxed. It is a good practice for women
new to breast screening to explain the results procedure with the possibility of recall
to reduce getting unnecessary worry if they are recalled as suggested by
CancerBACKUP(2004).
Assessment Clinic
According to NHSBSP (2009), the mammograms are examined and results sent to
the woman and her GP within 2 weeks. In 2008/2009, around 8.6% of women
attending for a first screen and around 3.2% of those attending a subsequent screen
were invited to the assessment clinic for further investigations because a potential
abnormality was detected, (ibid). At the assessment clinic more tests are carried out
at the radiologist’s request. The primary goal of the assessment clinic is to perform
the triple tests, (NHSBSP Pub.49,2005) and achieve a definitive diagnosis.
Lee et al. (2003), describes these tests which may include clinical examination,
mammograms with different angles, paddle views, magnification views, extended
CC views, ultrasound examination, fine needle aspirations, stereo-tactic core biopsies
and ultra sound guided core biopsies. Hass et al. (2007) states that ultrasonography is
primarily used as a diagnostic tool in the evaluation of a positive finding on a
screening mammography. Although ultrasonography is not the first choice procedure
for most assessed women it is safe to use in young women and pregnant women who
present with a breast mass,(ibid). Triple tests can be performed on the same day with
the final diagnosis in 7-10 days when the woman attends the follow up appointment
for results. Most importantly, the woman’s anxiety is reduced and woman can be
educated about her diagnosis by the breast care nurses and have time to consider her
options for care,(Alison,2007). It is the responsibility of the breast care team to
coordinate follow-up and prevent any error of missed details when transferring the
woman to different imaging procedures.
7
Multi Disciplinary Team Meeting (MDM)
The multi disciplinary team meeting is by definition a fixed clinical
commitment,(EJSO Guidelines,2009). For medical staff, this should be counted as
one session or programmed activity and this reflects the time involved in preparation,
the meeting itself and post-meeting administration,(ibid). In order to provide quality
care, the breast care team must work together in a coordinated way such that all
options are considered when discussing possible treatment strategies,(ibid). If a
breast care centre utilizes the multi-disciplinary approach, it gives standard care for
the woman, Siminoff(2006). Furthermore, it avoids the difficulty that woman face in
organizing their care after breast cancer diagnosis, (ibid).
The MDM allows the group to openly discuss treatment options and use evidence
based treatment to plan optimal management of breast cancer,(Alison,2007). Those
taking part in these scheduled meetings include breast surgeons, radiologists,
pathologists, medical and radiation oncologists, mammographers, breast care nurses,
administrative staff, trainees and a dedicated MDT co-coordinator,(EJSO
Guidelines,2009). The MDT co-coordinator should have the responsibility to coordinate this process,(ibid). Furthermore, a record of attendance should be kept, and
trainees should record attendance in their log book,(ibid). Although the MDM is
important for teaching students, it is limited because of their busy schedule of
women’s list. To be effective, it is essential that all participants are present and that
the necessary data is available and prepared ahead of time. During my visits to the
MDM, I understood that communication among team members is essential making
sure the whole team is aware of each patient’s situation.
Working as a team provides the tools to disseminate information to health care
providers and to patients, which will in turn enable constant quality improvement in
breast cancer care, accelerate the classic timeline of diagnosis to treatment and
generate more options to care, (Malin et al., 2006). In a team members work together
to explain the treatment options and their associated outcomes, as well as an
explanation of why there is controversy. In this situation, womens’ values and
preferences can be deliberately included in the decision- making, reducing anxiety
8
and confusion. Alison (2007), illustrates the specific objectives of multi-disciplinary
breast cancer care, (Annex-1).
The MDT should meet on a weekly or fortnightly basis depending on women case
load. A representative from each of the ‘core members’ must be present and video or
telephone conferencing if the meeting is conducted across several sites. All new
patients and those with complex ongoing management issues who would benefit
from a multi-disciplinary discussion should have their cases presented. The multidisciplinary meeting brings together a highly coordinated team composed of
specialists from all the disciplines involved in breast cancer care. The Breast Surgeon
might, for example, recommend further imaging. Ideally the surgeon can review the
films with the radiologist or the images can be reviewed and reported back to the
surgeon. Meanwhile, the surgeon may want to collaborate with the medical
oncologist and discuss the benefits of adjuvant versus neo-adjuvant therapy as stated
by Hass et al. (2007). Other specialities begin to get involved early in treatment
planning, pathology, radiation oncology and psychological services, requiring other
essential staff to be connected, necessary in providing quality breast cancer care.
Women with a strong family history may benefit from genetic testing, (Hass et
al.2007). Young women with breast cancer who are still interested in having children
may need to be referred to a fertility specialist. A pregnant woman with breast cancer
who does not want to terminate her pregnancy may need to be referred to an
Obstetrician and Oncology specialist. Therefore, a truly integrated multi disciplinary
team incorporates surgical and medical scheduling, genetic counseling, nurses and
support staff into the team infrastructure to optimize care, (Alison,2007). It is also
important to include the woman in all these discussions so that shared decision
making is incorporated into the treatment planning.
Collection of data is an extremely useful tool in many aspects of breast cancer care,
(Nance et al.,2005). Data collection and documentation of recommendations should
be performed for each woman, (EJSO Guidelines,2009). To enable an MDM to be
successful a consensus needs to be reached among the members with
recommendations based on best available evidence,(Alison,2007). The structure and
9
running of an MDM is not possible for small cancer units which may lack the
specialization and resources required. By establishing a network between the local
secondary centers and the larger tertiary center, whereby patients can be referred for
discussion, the MDM can positively impact on cancer care for a wider group of
patients. The surgeons who may be working in relative isolation have access to an
MDM as a second opinion. It can be difficult to collect all necessary data on a
woman when different specialities are not working together.
Care for the breast cancer patient is changing rapidly and is affected by the myriad
changes
from
clinical
trials,
new
drug
development
and
advances
in
technology,(Campos,2005). The MDM should bring specialists and scientists
together providing the infrastructure that facilitates new and ongoing researches.
Both NHSBSP and National Cancer Institute should encourage such research
programmes and support with grants. The MDM’s principal aim should be to ensure
that every woman receives optimal treatment as defined by national guidelines
NHSBSP( 2009) and EJSO(2009) , an up to date knowledge of medical literature and
their individual circumstances.
10
Radiotherapy
I visited the radiotherapy department as a part of my clinical visits and learnt that
radiotherapy was a critical and an essential part of the breast cancer treatment.
'Although radiation can be considered as a potential cause of cancer because
radiation damaged DNA causing mutations, but it is because of this DNA damaging
quality that it can also be used to treat cancers’,(Blows, 2005) 'The aim of radiation
therapy is to deliver a precisely measured dose of irradiation to a defined tumour
volume with as minimal damage as possible to surrounding healthy tissues, resulting
in eradication of the tumour, a high quality of life and prolongation of survival at
competitive cost’,(Halperin, Perez & Brady,2008).
Souhami & Tobias(2005), describe that following treatment by surgery alone, local
recurrence of disease in the chest wall, ipsilateral lymph nodes or residual breast
occurs with a frequency of 7-30% and post operative radiotherapy greatly reduces
the
frequency of
local
recurrence.
According
to
the
Cancer
Research
Campaign(CRC) King’s/Cambridge study, the local recurrence is indeed reduced by
radiotherapy (from 30-11% at 10 years) but that survival is unchanged, at least up to
10 years from initial treatment,(ibid).
I met Mrs. R at the assessment clinic. Following confirmation of a breast cancer
diagnosis and appropriate MDT discussion to plan management, the results should be
discussed with the patient, (EJSO Guidelines,2009). According to the results of the
triple tests, Mrs. R was given an appointment one week later to meet and discuss
things further with a breast surgeon. Reaffirmation of information given by the
Radiologist about the pros and cons of surgery options helped Mrs. R to consent for
lumpectomy followed by a course of radiotherapy to avoid local recurrence. The
same breast care nurse was present at this appointment. I think it is important to have
appropriately trained, skilled, knowledgeable nurses available in breast clinics to
give emotional support for the women. On hearing the words ‘cancer’ and
‘radiotherapy’, Mrs. R was very shocked. She was frightened that the radiation
would harm her. She felt she would lose her quality of life and social existence. The
11
breast care nurse and the radiologist spent considerable time with her giving
psychological and emotional support .
Some women with early stage breast cancer will choose mastectomy to avoid the
course of radiation, either due to the logistics of 6 weeks of radiotherapy or due to
fears of radiotherapy,(Halperin, Perez & Brady,2008). An appointment was next
made for her to attend the clinical oncology out-patient department with a family
member or a friend in order to meet her consultant oncologist. She had notice of her
appointment when she was at home post-operatively, waiting for her lumpectomy
scars to heal with the knowledge that her six weeks of radiotherapy loomed ahead.
Radiotherapy can engender many fears for patients. Misinformation is common, and
patient’s family and friends may reinforce these concerns due to lack of information,
(Yarbro, Frogge & Goodman,2005). The need for psychological and emotional
support for her was equally as great as the need for physical and practical care.
Her oncology appointment involved an examination, discussion of her condition,
type and extent of the treatment, treatment procedure, aims of the treatment, side
effects and an agreement about future plans. She understood that she was under the
care of a consultant oncologist who had prescribed radiotherapy for her. It is always
helpful to involve a third party- husband, partner or friend to assist the woman to
recall what has been discussed. I would recommend we provide a recording of the
consultation, which woman may take home and replay at their leisure to gain more
understanding. It is not always enough just to tell women facts or handout a leaflet.
The family members need to ensure that the message has been understood.
Having three consultations with the specialist nurses and the oncologist before
starting treatment, Mrs. R’s particular anxieties were discovered and as far as
possible allayed. Having full information about the procedure, informed consent was
given to have radiotherapy,(The statements of professional conduct, 2004). Before
radiotherapy began she was given a treatment planning appointment. The first step
was to determine the tumour location and its extent. Exact location is very important
to determine the target volume, (Hass et al.2007).
12
For all planning techniques, quality assurance(QA) of the planning process and the
daily treatment delivery is vital. This requires team work by all members of the
radiotherapy department. Written directives for treatment planning, treatment
delivery and quality assurance policies are still necessary. The woman’s treatment
chart is used as a communication tool between staff regarding the details and flow of
treatment and should be easily accessible to all members of the department. The
actual treatment chart may be a computer record. Treatment planning parameters, in
terms of dose and the area to be treated in the radiation field must be clearly
documented in the woman’s chart. The treatment parameters may be entered into a
record and verify computer system that contains all of the information about the
prescription plan. The radiotherapist uses this record and verifies information during
treatment delivery to ensure that all of the planned parameters will be used to treat
the woman.
A treatment decision was made to give external radiotherapy for Mrs. R as a series of
short, daily treatments followed by a boost dose as an out- patient in the radiotherapy
department. According to the Journal of Clinical Oncology(2007), an additional
boost dose of radiation to the original tumour site, reduced the risk of cancer
recurrence in the same breast, though it did not help them live longer,(NCI,2010).
Giving radiotherapy in fewer, but larger doses may be an alternative to standard
radiotherapy for some women with early stage breast cancer, according to a study
published in the New England Journal of Medicine,(2010),(ibid). Once the treatment
area had been finalized, ink markings were made on Mrs. R’s skin to pin point the
exact place where the radiation to be directed.
It was necessary for the patient to be alone in the treatment room, still in supine
position. Although she was continuously watched on closed circuit television and
could be heard on an intercom system, the fundamental sense of being cut off was
hard to remove completely. Much of this natural anxiety can be reduced if the patient
understands the rationale for being alone and has had an opportunity to see the
department and the machines before her first treatment. Giving the treatment in
fractions ensures that less damage is done to normal cells than to cancer cells,
13
(Macmillan&Cancerbackup,2008). The damage to normal cells is mainly temporary,
but is the reason why radiotherapy has some side effects,(ibid).
Mrs. R had some side effects of radiotherapy such as tiredness, loss of appetite, skin
reactions; redness, sore and itchy. At one point Mrs. R’s skin got very sore and her
treatment was delayed for a short time to allow the area to recover. She was required
to have extra time to rest, try to maintain a healthy diet and drink plenty of fluids.
Mrs. R was asked to stop smoking and to have nutritious food during and after
radiotherapy. Research has shown that it may make the radiotherapy more effective
and reduce side effects, (Macmillan&Cancerbackup, 2008). During the treatment she
had regular blood count tests because radiotherapy may affect the bone
marrow,(ibid). She was advised about how to look after her skin during and after the
treatment. It was suggested she wear loose-fittings natural fibre clothes and not to
wear a bra to avoid skin irritation if this rubbed against the treated skin,(op.cit.).
Within 4 weeks after the treatment ends, any side effects experienced gradually
began to wear off. There may be a slight permanent change to the texture of treated
breast and occasionally swelling or thickening around the scar. Menopausal
symptoms such as hot flushes, sleep disturbances, vaginal dryness and emotional
liability related to oestrogen suppression after breast cancer treatment can also occur.
These may temporarily be responsible for a significant effect on a women’s sexual
health, such as a decreased interest in sexual activity, feelings of decreased sexual
attractiveness and ultimately on quality of life,(Hass et al.,2007). Although radiation
therapy is associated with some side effects, it is generally well tolerated and reduces
the risk of local-regional recurrence. Patient education regarding the expected side
effects and long term surveillance plan are key to patient satisfaction,(op.cit.).
Mrs. R had been given an appointment at the end of her treatment with her
oncologist one month after finishing her course of radiotherapy to discuss her
progress. A follow-up evaluation should be performed every three months for a
minimum of 3 years, then every 6-12 months for the next 2 years , then
annually,(Hass,2007). Follow-up recommendations are in Annex-2, (ibid). Survival
14
rates based on stage distribution following a radiation therapy were 97.9% for
localized disease, 81.3% for regional disease and 26.1% in women with distinct
disease,(op.cit.). National Cancer Institute(2010), states that nearly 90% of women
diagnosed with breast cancer will survive their disease at least 5 years. Given these
facts, it further states that lumpectomy followed by radiotherapy has replaced
mastectomy as the preferred surgical approach for treating women with early stage
breast cancer.
Conclusion :
Professor Ann Keen has mentioned that, ‘ Recent statistics show that the number of
women in the UK dying from breast cancer has fallen to its lowest level in almost 40
years’.(NHSBSP-Annual review,2009). This decline in breast cancer mortality rates
is proof of the real improvements in our cancer services and a tribute to the continued
progress made by the NHS Breast Cancer Screening Programme,(ibid). Former
Prime Minister(PM), Gordon Brown referred to the screening programme in the first
of the prime ministerial debates on ITV on 15th April 2010 and David Cameron
accused the PM of not increasing NHS budgets and argued that cancer outcomes
have not improved under the labour government. Brown replied, ‘If people get early
detection ,and that means screening, I had a woman write to me who said that she
would not be alive today if we had not introduced the age extended breast screening
and we had not given her the chance to see a specialist in 2 weeks’(NHSCSP,2010).
Mammography often demonstrates a breast cancer before it is clinically evident,
(Souhami & Tobias,2005). Therefore, I would like to thank all of the academic and
non-academic staff of the Professional Practice in Mammography,2009 course for
helping me to enhance my knowledge and skills to become a better mammographer
to participate actively in the NHSBSP,UK.
15
Annex-1
As stated in Alison (2007), Specific objectives of multidisciplinary breast cancer care
are,

Integrate physicians and practitioners involved in breast care into a practice
group that will re-engineer diagnostic and treatment plans to maximize
quality and minimize inefficiency.

Encourage and facilitate effective communication between all specialities
involved with patient care.

Create an organizational system and an environment to ease the passage of
patients through the maze of processes and decisions at a time of emotional
crisis: shared decision making, visit preparation, patient education, and
patient navigation.

Establish treatment plans based on presenting symptoms, stage of disease
along with a set of quality outcomes (including patient satisfaction)and
measures, back up by established literature, and evolving internal experience
which can then be used to track quality of care.

Use team approach that facilitates patient focus, constant quality
improvement approach to care. Such a system will also be used to automate
processes of follow-up and tracking, to reduce error and improve services.

Educate to facilitate, arrange and transition to new systems of care and to
make transparent the basis for treatment recommendations.
16
Annex-2
Follow-Up recommendations according to the Hass et al., (2007),
The evaluation should include the following:
*History and physical examination
*Careful visual inspection and physical examination of the breast and regional
lymphatic bearing areas.
*Circumferential measurements of the mid hand, wrist, forearm, and upper arm of
both upper extremities and evidence of lymph oedema.
*Appropriate radiographic studies. Women treated with breast conserving therapy
should have their first post-treatment mammogram approximately 6 months after
completion of radiation therapy, then annually or as indicated for surveillance of
abnormalities. If stability of mammographic findings is achieved, mammography
can be performed yearly thereafter. All women with a prior diagnosis of breast
cancer should have yearly mammographic evaluation of the contra-lateral breast.
*Radiograph or laboratory studies as clinically indicated. There is insufficient data to
suggest routine use of complete blood counts, automated chemistries, chest
radiographs, bone scans, liver ultrasounds, CT scans and carcinoembryonic
antigen (CEA), CA-15-3, or CA27.29 tumour markers for breast cancer
surveillance.
*Pelvic examination with appropriate Pap smear annually. If patient is in tamoxifen,
ultrasonography examination or endometrial biopsy should be performed annually
to evaluate for evidence of endometrial carcinoma.
17
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18
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19
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