breast cancer care in the czech republic - europa

Breast cancer care in the Czech Republic

Bohuslav Melichar

The Czech Republic

google.com, wikipedia.org, czso.cz

Institute of Biostatistics and Analyses, Masaryk University

Population: 10,512,208

Area: 78,866

km2

GDP per capita: $18,337

Breast cancer screening programme initiated in 2002

•

Screening for cancer of breast, colorectum and uterine cervix is effective in decreasing mortality of the disease

•

These programmes are recommended to all member states by the Council of the European Union (2003/878/EC)

•

To guarantee their effectiveness, safety and cost-effectiveness, it is highly recommended to implement the prevention as organized programmes comprising:

–

an explicit policy, with specified age categories, method and interval of screening–

defined target population–

a management team responsible for the implementation–

a health care team for decisions and care–

a quality assurance structure (performance monitoring including collection of all relevant data)

–

a method for identifying cancer occurrence in the target population

Organised cancer screening programmes

IARC Handbooks of Cancer Prevention


•

Bulletin of Ministry of Health•

Recommended standard

Prepared by•

Association of Czech Breast Radiologists•

Expert Committee on Breast Radiology (Czech Radiological Society)

•

State Office for Nuclear Safety

•

approved by Breast Cancer Screening Committee at the Czech Ministry of Health (MH)

(incl. representatives of MH, expert medical societies, healthcare payers, nuclear safety)

•

outer (incl. physicians, patients) and inner (MH) review process

•

signed by minister of health

Czech National Guidelines


•

target

age groups–

women between 45 and 69 years of age–

the programme is open for women over 70 years of age since 2010–

women are referred to screening examination by their GP or gynaecologist–

no centralised direct invitation yet

•

screening method and interval–

two-view mammography (CC + MLO, recommended double reading)–

2-year screening interval

•

further assessment–

all screening centres also act as assessment units–

most of further assessments are performed on the screening visit

day

Screening programme setting


•

management of the screening programme–

Breast Cancer Screening Committee at the Czech Ministry of Health–

cooperating with•

Association of Czech Breast Radiologists•

Expert Committee on Breast Radiology (Czech Radiological Society)•

Institute of Biostatistics and Analyses, Masaryk University–

nominated regional coordinators, regular visits of centres•

accreditation of screening centres

–

Committee, according to•

requirements for screening units

–

see below•

requirements for diagnostic units

–

equipment, volume, Eur Guidelines•

conditions for mammography reimbursement

–

target population, referral by GP/Gyn, second reading, diagnostic•

screening and diagnostic methods

•

criteria for good radiography

National guidelines


1.

Integration and comprehensiveness of a diagnostic process–

mammography, USG, needle biopsy, available stereotactic, MR, VACB2.

Rapid performance of screening & pre-operative diagnostic procedures

–

negative within 3 days, assessment within 15 days3.

Education and experience of radiologists and radiographers

–

continuosly educated radiologist and radiographer, available physicist4.

Volume of mammography screening examinations

5.

Coverage of the population by the network of screening centres6.

Proper technical equipment of the facility

–

according to Eur Guidelines, maximal age of MG 8 years7.

Adherence to radiation protection guidelines

–

according to Czech law8.

Interdisciplinary cooperation and continuity of care

–

connection to comprehensive cancer care, full multidisciplinary approach9.

Long-lasting continuity of screening process in the centre

10.Performance monitoring by means of data audit (performance indicators)11.Enabling verification of all these requirements

Requirements for breast screening units


CRITERIA FOR A SCREENING CENTER

•

Minumum 5000 women examined yearly•

Minimum of 20 malignant tumors recorded

•

Further assessment rate < 25% in first examination, < 15% in subsequent examination

•

Recall rate < 6%•

Detection rate of ≥

5 per 1000 for first examination, ≥

2 per 1000 for

subsequent examination•

Proportion of stage 2 and higher ≤

30%

•

Proportion of tumors < 10 mm ≥

25%•

N0 ≥

70%

•

Invasive procedures during screening < 10%•

Ratio of surgical intervention for benign/malignant tumors < 25%

Vytvořil Institut biostatistiky a analýz, Masarykova univerzita

WALKTHROUGH OF THE PATIENTS

•

Screening and diagnostic units connected to a multidisciplinary team that convenes regularly (mostly weekly)

•

Multidisciplinary team includes radiologist, breast surgeon, pathologist, medical oncologist and radiation oncologist

•

Decision of treatment strategy before

any therapy

•

National guidelines on breast surgery are being currently created

•

Medical treatment by medical oncologist•

Life-long follow up by medical oncologist


Comprehensive Cancer Care in the Czech Republic


Map of comprehensive cancer centers

COMPREHENSIVE CANCER CENTERS

•

Administration of targeted treatments restricted to comprehensive cancer centers

•

Radiotherapy (linear accelarator units) also mosty restricted to comprehensive cancer centers

•

It is strived to refer as many patients as possible to Comprehensive cancer centers

•

High concentrations of patients represent an opportunity for clinical trials (compensate the limitation of resources for new drugs


Cancer screening information support

Monitoring using Administrative Data

Performance Monitoring using Cancer Screening Registry

Monitoring of Cancer Burden•

epidemiology of cancer in target population•

evaluation of screening programmes impact

•

performance indicators at screening centres•

detection of cancer and precancerous lesions

•

population-based performance indicators•

monitoring of programmes accessibility by target population

Source of data: CZECH NATIONAL CANCER REGISTRY

Source of data: RECOMMENDED HEALTH CARE FACILITIES

Source of data: HEALTH INSURANCE COMPANIES –

NATIONAL REFERENCE CENTRE

Information Support ProviderMASARYK UNIVERSITY, INSTITUTE OF BIOSTATISTICS AND ANALYSES


Comprehensive databases available; however, linkage is not yet possible

About project

News

Epidemiological Epidemiological analysesanalyses

Publications, reports

Analytic tools tutorial Incidence and mortalityIncidence and mortality

Time trendsTime trends

Regional overviewRegional overview

Age of patientsAge of patients

Stage of diseaseStage of disease

International dataInternational data

Comparative standardsComparative standards

Comprehensive overviewComprehensive overview

Epidemiological Epidemiological analysesanalyses

http://www.svod.czhttp://www.svod.cz

On-line portal for cancer epidemiology

Dedicated software for data collection and analysis

Client data management/invitation process

Examinations/results

Data analysis


Data model of central database

SUBJECT

Screening centerSubject ID

Date of birthHealth insurance company

Postal code

SUBJECT

Screening centerSubject ID

Date of birthHealth insurance company

Postal code IMAGING

Imaging methodDate of examinationExamination finding

coded by BI-RADS classificationTabar classification

Axillar lymph nodes’ statusDouble reading consistency

IMAGING

Imaging methodDate of examinationExamination finding

coded by BI-RADS classificationTabar classification

Axillar lymph nodes’ statusDouble reading consistency

HISTOLOGY

Date of biopsy/operationMethod

Localization techniqueSide

Date of histologyResult

ICD-O-3 morphology codeICD-O-3 topography code

ICD-10 classificationpTNM classificationHistological grade

HISTOLOGY

Date of biopsy/operationMethod

Localization techniqueSide

Date of histologyResult

ICD-O-3 morphology codeICD-O-3 topography code

ICD-10 classificationpTNM classificationHistological grade

LESIONS

SideLocalization

ExtentLesion size

LESIONS

SideLocalization

ExtentLesion size


Performance Monitoring of Screening Centres

1.

Attendance by women and their retention

in the programme•

coverage of the target population by screening examination

2.

Indicators of volume•

volume of women screened•

volume of breast cancer cases detected

3.

Performance indicators of the screening processa.

Validity of the screening test (estimates of sensitivity and specificity)•

breast cancer detection rate (number of women diagnosed with cancer per 1,000 screened)

•

further assessment rate

(proportion of screened women undergoing additional examination)

•

recall rate

(proportion of screened women recalled to the screening centre for additional examination)

b.

Quality of preoperative diagnosis•

benign to malignant open biopsy ratioc.

Prognostic factors of detected cancer cases (surrogate for mortality reduction)proportion of advanced cases (TNM stage II+)proportion of invasive cases

•

proportion of invasive cancers

that are node-negative•

proportion of invasive cancers that are 10

or less

mm in size


Feedback reporting to screening centres

KEY PERFORMANCE INDICATORS

Graph of placing

Position among other centres

Statistical summary

•

accredited centers are provided with results of performance monitoring


Dedicated web portal –

www.mamo.cz

INTERACTIVE MAP OF CENTRES

EDUCATIONAL VIDEO

COUNSELLING SERVICE


CLINICAL REGISTRIES

•

Registry MAGISTR for pathologists•

Registry BREAST for targeted drugs


0%

20%

40%

60%

80%

100%

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Time trends in distribution of breast cancer stages

Stag

e di

strib

utio

n

YearStage IVStage IIIStage IIStage I

Invasive breast cancer

Organised breast cancer screening

* DCO, cases diagnosed by autopsy, early deaths, therapy had not been started due to objective reasons etc.

Source of data:

Czech National Cancer Registry

Unknownincomplete recordsobjective reasons*


Time trends in coverage

13,1%

27,9%

33,8%38,1%

44,8%

51,2% 50,0% 51,1%54,4%

0,6%

0%

10%

20%

30%

40%

50%

60%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Cov

erag

e by

exa

min

atio

n(age group 45-69, year 2011: 1,762,887)


Time trends in coverage by age

61.3%58.6% 55.6%

52.1%

44.4%

30.7%

9.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45-49 50-54 55-59 60-64 65-69 70-74 75+

Age group

Cov

erag

e by

exa

min

atio

n(age group 45+, target population in 2011: 2,448,671)

20072008200920102011

Year:


Time trends in coverage by regions

73.4%

63.1%57.5% 56.8% 56.1% 56.0% 55.8% 54.4% 52.8% 51.2% 49.4% 49.3% 49.2% 46.8%

0%10%20%30%40%50%60%70%80%90%

100%

Vysočin

aJih

omoravský

OlomouckýHrad

ecký

Jihoče

skýZlínský

Plzeňsk

ýLibere

ckýMorav

skosle

zský

Karlovar

skýStře

dočeský

Ústecký

Pardubick

ýPrah

a

Region

(age group 45-69, year 2011: 1,762,887 )C

over

age

by e

xam

inat

ion

Year: 20072008200920102011


Coverage by breast cancer screening -

districts

Coverage [%]

Overall coverage: 49.5 %

(range in disctricts14,8-73,9 %)

KT: 59,4

JH: 55,9

ZR: 63,4

KV: 44,2

BR: 44,4

ZN: 57,0

PB: 51,3

CK: 51,4

TR: 68,8

BN: 56,7

OL: 51,7

PT: 56,6

TC: 49,7

JI: 61,8

TA: 62,3

SY: 61,0

PS: 46,2

SU: 54,8

PE: 73,9PI: 63,6

HB: 58,8

FM: 34,0

UO: 49,5

BV: 68,4

CL: 51,3

TU: 38,2

VS: 54,3

LT: 43,5

LN: 28,5

PJ: 52,9OP: 59,2DO: 62,6

ZL: 31,6

HO: 48,9

MB: 56,1

CR: 43,3

RK: 56,2

NJ: 63,0

BK: 63,5

CV: 55,4

KH: 54,0

RA: 44,6

JC: 59,2

PA: 35,9

HK: 52,3NB: 14,8

KO: 43,5

SM: 38,0

CB: 56,2

BO: 58,6

ST: 54,1

LI: 47,8

UH: 50,3

CH: 41,6

VY: 58,1

DC: 55,3

PR: 57,7

NA: 61,8

PV: 35,3

KM: 64,1

JE: 38,1

SO: 53,6

KD: 44,7

ME: 34,0

BE: 55,9PZ: 44,3

PH: 44,3

RO: 46,5

AX: 43,5

TP: 39,1MO: 37,4 JN: 52,1UL: 49,6

KA: 38,4

BM: 60,9

OT: 46,2

PM: 40,1

> 70,0

60,0-70,0

50,0-60,0

40,0-50,0

< 40,0

Women 45-69, Year 2010


KT: 2,6

JH: 4,9

ZR: 4,9

KV: 9,2

ZN: 3,1

BR: 7,9PB: 6,9

CB: 4,8

CK: 6,0

TR: 2,1

BN: 3,7

PT: 2,4

OL: 9,2

JI: 2,7

TA: 5,0

TC: 4,3

SY: 3,1

PS: 7,6

SU: 6,8

PI: 3,1

HB: 3,6

BV: 3,2

LT: 9,5

CL: 5,3

VS: 3,8

LN: 9,5

PJ: 7,4OP: 4,4

PE: 13,5

ZL: 9,3

DO: 2,7

ST: 3,1 FM: 16,7

UO: 11,8

HO: 4,9

MB: 6,2TU: 11,9

RK: 6,5

UH: 4,6

NJ: 4,3

BK: 4,3

CV: 3,8

KH: 6,7

JC: 3,8

RA: 6,8

PR: 2,2

HK: 8,9

CR: 20,3

PA: 16,5JE: 5,2

NB: 19,3

KO: 11,5BE: 3,9

SM: 13,0

BO: 2,7

LI: 4,7

CH: 3,5

VY: 3,4

DC: 2,8

NA: 5,2

KM: 4,1

SO: 4,0

KD: 4,7

PV: 14,0

PZ: 8,0

ME: 12,4

PH: 7,1

RO: 4,6

AX: 8,8

TP: 6,1 JN: 3,2UL: 5,4

MO: 10,4

KA: 8,3

BM: 3,4

OT: 8,3

PM: 10,8

Overall percentage: 7.1%

(range in districts 2.1-20.3 %)

Percentage examined

> 12,5

10,0-12,5

7,5-10,0

5,0-7,5

< 5,0

Annual percentage of women examined with diagnostic mammography

Women 45-69, Year 2010


Summary

•

Czech national breast screening guidelines implement key elements of European Guidelines–

physico-technical quality control of mammography equipment

–

standard for radiography–

quality assurance using key performance indicators

–

system of accreditation–

rapid screening process

–

staff with proper specialised qualification, undergoing continuous education

–

operation within multidisciplinary team

•

Differences from EU Guidelines–

programme is currently not population-based

–

missing linkage of different registries–

not yet including guidelines for pathology and surgery


PROBLEMSDelayed availability of new anticancer agentsLimited and decreasing financial resourcesSystem of payment –

budget rather than the money following the

patientBinding guidelines for therapy currently absent, some patients still managed in local centers in suboptimal conditions


Acknowledgements

Ladislav Dušek, Ph.D.IBA Brno

THANK YOU FOR YOUR ATTENTION

breast cancer care in the czech republic - europa

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