Organized Breast Cancer Screening Programs in Canada - Report on Program Performance in 2001 and 2002

Summary and Future Directions

The availability of performance measures and targets allows for the continuous improvement of the quality of organized screening programs. Although most performance targets for organized programs were met, the current evaluation indicates three areas on which to concentrate future efforts for improvement: capacity, referral practices, and timeliness of diagnostic follow-up.

Although organized screening programs have expanded and grown significantly, no program currently meets the performance target of screening at least 70% of the target population. Organized programs can offer benefits that include: a population-based outcome goal, special emphasis on hard-to-reach communities, organized quality assurance including equipment and interpretation, high quality diagnosis and follow-up and outcome data and performance measurement, as presented in this report. Greater participation in organized screening programs by women aged 50 to 69 will bring the benefits of breast cancer screening to more Canadian women. Continued progress toward a 70% participation target will require that issues of program capacity and the growing target population be addressed.

For the period covered in this report, performance targets for the proportion of screened women who receive an abnormal screening result (abnormal call rate) were not met. Increased support for expanding programs will be critical to ensure optimum implementation of guidelines recommended by the Quality Determinants Working Group of the National Committee for the CBCSI¹². Continued monitoring of abnormal call rates will be critical, as will ongoing efforts to reduce these rates while maintaining optimum cancer detection rates.

Although timeliness of diagnostic follow-up has improved only slightly in the four years since national targets were adopted, several individual programs have made remarkable strides in expediting the diagnostic work-up after an abnormal screening examination. In order to achieve performance targets set for diagnostic follow-up, further evaluation and exchange of various effective strategies may allow other programs to enhance their own processes. Evaluation of new strategies to improve the timeliness of surgical assessment will be critical in order to achieve targets for the interval from screen to diagnosis for women requiring biopsy to confirm their diagnosis.

The goal of monitoring and evaluating organized breast cancer screening programs in Canada is to promote high-quality screening, ultimately leading to reductions in breast cancer mortality and morbidity and the minimization of the unwanted effects of screening. Although a number of new technologies are on the horizon, new screening modalities are unlikely to replace mammography in the near future for screening the general population²¹. Mammography remains the only breast screening modality proven to reduce mortality from breast cancer in the population. Monitoring efforts, such as those reported here, continue to be critical in order to provide women with an accurate picture of the benefits and harms of participation in screening programs. Ongoing monitoring and evaluation is a necessary mechanism to provide direction for programs in their continuous efforts to provide high-quality screening and to reduce the burden of breast cancer mortality on Canadian women and their families.

Organized breast cancer screening programs have grown and evolved substantially since the inception of the first program in 1988. With many programs surpassing their 10-year anniversary, it is becoming timely for a formal evaluation of the impact of screening on mortality in the population. Critical areas for national, evidence- based, guideline development include the screening of women aged 40 to 49 and 70 to 79, a practice that is being increasingly adopted both within and external to screening programs.

Breast screening programs are also encountering challenges that cross disease boundaries. For example, recruitment and recall strategies for breast, cervical and in the future, colorectal cancer screening will need to be examined in an integrative fashion. Health systems issues including health human resources, training and capacity in the cancer care sector cross disease boundaries. Issues pertaining to breast cancer screening remain critical components both within the disease-specific Canadian Breast Cancer Screening Initiative and as a component of a broader Canadian Strategy for Cancer Control.

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