BREAST SCREENING PROGRAM

HEALTHCARE PROVIDER

INFORMATION MANUAL Version 2

May, 2015

Stanton Territorial Health Authority

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Breast Screening Program

Table Of Contents

Introduction 3

What is the BSP? 5 Screening Process 7 Healthcare Provider and Self-Referral Flowchart 10 Fast-Trac Scheduling 11 Assessment Review 14 Women Who Do Not Qualify 16 Appendices 17

Appendix A: Fast-Trac Authorization letter and form 17 Appendix B: Assessment Review letter and form 19 Appendix C: Sample Letters 21

Normal One Year to Client Normal Two Year to Client Abnormal to Client – GP Participates in Fast-Trac Abnormal to Client – GP Does Not Participate in Fast-Trac Normal One Year to Healthcare Provider Normal Two Year to Healthcare Provider Abnormal to GP that Participates in Fast-Trac Abnormal to GP that Doesn’t Participate in Fast-Trac Follow-Up Physician's Report Return to Screening Post-Abnormal Workup to Client Return to Screening Post-Abnormal Workup to Healthcare Provider One Year Re-call to Client One Year Reminder Re-call to Client Two Year Re-call to Client Two Year Reminder Re-call to Client

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Breast Screening Program

Introduction OUR MISSON is to reduce death from breast cancer by providing eligible women a comprehensive and organized breast screening program. The Breast Screening Program is being delivered under the auspices of Stanton Territorial Health Authority. The program consists of mammography examination and information on breast health. This can only be accomplished by fostering partnerships with health care providers, health authorities and community interest groups. The Breast Screening Program offers biennial mammography screening examinations to women age 50 to 74 in the communities of Yellowknife, N’dilo, Dettah and Behchoko that are asymptomatic, who do not have a personal history of breast cancer, have not had a mammogram in the last twelve months, and have not had breast augmentation (implants). Women age 40 to 49 who request to participate and meet the eligibility requirements may enter the program. For the initial screen, the BSP will require a physician referral to ensure that the harms and benefits of screening have been discussed and the client has made an informed decision to participate. After the initial exam, the BSP will send recall notices to the clients at the recommended interval and they can book an appointment without a referral. Women that are 75 years of age and over and are in good general health may participate as well but will not be recalled.1 Breast cancer is the most frequently diagnosed cancer in Canadian women and the second leading cause of cancer deaths. It accounts for almost one in three cancer diagnosis among Canadian women. An estimated 24,400 women will be diagnosed with breast cancer and 5,000 will die of it. These translate to an average of 470 Canadian women being diagnosed with breast cancer and 96 Canadian women dying of it every week. A woman has a one in 9 chance of developing breast cancer and a one in 30 chance of dying from it over the course of a lifetime. 2 In a report that was published in March 2014 by the Northwest Territories Department of Health and Social Services titled “Cancer in the Northwest Territories 2001-2010” it stated that 33.1% of all cancers in women were breast cancer. One of the strategies for the fight to reduce cancer mortality is early detection through cancer screening. This program is one of those strategies at work.3 Your participation is crucial for the promotion of the program and, most

1 NWT Breast Health Advisory Committee. Breast Cancer Screening Clinical Practice Guidelines for the NWT. Northwest

Territories Department of Health and Social Services, November 2013. 2 Canadian Cancer Society. Canadian Cancer Statistics 2014. Canadian Cancer Society, Statistics Canada, Public

Health Agency of Canada, Provincial/Territorial Cancer Registries, cancer.ca/statistics May 2014. 3 NWT Department of Health and Social Services. Cancer in the Northwest Territories 1990-2000: A Descriptive Report.

February 2004.

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importantly, the early detection and successful treatment of breast cancer in the women of the Yellowknife, N’dilo, Dettah and Behchoko communities. This booklet will provide more information on the programs details including recruitment strategies, reporting mechanisms, follow-up mechanisms and sample letters that are sent to the clients and physicians. The BSP will publish a report bi-ennially containing such information as recruitment rates and compliancy, screening results, abnormal call rates, wait times for results and abnormal results resolutions and cancer detection rates.

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Breast Screening Program

What is the Breast Screening Program (BSP)?

The BSP provides specialized comprehensive breast screening services to women aged 50-74 (target group), 40-49 (who request to participate in the program and have initial physician referral) and those age 75 or over, and in general good health for the earliest possible detection of breast cancer, thus offering the best chance for survival.

The BSP is available to the women of the Yellowknife, N’dilo, Dettah and Behchoko communities.

These services are provided within the context of an organized program which has the following essential components: a population-based outcome, special emphasis on hard-to-reach groups, meticulous quality assurance, outcome data and analysis, information systems and linkages, and women-centered focus.

The screening modality used will be two-view mammography along with information on breast health awareness.

The BSP provides this modality in a single location to a large number of women. The environment is women-centered and the staff is sensitive to the needs of women in this age group.

One of the long-term goals of the BSP is to screen 70% of average risk women aged 50-74 (target group) every two years, 40-49 who request to participate every year and those over 74 every two years.

The BSP will use a recall system to maintain retention and encourage women to remain proactive in their own breast health.

Breast screening is effective.

Numerous randomized control trials have demonstrated that organized mammography screening can reduce mortality by 30% over a 7 to 10 year time frame for women aged 50 to 69. However, this can only be achieved if screening is of very high quality and the women are part of an organized screening program that has the mechanism to recall them every two years.

Mammography

For mammography to be of high quality, it should be performed only with modern digital x-ray equipment. The mammographers providing the examinations should be thoroughly trained in all aspects of mammography. A continuous quality control monitoring system must be

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maintained in accordance with the Canadian Association of Radiologists - Mammography Accreditation Program.

The facility should perform regular audits to assess the accuracy of the results of screening and diagnostic mammography. These include the determination of positive predictive values, cancer detection rates, interval cancer rates, sensitivity and specificity.

Accessibility to all Women

Accessibility to all women in the target age group and the program area must be ensured. Different models are required to break through barriers such as distance. This has been addressed with the inclusion of the Behchoko community by creating a partnership with the community health center and medical travel staff.

Women that currently do not have a family physician that results can be sent to, either normal or abnormal, and wish to participate in the BSP are asked to contact either of the Yellowknife Health and Social Services clinics and request an appointment with any provider that is taking on new clients. Once they have secured a healthcare provider, they are encouraged to contact the BSP to book a mammogram.

Partnership with Healthcare Providers

The most successful source of recruitment is through the healthcare provider. The BSP will work with healthcare providers to encourage them to refer clients directly to the program by providing eligible women in their practice with information from the BSP inviting them to contact the program for an appointment.

Fast-Trac Scheduling for diagnostic follow-up will ensure that clients and their healthcare provider will obtain complete results as soon as possible. The Fast-Trac Scheduling will be explained in greater detail later in this package.

Ongoing Monitoring and Evaluation:

Screening should be evaluated in terms of cancer detection and recruitment of the eligible population. The BSP will collect and evaluate data related to:

1. Identification of the screened population (including demographic, health practices and risk factors).

2. Screening data (including referral rates, cancer detection rates and positive predictive values).

3. Assessment data (including biopsy rates, benign to malignant ratios).

4. Cancer details including histology, tumour size and nodal involvement.

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Breast Screening Program

Screening Process

Eligible women for screening mammograms

Asymptomatic women aged 50-74 years or 40-49 who are requesting to be screened and have made an informed decision by discussing the harms and benefits of screening with their healthcare provider.

Women with personal history of ovarian cancer.

Women with 1st degree family history of breast cancer or ovarian cancer.

Women age 75 or over will be screened on request from a physician or woman herself but will not be automatically re-called.

Women will be screened either annually or biennially up to 74 years of age.

Women in the Yellowknife, N’dilo, Dettah and Behchoko communities. Booking process

Appointments are booked one of three ways: o The client will contact the program directly after being referred by

the clinic or after hearing of the program via any of the advertising methods the program employs.

o The program will contact her after receiving a referral notification from the clinic or healthcare provider.

o Women contact the BSP after receiving their annual/bi-annual re-call letter.

All clients will undergo initial telephone interviews to verify the eligibility to the BSP during the first contact. Eligibility will be confirmed for clients being re-called for annual & bi-annual screening examinations.

The program will book an appointment for the client accordingly.

The client will be notified of an appointment immediately after entering the necessary data into the BSP software.

The clients outside of the Yellowknife area will be notified of appointments through Medical Travel and/or the Community Health Center (CHC).

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Examination Process

All clients will receive a reminder call the day before their exam. Reminder calls for appointments on Mondays or after statutory holidays are done the morning of the appointment.

Paperwork and previous examinations, if applicable, will be prepared for the clients visit at least one day ahead the appointment date.

On the day of mammogram at screening program, the clients will complete a history and life style questionnaire. The staff will provide assistance to clients that request it.

The appointment should take approximately 30 minutes.

Result Dissemination Process

After completion of the mammogram, the examination will be reported by a radiologist.

The results are then entered into the BSP database where result letters are generated for both the healthcare provider and the client. The result is also available electronically on the NWT Electronic Health Record (iEHR), the Hospital Information System (Medi-Patient) and in the Picture Archival Communication System (PACS).

Normal result letters will be sent to the healthcare provider a couple of days before the clients’ letters are mailed.

The BSP makes every effort to send all normal results within two weeks after the examination date. 4

Abnormal Result Letters along with the radiologist report and the type, time and date of the suggested diagnostic follow-up tests is faxed to the healthcare provider as soon as the radiologist reports an abnormal finding. A hard copy of the letter and report are sent via internal mail.

The patient will be called the next day after the healthcare provider is notified and given a predetermined appointment for the suggestive diagnostic test (appointment is changeable according to client’s convenience). **This can be further explained in the Fast-Trac Scheduling Pg 11**

All client cases that required further investigation go through the Assessment Review. Cases that are result in benign or normal without

4 Canadian Breast Cancer Screening Initiative. Report from the Evaluation Indicators Working Group – Guidelines for

Monitoring Breast Cancer Screening Program Performance(3rd Edition) Pg 20-21. Canadian Partnership Against Cancer.

February 2013.

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an intervention are signed off for the BSP medical director or by the BSP program coordinator. Cases that require biopsy or result in a cancer diagnosis are reviewed and signed off by the BSP medical director during an Assessment Review Round Table which is held approximately every 6 months. The medical director and other healthcare professionals are invited to attend.

Annual & Bi-annual Re-call:

Clients will receive a re-call letter from the BSP based upon the radiologist recommendation at the time of the previous screening date.

Re-call letters will be sent out 2 weeks before the first of the month that the client is due for annual/bi-annual examination.

If the BSP does not receive a response from the client, a second reminder is sent 6 weeks after the mailing of the 1st re-call letter.

Healthcare providers and clients may request annual examinations for women that have been recommended bi-annual examinations on special request to the BSP.

Healthcare providers will continue to receive a result from each examination.

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Breast Screening Program (BSP) Self-Referral

Patient Recruitment & Re-call Flow Chart

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Breast Screening Program

Fast-Trac Scheduling When the Breast Screening Program (BSP) first began, it implemented an expedited method for booking clients for follow-up diagnostic imaging tests after they have had an abnormal screen result. It was named Fast-Trac Scheduling. In a report released by Canadian Partnership Against Cancer in February 2013, the wait time from screen to resolution is an important indicator of performance across the entire screening episode from index screen to final diagnosis. An abnormal screen result is associated with anxiety and can have a negative psychological impact on a client, even if follow-up is ultimately benign or normal. The target time from abnormal screen to a completed assessment is 90% completed in 5 weeks or less if no tissue biopsy is indicated and 90% completed in 7 weeks or less if tissue biopsy is indicated. 5 To accomplish this, the BSP created a partnership with the booking staff of the Diagnostic Imaging Department (DI). When the screening radiologist identifies an abnormal screening exam, the following steps occur:

The BSP clerical staff notifies the DI booking clerk of the type of test required and the urgency of the test.

The DI clerk contacts the BSP staff of the appointment date and time.

The BSP notifies both the client and their healthcare provider of the date, time, and type of follow-up appointment and confirms availability.

Clients that are recommended to have the following exams are NOT booked at Stanton:

o Whole breast ultrasound (bi-lateral or uni-lateral) o Image-guided biopsy

The healthcare provider is immediately notified that these clients require imaging that can be provided at a southern facility of their choice and the provider arranges the appointment and contacts medical travel in order to expedite the process. Please see “Expedited Southern Referral Process” pg 12.

In many organized screening programs in Canada, this is not an option. The healthcare provider and the client are both notified by letter that an abnormality was been found. The client is told to contact their healthcare provider for information about getting their follow-up tests booked and the healthcare provider’s office is responsible for booking the appointment. With Fast-Trac

5 Canadian Breast Cancer Screening Initiative. Report from the Evaluation Indicators Working Group: Guidelines for Monitoring Breast Cancer Screening Program Performance (3rd Edition). Canadian Partnership Against Cancer; February, 2013.

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Scheduling, this extra step is deleted and the clients can potentially be booked within 7 days of the original screening mammogram date. As this process could be seen as providing patient care, the BSP has sent a letter of explanation and an authorization form (Appendix A) for all healthcare providers to read, review, sign and return if they wish to participate in the Fast-Trac Scheduling. Healthcare providers that do not sign and return the authorization forms will be responsible for contacting the DI department and booking the follow-up examination for the client. The healthcare providers will also be responsible for notifying the client of the appointment date and time.

Expedited Southern Referral Process The BSP has been able to meet the national target of completing abnormal workups in 5 weeks or less from the date of the screening exam for those that require extra imaging only (e.g. magnification mammography views and ultrasound). This has been achieved through cooperation between the BSP and the Diagnostic Imaging department at Stanton. However, any of the workups that include whole breast ultrasound and large core biopsy cannot be performed at Stanton and must be referred to a southern breast imaging centre. The national target for the completion of these types of workups is 7 weeks or less and the BSP was not been meeting this target. There were many delays noted but one of the biggest was the lag time between a referral being sent to a southern facility and an appointment time being sent back to the referring physicians’ office. After investigation it was found that the main reason for delay was that referrals were being sent without the images and reports from the most recent abnormal exam. Imaging centers require these for preview before booking the most appropriate exam. The BSP and the Yellowknife Health and Social Services Authority (YHSSA) managers developed a process for expediting the referral process.

LPN sends referral to STHA Breast Screening Program (BSP).

BSP will send the referral to Insight once the appropriate diagnostic information is prepared. This couriered within 24 hours.

BSP will fax the originating clinic the way bill number and the date the referral was sent.

LPN will note the way bill # and date sent in the note section of the referral.

When appointment information is received from southern clinic, the LPN will note when the appointment information was received.

LPN will continue with medical travel process and informing patient of appointment.

The timelines will be tracked for Quality Assurance information only.

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Pathway for Southern Referral

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Breast Screening Program

Assessment Review Organized screening programs throughout Canada are expected to maintain the highest level of quality assurance. One of the areas that should be incorporated into a screening program is a procedure for review of diagnostic workup cases. “Screening programs should implement an automatic system for ensuring abnormal mammography results are followed up. A system should be in place to ensure that the primary care provider is contacted if the screening centre does not receive results.” 6

The Breast Screening Program (BSP) has implemented a procedure for reviewing diagnostic cases called Assessment Review. Results from this assessment are sent to the healthcare provider (Appendix B). All diagnostic workup cases are reviewed in the BSP; some as simple as spot compression views to open surgical biopsies. Cases that result in benign or normal without an intervention are signed off for the BSP medical director by the BSP program coordinator. Cases that require biopsy or result in a cancer diagnosis are reviewed and signed off by the BSP medical director during an Assessment Review Round Table which is held approximately every 6 months. The medical director and other healthcare professionals are invited to attend. During this round table, the original abnormal mammogram, all diagnostic imaging and results, and any pathology results if applicable are made available to review. If the medical director is in agreement to the final result, then the case is signed off. The client is either returned to normal routine screening or referred to external assessment if extra imaging is suggested to be performed concurrently with the mammogram if the result is benign or normal. If the result is positive for carcinoma, the client is excluded from the BSP as she no longer qualifies for “screening mammography”. On occasion, the medical director may make further recommendations after having the opportunity to review the case with his peers and having all results presented as a complete case. If this occurs, the BSP then notifies the healthcare provider of the recommendations made as a result of the Assessment Review and the results are entered into the database. The client is then tracked to establish if the final recommendation has been completed. If the recommendation is of high priority, then the medical director will telephone and /or fax the family physician with the recommendation. Once the final

6 Canadian Breast Cancer Screening Initiative. Quality Determinants of Breast Cancer Screening with Mammography in

Canada Pg 33. Canadian Partnership Against Cancer; February, 2013.

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recommendation is completed, the client is either returned to the BSP if benign or excluded if a carcinoma is found. A notification letter is also sent to the client informing her that the entire screening episode has been reviewed, that all extra exams are completed and when she can return to screening. The client is also sent a recall letter at the appropriate interval. If the client cannot return to screening, she is informed to contact her healthcare provider at the next appropriate interval to have further imaging arranged.

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Women Who DO NOT Qualify For The Breast Screening Program

A woman who has any breast symptoms such as:

- Nipple Discharge - Breast Lump - New Onset of Nipple Retraction - Dimpling of the Breast - P’eau d’orange : abnormal skin thickening on the breast - New onset of pain without any previous history of pain

(Woman with pain associated with menstrual cycle or trauma will be retained in the program)

A woman who has a personal history of breast cancer

A woman who has had breast augmentation (implants)

A woman under the age of 40

A woman who has had a mammogram within the past year

A woman that does not have valid NWT health care coverage

Any woman living outside Yellowknife, N’dilo, Dettah and Behchoko

Any woman who may be pregnant or is breast-feeding (A woman may enter the program after 3 months of cessation of breast-feeding)

* Any woman that does not qualify for the Breast Screening Program should be referred to the Diagnostic Imaging (DI) Department for mammography services. All appointments must be booked by the healthcare providers’ clinic and a requisition for the exam must be sent to DI. Call 669-4110 to book an appointment with DI. *

If you have any questions about patient eligibility, please call the Breast Screening Program at 867-765-4020.

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Appendix A

S T A N T O N T E R R I T O R I A L H E A L T H A U T H O R I T Y

B R E A S T S C R E E N I N G P R O G R A M

Letter of Authorization for Diagnostic Imaging Follow-Up Dear Dr. XXXXXX: The Breast Screening Program may have the opportunity to provide its service to women who will identify you as their healthcare provider. On occasion, the Breast Screening Program (BSP) radiologist makes recommendations for further diagnostic mammography or breast ultrasound to be done. The BSP would like to introduce you to our Fast-Trac Scheduling for patient follow-up. The majority of organized breast screening programs in Canada do not have any involvement in the follow-up process of abnormal screening recommendations. The Screening Mammography Program of British Columbia is an exception to the rule. They have developed a system for expediting the completion of the recommended further tests. The BSP Fast-Trac Scheduling is similar. In fact, the Diagnostic Imaging (DI) Department at Stanton Territorial Hospital already uses a similar system to recall patients so the changes, if any, in your practice should be minimal. The Fast-Trac Scheduling works in the following manner:

When a screening abnormality has been found, the healthcare provider is given confirmation of the appointment particulars along with the BSP report. This result is sent approximately 1 day before the client is contacted.

The BSP will inform the patient by phone and mail of the type of tests that need to be done, the appointment date, and the time.

The patient will also be given explicit instructions that if they want to discuss the results of all the tests, they should make an appointment with their health care provider approximately one week after the completion of all suggested tests.

Once the suggested tests are completed, a report from the Diagnostic Imaging Department at Stanton will be sent to the healthcare provider and the BSP.

The healthcare provider will be responsible for coordinating any further investigative procedures that may be suggested from the final report (i.e. surgeon referral, core biopsy).

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Appendix A (cont’d)

All results from such procedures should be forwarded to the Breast Screening Program to complete the patients’ file and to assist in quality assurance monitoring of the program as well as to ensure the subsequent screening be performed at the appropriate interval.

If you wish to take advantage of the Fast-Trac Scheduling for your screened clients, please sign the attached Authorization Form and return it via internal mail to the BSP. By signing this form, you will expedite the follow-up process and eliminate the visit to the healthcare provider’s office for the sole purpose of booking a diagnostic test. If you have any questions, please contact the Breast Screening Program at (867) 765-4020. Sincerely,

Marcia Campbell, RTR, ACR Program Coordinator

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Appendix B Sample Assessment Review Letter April 22, 2014 Dr. XXXXXXXXXX Re: Patient Name Frame Lake Community Health Clinic Birth Date: 6 Jun 1971 312B Old Airport Road THIS: N7418619 Yellowknife, NT X1A 3T3 Screen No./Date: 02/27 Feb 13 ID: A11100195-9 Dear Dr. XXXXXXXXX: The Breast Screening Program (BSP) has an internal review of all abnormal screened clients and their follow-up results. This internal review or Assessment Review is done on a bi-monthly basis. Your patient, Patient Name, recently attended the Breast Screening Program (BSP) and was sent on for abnormal work-up. Her case was part of the most recent Assessment Review. After reviewing her entire screening and follow-up results, Dr. Don Beach has made the following recommendation: Repeat right breast ultrasound in 6 months to confirm stability

Your clinic will be responsible for booking this examination. Please find attached a copy of the report from the Assessment Review. Provided the results from the diagnostic examination are within normal limits, the patient may return to the Breast Screening Program at the appropriate recommended interval. If you have any questions or concerns, please contact Dr. Don Beach, Medical Director, BSP or Marcia Campbell, Program Coordinator, BSP. Thank you,

Marcia Campbell, RTR, ACR Program Coordinator

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Appendix B (cont’d) Sample Assessment Review Form

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Appendix C Sample Letters Normal One Year to client

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Normal Two Year to Client

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Abnormal to Client – GP Participates in Fast-Trac

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Abnormal to Client – GP Does Not Participates in Fast-Trac

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Normal One Year Return to Health Care Provider

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Normal Two Year Return to Healthcare Provider

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Abnormal to GP that Participates in Fast-Trac

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Abnormal to GP that Does Not Participate in Fast-Trac

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Return to Screening Post-Abnormal to Client

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Return to Screening Post-Abnormal to Healthcare Provider

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One Year Re-call to Client

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One Year Reminder Re-call to Client

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Two Year Recall to Client

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Two Year Reminder Re-call to Client