Practitioner Variation of applied Compression Force in Mammography Claire E. Mercer

MSc, BSc(hons)

Structure

Myself and my role

My PhD research

Collaboration

Research findings

Impact

Who am I ?

Lead Radiographer for Breast Imaging at the Nightingale & Genesis Cancer Prevention Centre, University Hospital of South Manchester

Nightingale Centre - one of 5 national training centres in the UK for mammographers

Undertaking my PhD by published works at the University of Salford

1 of 3 editors of a new mammography academic book – published early 2015

Collaborative working

Rita Borgen

Dr.Simon Cassidy

Professor Erika Denton

Dr. Jenny Diffey

Beverley Hilton

Professor Peter Hogg

Judith Kelly

Professor Richard Lawson

Sara Millington

Katy Szczepura

Melanie Taylor

Patsy Whelehan

Collaborative working

Mammographers

Research Radiographers

Consultant Mammographers

Phycologists

Statisticians

Physicists

My research

I’m here to share my research with you

Breast compression

Practitioner variation

Compression force standards

What is mammography?

Mammography is the x-ray examination of the breast tissue, the aim to detect subtle breast changes and pick up early stage disease

Breast screening is carried out by the NHSBSP

Women are routinely called for mammography in a three year cycle

To undertake mammography the breast tissue needs to be compressed in the mammography machine.

First: Quality Standards

Breast Screening

Heavily reliant on service and quality standards

Yet …. No standards for breast compression

What have we got to work with as mammography practitioners?

Not a lot….

‘the force of the compression on the x-ray machine should not exceed 200 Newtons’[1]

Large range to work with 40 to 200N

We can cease compression at any time

We don’t have any standards to work with!

1) NHS Cancer Screening Programmes. (2006). NHSBSP 63. Quality Assurance Guidelines for Mammography. April (42). ISBN 1 84463 028 5.

What is the impact of having no standards for breast compression?

What is the impact of having no standards for breast compression?

• Programme relies on screening attendance

• QA recommendations - over 70% of clients invited

should attend1

• Painful mammography contributes to non-re-

attendance2

• 25-46% citing pain as reason

• Real terms - 47,000 and 87,000 women each year in

England

1. 1. NHS Cancer Screening Programmes. (2006). NHSBSP 63. Quality Assurance Guidelines for Mammography. April (42). ISBN 1 84463 028 5. 2. 2. Whelehan, P., Evans, A., Wells, M., MacGillivray, S. (2013). The effect of mammography pain on repeat participation in breast cancer screening: A systematic review.

Breast, Aug: 22(4), pp.389-94.

No compression standards No evidence to work with

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Let’s get some evidence?

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How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

Let’s get some evidence?

How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

Let’s get some evidence?

KE

Y R

ES

EA

RC

H A

IM

How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

How does the breast behave under compression

Recorded compression and breast thickness 250 clients(1)

Commenced compression at 5daN , increased 1 daN increments

(1) Hogg P, Taylor M, Szczupera K, Mercer C and Denton E, 2013. Pressure and breast thickness in mammography—an exploratory calibration study, British Journal of

Radiology, 2013

Was it an issue that we had no standards for breast compression Was there variation in its application ?

Two studies

Single centre (1) 500 clients Exclusion criteria

One mammo machine

Longitudinal single centre (2) Different 500 clients

3 screening rounds

Same exclusion criteria

Same practitioners

Same mammo machine

(1) Mercer CE, Hogg P, Lawson R, Diffey J, Denton ERE. Practitioner compression force variability in mammography: a preliminary study. Br J Radiol Feb 2013;86:20110596. (2) Mercer C.E, Hogg P, Szczepura K, Denton E.R.E. Practitioner compression force variation in mammography: A 6-year study. Radiography 19 (2013) 200-206 (3) Mercer C.E, Hogg P, Szczepura K, Kelly J, Brogen R, Denton ERE, Millington S, Hilton B. A Multicentre Study of Compression Force in Mammography: Practitioner Variation and Client Effects. IN PRESS

Single centre (1) 500 clients

Compression : low, intermediate or high compression force

(p<0.0001 between each group)

(1) Mercer CE, Hogg P, Lawson R, Diffey J, Denton ERE. Practitioner compression force variability in mammography: a preliminary study. Br J Radiol Feb 2013;86:20110596.

Longitudinal Single Centre (1) 500 clients

• All practitioners perform similarly to first study – relationship between study data Spearmans 0.9

• Practitioners have own ‘set compression behaviours’ – little adaptation

(1) Mercer C.E, Hogg P, Szczepura K, Denton E.R.E. Practitioner compression force variation in mammography: A 6-year study. Radiography 19 (2013) 200-206

Consequences to client experiences over sequential screening

Consequences to client experiences over sequential screening

Multicentre longitudinal study (1)

• 500 clients • 3 sequential screens • 3 different screening centres

(1) Mercer C.E, Szczepura K, Kelly J, Brogen R, Denton ERE, Millington S, Hilton B, Hogg P. A Multicentre Study of Compression Force in Mammography: Practitioner Variation and Client Effects. IN PRESS

Consequences to client experiences over sequential screening

Multicentre longitudinal study (1)

• Clients: large changes over time

• Site 3 -26% change, site 1 & 2 50-60% change

(1) Mercer C.E, Szczepura K, Kelly J, Brogen R, Denton ERE, Millington S, Hilton B, Hogg P. A Multicentre Study of Compression Force in Mammography: Practitioner Variation and Client Effects. IN PRESS

Back to the start Get some evidence? 3 easy steps…

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Back to the start Get some evidence? 3 easy steps…

KE

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EA

RC

H A

IM

How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

Found possible cessation guidelines between 9 and 13daN

Back to the start Get some evidence? 3 easy steps…

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How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

Yes it is an issue Yes there is practitioner variation

Back to the start Get some evidence? 3 easy steps…

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EA

RC

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How the breast behaves when compressed

Was it an issue that we had no standards for breast compression -

Was there variation in its application ?

Consequences to client experiences over sequential screening

Profound effect • Comparison of images over time • Accurate diagnosis

The Future?

• PhD students at the University extending this work • Mammography book:

• key principles of research

• teaching and education

• Focus on new ‘pressure’ paddles[1]

• Establish: • guiding principles for compression force application • develop cessation guidelines • enable more accurate and effective image comparison

over sequential screening

• Encourage clients to re-attend • Consistent client experience • Accurate cancer detection

1.De Groot JE, Broeders MJM, Branderhorst W, den Heeten GJ, Grimbergen CA. A novel approach to mammographic breast compression: Improved standardization and

reduced discomfort by controlling pressure instead of force. Med. Phys. 40 (8), August 2013

Thank you for listening claire.mercer@uhsm.nhs.uk