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Title and Description
Luxembourg digital mammography programme
Reviewed/ candidate case
Quality reviewed case
Short description
The Luxembourg mammography programme was one of the first in Europe. Running since 1992, it regularly reviews its performance, and follows clear European guidelines. In 2004 it became digital.
Objectives and purpose
1) The programme aims to reduce the numbers of women in Luxembourg who might develop breast cancer. Indeed, it has considerably reduced the numbers who develop breast cancer since the programme began. 2) The programme is national; although coordinated in a single centre in Luxembourg city, it is federated throughout the country; it operates continuously. 3) The system has been developed through Luxembourg-based expertise, and has very much involved its clinical staff. The team has also coordinated with staff in other neighbouring countries (e.g., three German and one French hospital), and wider collaborations.
Detailed description
Many of the screening programs throughout Europe are based on analogue radiology technology and have optimized their workflow accordingly. So was the Luxembourg mammography screening programme set up in 1992. However digital radiology technology has had an enormous development in the last decade and having becoming the standard of new installations today. The digital mammographic imaging screening trial - DMIST has proven digital imaging to be equally or even better suited for mammography. Screening programmes are now faced with the challenge of incorporating the digital technology. This includes implementation of electronic image exchange, conception of new electronic workflows, establishing adapted quality assurance programmes and training of radiologists and technical personnel. The Luxembourg mammography programme is a nationwide population-based breast cancer screening programme for some 45,000 Luxembourg women aged between 50-69 years. Women receive an invitation every second year. Images can be taken in nine certified radiological centres in Luxembourg, where also a first reading is conducted. All images are read a second time in the coordination centre of the programme by a radiologist reading more than 10 000 mammograms per year. In case of divergence between first and second opinion, a third reading is organised in the coordination centre with both radiologists who have to provide a consensus result. The results of a mammography reading as well as treatment recommendations are transmitted to the woman’s physician, who notifies her. The ‘Programme Mammographie’ keeps all mammograms in a central archive. These images are sent to the radiological units at subsequent screening rounds upon request.
Since 2004, the workflow described above is supported by a screening information system (SIS) specifically developed for this purpose. In a first phase the SIS was integrated into several hospitals without a radiology information system. They were directly connected to the coordination centre for storing digital images via Luxembourgs secure healthcare network HealthNet. For hospitals with a stand-alone radiology information system a special interface was developed during the second phase of the programme in 2005. This interface allows for access by the coordination centre supporting second opinion.
During appointment, women obtain a unique identifier generated by the screening information system. Therewith it is ensured that all further mammograms refer to this identifier even if the images are stored locally at different hospitals. The coordination centre makes the prior analogue images available in digitised form by using a high-resolution scanner and special software. This avoids the problem of having to read alternating analogue and digital images for the same patient.
The prime beneficiaries of the scheme are Luxembourg’s women. So too, the public health authority (in terms of more effective and efficient service), and ultimately the country’s Sickness Fund because of decreasing cancer rates.
Funding
The development of the system was originally financed from three sources: Luxembourg’s Ministry of Finance, the country’s cancer control programme, and its Sickness Fund.
Interoperability and standards
There is interoperability between the central coordinating centre and the nine distributed screening centres.
The scheme was developed originally with clinicians from other European countries, aggregated from pilot initiatives that took place in nine separate countries.
The programme is in line with the European Commission’s 2006 European Guidelines for Quality Assurance in breast cancer screening and diagnosis, developed over the 2001/2 period: http://ec.europa.eu/health/ph_projects/2002/cancer/fp_cancer_2002_ext_guid_01.pdf
The programme respects commonly acknowledged standards e.g., HL7.
Timescale
Start of planning
1991
1st milestone
The programme was introduced in 1992. The mammography programme was the first in the country to be introduced after a revision of Luxembourg’s health law (Article 17) in 1992 in relation to different health centres interacting. In 2001 ‘Programme Mammographie’ started to develop a Screening Information System (SIS) in cooperation with the Public Research Centre Henri Tudor (CRP-HT) and Agfa, a private radiology device supplier.
2nd milestone
2004: Systematic shift from analogue to digital images.
3rd milestone
The introduction of an entirely new technology system. The system is coordinated in a single centre in the city of Luxembourg, although it is decentralised throughout nine other hospitals in Luxembourg.
Start of routine operation
1992
Evaluation
Ongoing
Characteristic of the application
Country
Luxembourg
Part in the healthcare chain
Health promotion, e.g. Information to citizens, vaccination
Diagnosis
Level of Implementation
Country-wide
Technology
Customised solution
Details on Technology
The software was developed in conjunction with Luxembourg’s Research Centre, the Public Research Centre (CRP) Henri Tudor The quality assurance software, called MoniQA, was developed by the Leuvens Universitair Centrum voor Medische Fysica in de Radiologie (LUCMFR) of Belgium Several Luxembourg-based information systems: Healthnet, E-gate, the State Informatics centre information system, the Luxembourg Ministry of Health internal network, and a radiology information systems (RIS)/PACS system have all been brought together. The digital imaging technologies are a commercial solution provided by Agfa. The system is compatible with HL7.
The service is renowned for its continuous evaluation of its processes and procedures. These are well written-up in the research literature. But have also resulted in some well-known guidelines that are publicly available.
- women’s health in Luxembourg in relation to breast cancer has vastly improved. The majority of Luxembourg women now respond regularly to an invitation to be screened (60 per cent in 2001; only 9 per cent before 1992). - 350 cancers are detected every year, but usually at a very early stage. - The double checking method helps to distinguish between false positives and false negatives.
Wider impact
- The scheme (with its local expertise combined with international teams) is enabling Luxembourg to think about its role as a country which is a) in its own way as a small country developing good practice), and b) interacting in a cross-border way with other neighbouring countries. - The scheme is enabling Luxembourg to consider what are its domains and centres of health specialism.
Results expected?
It would be difficult to say that today’s situation was entirely what was expected in 1991. The main focus originally was on the potential clinical outcomes. However, structural, organisational, access quality economic and safety, improvements have occurred steadily over time. Certainly:
- the organisational framework has become much clearly. - workflow has improved. - teamwork and personnel understanding of the processes has been enhanced. - quality assurance has improved (e.g., through double reading; through archiving of images).
Success factors
Success factors have included: - the initiative’s leadership and the involvement of three major funding mechanisms in the country - the development of the initiative over time (i.e., having a precursor project) - optimising the standardisation of the facilities and the software involved.
Failure factors
The connection of nine screening units present a realistic solution for Luxembourg, but initial experiences show that it is not scaleable. Therefore, standardised partial solutions to exchange images in the digital screening environment will be needed when more screening units or centres are to be connected. The implementation of new digital techniques into screening also requires new quality assurance concepts including the automated evaluation by dedicated software. Multidisciplinary teaching and adequate training programmes for screening administrators, radiologists, radiographers, medical physicists and information technology specialists are vital in order to ensure that all experts involved in screening activities are speaking the same language.
References
References and dissemination
The Luxembourg Ministry of Health website http://www.ms.etat.lu/ See especially ‘Direction de la Santé/Publications’. See also http://www.mammographie.public.lu/publications/index.html
The Mammography Programme’s list of publications includes items of general information (guides - including a guide of good practice, brochures, and procedures). Scientific papers include ‘Results of 10 years of screening in the Grand-Duché of Luxembourg’ and ‘The European breast screening cancer network’). There have been radio and television programmes on the subject.
Two examples of (many more) research papers written over a 10-year period available (sometimes at cost) on journal publishing websites include:
(2008) Organisational aspects of mammography screening in digital settings: first experiences of Luxembourg http://rpd.oxfordjournals.org/cgi/content/abstract/129/1-3/195
(2000) Breast cancer screening pathology: an assessment of the practice and needs in Belgium and Luxembourg http://www.springerlink.com/content/tvawqc34lf61r0cc/
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