The Finnish Way: Mammography Screening Saves Lives
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Jussi Perkiö, Director, Service Development and Medical Technology, PhD, Hospital Physicist, Suomen Terveystalo Ltd.
The goal of mammography screening is to reduce breast cancer mortality rates by detecting the cancer early enough for efficient treatment to be possible. In Finland, the mortality rates are one of the lowest in the world. One of the reasons is the efficient nationwide screening program.
Finland was the first country in the world to begin a nationwide mammography screening program governed by law in 1987. Beginning with 50-59 y.o. women, the target group was extended to 50-69 y.o. women in 2007. Finland has a high participation rate; almost 90% of the target group undergoes the screening study. Of all the participating women, approx. 3% is recalled to second imaging study and approx. 0.5% is diagnosed with breast cancer and directed to the treatment pathway. Annually, approximately 50 deaths due to breast cancer are prevented by the screening program.
The organizing and funding of mammography screening is the responsibility of more than 300 municipalities. The municipalities typically outsource the screening program as the program is demanding to put up and maintain and not cost-effective to run with low volume of participants. As a result, over 80% of all the nation’s mammography screenings are performed by one operative, a private healthcare service provider, Terveystalo, which has managed to standardize the screening process and obtain large enough volume to maintain very high quality – both clinical and operational quality as well as experienced quality – with low cost.
One of the key points in the process is the utilization of digital technology to allow the primary screening images to be read by specialist radiologists anywhere. This not only promotes equality by putting all the women to be screened in equal position regardless of their location, but also ensures that the specialist radiologists get to screen enough mammograms to maintain high quality in their expertise.
As for the digital imaging technology, it does not necessarily mean FFDM. While it is highly likely that FFDM will be the method of choice in the future, Terveystalo currently uses CR technology for the most part due to its flexibility, cost-effectiveness, and high-enough image quality. Due to advances in detector screen development, the image quality vs. dose levels have met Finnish requirements. Also, tomosynthesis, an inherently FFDM application, is so far not included in the screening process. To meet national requirements, Terveystalo has a technical quality assurance protocol in place, routinely measuring and documenting the whole imaging chain.
From the information technology point-of-view, the backbone of the common nationwide process is a fast and secure nationwide information system. Although screening data cannot be mixed with patient data, the systems, e.g. PACS, can serve both groups simultaneously.
The other key points for the efficient screening process are the high level of standardization and continuous improvement. Apart from the service provider, the process has three important stakeholders:
- Municipalities: appreciate clear contract models, see-through pricing, and reliable and on-demand reporting
- Women to be screened: value flexibility in the scheduling of the imaging study, comfortable and competent imaging study, and clear results without delay
- The national authority responsible for planning and evaluating national cancer screening programs: expect to get the data concerning invitations and findings to further evaluate the statistics, develop the screening program and guiding also political decision-making in the field.
The screening process has to be designed to provide all these and be flexible enough to allow municipality- and consumer-dependent modifications.
Based on experiences in Finland, an efficient mammography screening process is not easy to set up and maintain. However, by combining reliable technology with both medical and process expertise, the results are excellent.
Sharon P
The longest-running, most consistent mammography program is run in Sweden, yet their annual mortality rates of breast cancer are below the European average. And, the most esteemed research studies have found that mammography doesn’t reduce breast cancer mortality, or only in insignificant ways (read “The Mammogram Myth: The Independent Investigation Of Mammography The Medical Profession Doesn’t Want You To Know About” by Rolf Hefti. Also see http://www.TheMammogramMyth.com ).
Considering all of the great dangers/risks involved with mammograms, it is certain that this screening method has caused more harm than good.
Carestream Health
Thank you for the comment, Sharon. We reached out to Jussi Perkiö and he replied with the following:
“Thank you for bringing up the other side of the coin as well. Besides the benefits there always are disadvantages as well and ultimately the question is whether mammography screening is justifiable or not in reducing breast cancer mortality.
“In Finland, the group of over 50-year-old women participating in the screening program have 22% less mortality in breast cancer than those not participating (ref Finnish national institute for health and welfare).
“However, even a good screening program can have also other than purely positive effects.
“One disadvantage of the mass screening is over-diagnosis and over-treatment. Some of the cancers found in the screening process are slowly developing ones which never would develop into a disease requiring treatment. However, as it is not possible to know whether an individual cancer fall into this category, all the cancers are treated resulting in over-treatment.
“One disadvantage is false positives. Some of the findings lead to secondary screening and even biopsies that are ultimately found benign. These examinations and waiting cause needless distress and work.
“The screening program does not find all the cancers. It is possible to get a normal result and develop a cancer between screening time points. Also, using ionizing radiation in the screening adds the risk of getting a breast cancer; in the Finnish program it is estimated that there are 1-2 deaths due to breast cancer per one million screened women (ref Finnish national institute for health and welfare).
“Taking the OECD-countries as a reference, most of the countries have a mammography screening program in place, and a mean survival rate of 83.5%. Both Finland and Sweden are above this average with survival rates of 86.3% and 86.0%, respectively (ref OECD Health Data 2011). Overall, the breast cancer mortality rates have declined in most OECD countries over the past decade. Naturally, the screening program is not the only factor affecting the survival rates; the improvements in the treatment also play a significant role as well as the general awareness of the disease among women.
“The current view within the Finnish authorities is that within the group of women younger than 50 years and 70 years or above do not show enough evidence of mammography screening producing public health total benefit and therefore the inclusion of these age groups in the screening program is not justified.
“It is important to acknowledge the disadvantages of the screening program, continuously assess these with the benefits, and update the screening guidelines accordingly. However, to keep the disadvantages at a minimum within operational guidelines, it is extremely important to maintain a high quality screening process.”