Last autumn, during a press conference held for the publication of the first evaluation report on the German screening programme, Thorsten Kolterjahn, Chairman of the Advisory Board at the Mammography Cooperative, jubilantly stated that there could be no doubt as to the effect of this preventative procedure: ‘The results [of the report] prove that, in Germany, we have succeeded in introducing a programme for the early detection of cancer that is of outstanding quality.’
However, not everyone is as enthusiastic about screening. Critical voices continue to lament the low uptake rate, as well as the benefits of early detection and mainly base this on the quota of false negative and false positive results.
Education, not alienation
One problem with the criticism, however, has been the disagreement among the critics themselves, for the data used for the assessment of advantages and disadvantages was anything but homogenous; the studies quoted too diverse to gain a unified picture. The result was enormous insecurity among women who were deciding for or against participation in the programme. At the beginning of February 2010 the Mammography Cooperative published standardised figures resulting from the analysis and evaluation of comprehensive studies (see info box). In a joint letter, supporters as well as critics called on everybody to use these figures as a reliable and valid basis that helps women in their decision making process.
On the road
The use of mobile screening units is an act of courtesy. After countries such as the UK, the Netherlands and Sweden, where ‘mammobiles’ have become standard in screening programmes, there are now increasing numbers of these trucks seen on German roads, equipped with the latest, low-radiation, digital, full-field mammography systems (FFDM). The reasons for their acquisition may vary, but the objective is the same: Voluntary screening should be as available and comfortable as possible for women.
Indeed, an evaluation of data in the Weser/Ems region has shown that nowhere is the rate of participation as high as with the mobile screening units. Dr Renate Tewaag, head of the Radprax radiology practice and the doctor in charge of the screening programme in the Bergisches Land, Wuppertal, Solingen and Remscheidt areas, confirms this experience: ‘In Germany it’s just unknown for patients to have to drive up to 50km for an examination – particular for a preventative examination. However, that would have been necessary in this rural region, which is why we opted for the mobile solution. And experience has taught us that, in those regions where we meet women half-way, the response to the screening programme is very good.’
An important prerequisite for acceptance is the comfortable ambience and obviously the quality of the systems used: ‘Our mammobile, which has been in use since February 2008, shows the map of the region with mammography screening logos displayed in those sites where the trucks are located. This gives us high recognition and also helps women to identify with the region. The atmosphere inside the trucks is similar to that of a surgery, women feel well-looked after. We have not made any compromises with the technical equipment. With the digital mammography unit from Hologic we deliberately decided on a manufacturer with a wealth of experience in mobile solutions, gained particularly in the Netherlands. Apart from image quality, the stability of the detector and therefore the reliability of the system on the road is an important factor,’ Dr Tewaag points out. A decision that has proved its worth ever since: For two years the mammography system has been running all through the year and without problems – with a usage rate of around 60 participants a day.
Dr Andrea Jachtmann, specialist in Diagnostic Radiology at the Maria Hilf Hospital in Krefeld and responsible for the screening units in Mönchengladbach, Viersen and Krefeld, recounts similarly positive experiences with Hologic technology: ‘The equipment is of high quality, which facilitates an efficient mode of operation. A particular feature is the resolution, which particularly shows the smallest sites of calcification without CAD – an important prerequisite for the success of screening.’ The success in Mönchengladbach/Krefeld proves this relevance: With a detection rate of 0.9%, the unit is among the three best in North Rhine-Westphalia.
Dr Jachtmann and colleagues are currently working with two mobile surgeries, one of which was installed around a year ago, the second just a few months ago: ‘At the beginning of screening our two main sites in Mönchengladbach and Krefeld each had two mammography systems installed but, over the course of the programme, we had to increase this. Meanwhile we now examine up to 240 patients a day. When it came to the extension we were faced with the decision as to whether to modify the existing surgery rooms or to become mobile. Our decision went in favour of mammobiles to make us flexible and, if necessary, meet women half-way. Now we have a fully equipped mobile unit in front of the surgeries in Krefeld and Mönchengladbach respectively.
The decision for more flexibility was also taken because of the hesitant participation rate in the area. ‘With the initial examinations, a response rate of 54% from our point of view is still too low,’ Dr Jachtmann said. ‘However, we realised that the willingness to participate continuously increases through word-of-mouth. In the case of women who participate for the second time, this rate, after all, increases to 82%. So far, our trucks have not yet been used; however, if we find that we can reach more women this way we will start the engines immediately.’
Neither valid data nor mobile screening units will silence all critical voices -- but they don’t have to. The important thing is that they pave the way in the right direction and have a clear objective: To make the decision whether or not to participate in mammography screening as transparent and simple as possible for 10 million women.