Evidence-Based Practice Project
3-D Mammography Detection and Breast Cancer Survival Rates
Daniel J. Hartley
University of North Carolina Wilmington
NSG 415 Nursing Research
December 7, 2018
Abstract
Background: Breast cancer is the most frequently occurring cancer among women throughout the world. Furthermore, it can be diagnosed in males, but is far less likely. It is responsible for claiming the lives of thousands of people each year. With advancing technology, this type of cancer is being caught and treated sooner. The main diagnostic test for breast cancer is a mammogram; however, 3-D mammograms are becoming more useful in detection.
Purpose: Using the Evidence-Based PET model, the purpose of this project is to determine whether 3-D mammography is more useful in detecting breast cancer than traditional 2-D mammography.
Method: A literature review was performed through Randall Library’s ProQuest Summon aggregated search service. Seven articles were selected for review, including five research articles and two meta-analyses. The literature included a questionnaire sent to residents to determine their knowledge of breast cancer, a study on breast cancer detection in one specific city, and some reviews of cancer screenings.
Results: Throughout the studies, there was an overwhelming correlation that 3-D mammography of the breasts yielded earlier detection and greater survival rates. Although there were some limitations within the studies, this was the concluded result, overall.
Conclusion: Because it is a newer test, 3-D mammography is not always completely covered by insurance. Although this is the case, it is normally worth spending the money to detect possible cancer diagnoses. As further studies are being conducted and published, an increasing number of insurance companies are covering this diagnostic procedure.
Implications to Nursing: A change in diagnostic testing to 3-D mammograms are reasonable given the higher detection and survival rates of breast cancer. To effectively integrate this into practice, cooperation from the entire healthcare team is needed. Such providers include nursing staff, radiologists, radiology technicians, social workers and primary health care providers. By including these people there could be a tremendous change within the breast cancer trajectory.
3-D Mammography Detection and Breast Cancer Survival Rate
Altering lives and families for many years, breast cancer has been one of the most internationally prevalent diseases among women. To be more precise, approximately 330,000 women will be diagnosed with breast cancer this year in the United States. Of this number, about 266,000 will be diagnosed with invasive breast cancer. Unfortunately, women are not the only victims of this disease. Roughly 2,550 men will also be diagnosed with breast cancer in the United States, this year (Breast Cancer – Statistics, 2018). As more research continues to be done and findings are released, more women are having annual mammograms and doing self-breast examinations each month.
Technology has recently allowed women to receive 3-D mammograms, allowing for better viewing of the breast and surrounding tissues. 3-D mammograms take approximately the same amount of time as a traditional 2-D mammogram, yet the results provide a greater amount of information and the ability to detect even minute cases. In one study, 454,850 breast cancer examinations were reviewed. Of these, 281,187 were done with digital breast tomosynthesis mammography, compared to traditional mammograms. Forty-one percent more invasive cancers were found because of the technological advancement (Bernstein, 2014).
3-D mammograms are becoming a more widespread practice, as more insurance companies are agreeing to cover the increased cost. These procedures are helping to save the lives of many individuals and their families, as early detection of cancer can lead to a faster plan of action to fight the disease. As younger adults often have their focuses set on other life happenings, it can be forgotten that they could be diagnosed, also. There is a 5% chance that women under the age of 40 will be diagnosed with breast cancer (Breast Cancer Under, 2015).
Using the Evidence-Based PET Model, the purpose of this paper is to establish whether patients who receive 3-D mammograms have a greater chance of survival. The paper will be based and directed on the PICOT question: Do breast cancer patients (P) who receive 3-D mammograms (I), compared to those who receive traditional mammograms (C), have a higher survival rate of breast cancer (O)?
Synthesis of Evidence
Selection of the Articles
As I began my search for articles, I knew just the place to look. The university has a great database within Randall Library that is full of useful resources. I performed the following searches: “3-D mammography and detection” and “3-D mammography accuracy.” I was able narrow down these selections by looking at only research journals, as well as titles that were pertinent to the topic at hand. Furthermore, I continued my search on Google.com, where I searched some of the same keywords that I did in the library database. I was also able to narrow down these results by also looking for research articles and relevant titles. Because breast cancer affects so many families and individuals internationally, there were many articles that were written in other languages. This boundary was able to narrow down many of the search results. Some of the additional parameters I used were articles that had the full text available, articles that were peer-reviewed, and articles that were published within the last five years. As 3-D mammography is still somewhat new, there were not many articles published outside of the five-year window.
When I read through the articles, I was able to find some really great information that I feel expanded not only my knowledge of mammography and its techniques, but also my understanding of breast cancer and how it affects individuals and their families. With so many different articles to sort through, I was able to read through each of the abstracts to determine with ones would be most useful and provide the most information for my evidence based practice paper. Additionally, I was able to read through the methods and collected data. This was much more difficult than I thought it would be because there were so many authors’ contributions, as well as medical language I did not completely understand.
Of the seven articles that I selected, five of them are research articles and two were meta-analyses. The evidence hierarchy of each selected article were analyzed and reviewed. Using the Rating System for Hierarchy of Evidence provided by Melnyk and Fineout-Overholt (as cited in Schmidt & Brown, 2015), two were a Level I, three were a Level II, one was a Level III, and one was a Level V. This was determined as two of the studies were meta-analyses, one was a survey, three were randomized controlled studies, and one was a controlled study without randomization (Table 1).
Critique of the Articles
Throughout reading these articles, there were some strengths and limitations that I was able to easily identify. As a whole, the articles gathered data from many different mammogram screenings. None of the studies were done based on a single screening. I feel that by doing this, each article was given greater validity of their results. Furthermore, each article made use of numerical data and comparisons. This made the findings more transparent and allowed them to be easier understood and interpreted. One main shortcoming, however, was that none of the articles examined males with breast cancer. Each of the studies main focus were women, mainly over the age of 40. I feel that this added limitations on the topic, as a whole.
In one articles, fourteen researchers examined over 500 mammography screenings (Lee et al., 2014). While I understand the efficiency of using more examiners, this adds more margin for error within the study. If each of the people were not properly trained using a consistent training method, each of examinations could have been interpreted differently, depending on who the person was reviewing the screening. In this study, “an additional 0.5 deaths were averted and 405 false-positive finding avoided per 1000 women” (Lee et al., 2014). In another study, questionnaires were passed out in one Brazilian city called Campo Grande, Mato Grasso Do Sol (Adriane et al., 2016). This focus on location could provide limitations, while also providing some strengths. One main limitation is that the questionnaire was distributed to only one city in Brazil. Without any specific background, we cannot determine what the socioeconomic class of these citizens were, the education these people received, or if these residents had access to helpful resources and medical centers. If these people are more educated, or have readily available resources, their responses will not be a complete and accurate depiction of the knowledge of mammography for all Brazilian citizens. The results were that when compared to nurses, doctors had a significantly different amount of knowledge regarding early detection (Adriane et al., 2016). The study responses may have been much different if the researchers had gone to more rural places, where the access to certain knowledge is sparse.
In one study done to determine the integration of 3-D mammography, the researchers only studied women who were over the age of 48 (Ciatto et al., 2013). This provides a great limitation to the study, granted the age restriction. As more research is conducted worldwide, we are learning that even more people are being diagnosed with breast cancer at a younger age, many under the age of 40. If this study would have broadened the age, I feel that their results would have been much different. Overall, the conclusion was that “conditional recall could have reduced false positives by 17.2% without missing any of the cancers detected in the study population” (Ciatto et al., 2013).
With all things taken into consideration, each of these studies provided great data and conclusions that can be used throughout the clinical setting. In the study performed by Lee, and associates, they looked at the cost-effectiveness of 3-D mammography. Their data showed that by detecting cancer early using 3-D mammography, individuals can save more money than by having to pay for treatment for a cancer that was overlooked. Specifically, the cost of each quality-adjusted year of life was $53,893. Of 1000 screenings, 405 false-positives were avoided, as well. This not only saves the patient money, but it also ensures that they are not having to undergo more invasive testing, as well as incurring any emotional distress that accompanies fighting a serious illness.
Remaining mostly the same throughout each study was that 3-D mammography provided better cancer screenings for patients. This can be something that doctors, nurses, and other healthcare providers are encouraging their patients to do to prevent any unneeded expenses, lifestyle changes, or emotional trauma. In these studies, I would recommend that they consider also performing screenings on men. This would provide more comprehensive findings, as well as potentially bringing further awareness to males and their risk for being diagnosed with breast cancer. By working together and drawing conclusions off conducted research, it is hopeful that the number of survivors will increase, while the number of non-survivors decreases.
Translation – Fit and Feasibility
This portion of the project is to reflect on all parts of the studies and determine if the use of 3-D mammography leads to earlier detection of breast cancer, thus leading to increased survival rates. The studies’ samples and environments will be analyzed to see if the proposed evidence based practice can be implemented in the discussed settings, effectively. In addition to this, potential stakeholders and resources will be addressed.
Comparisons and Recommendations
Samples: In five of the studies, the sample was patients who had already underwent their breast cancer screenings (Lee et al., 2014; Greenberg et al., 2014; Houssami et al., 2017; Kaniklidis, 2015; Yaffe, 2016). Their results were studied and conclusions were drawn from this data. One of the studies was simply a questionnaire that was distributed to residents of Campo Grande, Mato Grosso do Sol (Adriane et al., 2016) by healthcare providers in the area. The last study was one where 2-D mammograms and 3-D mammograms were performed (Ciatto et al., 2013) and the results were reviewed. The proposed area for the implementation of this project is in radiology offices and in hospital settings, where women would traditionally go for a mammogram, and whose patient population is over the age of 40. The age of 40 is recommended for women to begin getting their mammograms and at the age of 45, they should begin getting them on a yearly basis. Given this information and the similarity of the sample population to the proposed sample, the findings of the literature can be effectively applied.
Environment: In most of the literature in which I analyzed, the studies were done in radiology offices after the tests had been conducted. The one study that was different was conducted throughout a city, called Campo Grande, Mato Grosso Do Sol. Throughout the studies, there was a lack of background information about the type of settings that were used.
Resources: For most patients, 2-D mammography is covered by their medical insurance, as it is a preventative test. Medicaid and Medicare also cover the cost of these tests. Because of the Affordable Care Act, which was passed in September 2010, newly-enrolled health insurance plans must pay for the cost of a mammogram every 1-2 years without any cost to the patient, if they are over the age of 40 (Coverage, 2018). The average cost out of pocket for a 2-D mammogram is $286.62, while the average cost of a 3-D mammogram is $378.02 (Introducing, 2017). While there is an increase in this cost, it is important that patients, especially those with a family history of breast cancer or breast related conditions, be informed of the effectiveness of 3-D mammography. By paying the extra money to have a 3-D mammogram done, women could save thousands of dollars, as well as their health. Moving over towards 3-D mammography strictly is likely not something that will happen, as there are still many people who prefer traditional mammograms; however, with the education from the radiologists, nurses, technicians, and other health care staff, more patients will realize the benefits and begin to utilize the advanced technology.
Translation Path Recommendations
Evaluations and Rationale
In this evidence based practice project, seven articles were analyzed and studied to determine whether or not 3-D mammograms yielded an early detection of breast cancer and increased survival rates. Based on the conclusions drawn from the articles, a shift toward 3-D mammogram usage in radiology clinic and hospitals is recommended.
Evaluation: The area in which I chose for possible implementation is similar to that of which the studies I reviewed. Because of this, the usage of 3-D digital breast tomosynthesis could allow for early detection among many patients, potentially saving many lives. Moreover, given the price increase and further education, it is feasible to translate this into practice. With all of the articles findings indicating that 3-D digital breast tomosynthesis detected breast cancer earlier, it would be beneficial that the information be disseminated among the general public. On a wider scale, this could also decrease nation-wide healthcare spending, whether it be for breast cancer directly, or problems associated with the cancer diagnosis. Although the Kaniklidis (2015) study was done in another country, only 50% of the doctors and 13.1% of the nurses had education on mammography. To effectively reduce national and global healthcare costs, we need to ensure that all people, healthcare providers included, receive the best education possible so they are better able to serve the patients in which they encounter. The Lee et al. (2014) study found that 405 out of 1000 screenings were false positives and could have been avoided if the patient had undergone 3-D digital breast tomosynthesis. Furthermore, the Greenberg et al. (2014) study indicated that patients who had 3-D digital breast tomosynthesis done had a 16.1% less of a chance for being brought back in for further testing.
Rationale: In the reviewed studies, the mammogram results were analyzed (Lee et al., 2014; Greenberg et al., 2014; Houssami et al., 2017; Kaniklidis, 2015) or both 2-D and 3-D digital breast tomosynthesis were conducted (Ciatto et al., 2013). The conclusions vividly showed that 3-D digital breast tomosynthesis was better at detecting breast cancer early, leading to increased survival rates. Thus, continued common practice of using a standard 2-D mammography may fail to notice a mass within the breast. If the mass is seen on the mammogram, it could be misdiagnosed. Misdiagnoses can lead to untreated disease progression and potentially deadly effects for the patient. Not only does this effect the patient, it has a lasting emotional, physical, and financial toll on the family. While 3-D digital breast tomosynthesis is not yet fully covered by all insurances, Medicare, and Medicaid, it should still be an option for all women receiving mammograms. They should be informed of the benefits and educated on the chances of early detection.
Change Steps:
The Kotter International 8-Step Change Model is an organized and effective means in which evidence-based practice can be implemented. It will be used to guide the implementation of the use of 3-D digital breast tomosynthesis. First, a sense of urgency must be created so that the population understands the importance of the evidence-based practice change. The education can be disseminated to the healthcare team and with these statistics, they will be encouraged to promote change. Next, a team will need to be assembled to implement the change. This team will need to consist of radiology technicians, radiologists, primary care physicians, nurses, and nursing management. Each person will need to be confident in the evidence-based practice, and be willing to advocate for the change. Their morale and confidence will encourage more patients to opt into receiving 3-D mammography over the traditional 2-D mammography. Once this is complete, a vision will be created and initiatives will be implemented. Such vision might be that 50% of the patients who normally receive traditional 2-D mammograms will choose 3-D mammograms, leading to an increased rate of detection of breast cancer. An initiative for the healthcare team might be that the staff member who leads the most people to receive 3-D mammograms is awarded with a monetary gift, or a trophy. Fourth, a volunteer army will need to be gathered. These people can join the healthcare team and be proponents for 3-D mammography over traditional 2-D mammography. Such people might be other providers within the healthcare setting, professionals in the community, or individuals whose testimonies involve 3-D mammography. With this alliance, more people will be influenced and feel a stronger need to take part in the new practice. Furthermore, potential barriers must be removed. Some specific populations might be those who speak a different language than that in which is native to the community, people with disabilities, and those of lower socioeconomic class. To combat these potential barriers, education can be disseminated in the offices where these societies receive treatments or advice. Such locations include case management facilities and community health departments. In addition, short-term wins should be acknowledged. When a healthcare facility is able to use the evidence-based practice to detect problems for one patient, this is one person whose life may have been saved. These victories are essential, as they serve as strong motivators. Next, even as the vision is coming to life and the evidence-based practice is becoming a more widely-used technique, the supporting team cannot lose their motivation and drive. Instead, they should remain focused on the patients and saving as many lives as possible via the use of 3-D mammography. Lastly, after some time has passed, there needs to be a review of the 3-D mammograms performed. An analysis should be conducted to determine how successful this change was, and the results should be published to promote even further implementation of change. Soon, this change will become the new normal and more people will be survivors of breast cancer.
References
Adriane, P. B., Arianne Tiemi, J. M., Arnez, A., Mara Lisiane de Moraes,dos Santos, Leila
Simone, F. M., & Almeida, d. M. (2016). Knowledge and practice of doctors and nurses
regarding early detection of breast cancer. Revista Brasileira Em Promocao Da Saude, 29(2), 153-162. doi:http://dx.doi.org.liblink.uncw.edu/10.5020/18061230.2016.p153
Bernstein, L. (2014, Jun 25). Study finds 3-D mammography more effective at detecting most
lethal breast cancers (posted 2014-06-25 14:23:27). The Washington Post. Retrieved from
https://search-proquest-com.liblink.uncw.edu/docview/1540039121?accountid=14606
Breast Cancer – Statistics. (2018, January). Retrieved October 12, 2018, from
https://www.cancer.net/cancer-types/breast-cancer/statistics/2015
Breast Cancer Under 40: Early Detection. (2015). Retrieved October 12, 2018, from
https://my.clevelandclinic.org/health/articles/16805-breast-cancer-in-young-women
Ciatto, S., Houssami, N., Bernardi, D., Caumo, F., Pellegrini, M., Brunelli, S., . . . Macaskill, P.
(2013). Integration of 3D digital mammography with tomosynthesis for population
breast-cancer screening (STORM): A prospective comparison study. The Lancet
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Greenberg, J. S., Javitt, M. C., Katzen, J., Michael, S., & Holland, A. E. (2014). Clinical
performance metrics of 3D digital breast tomosynthesis compared with 2D digital
mammography for breast cancer screening in community practice. American Journal of Roentgenology, 203(3), 687-693. doi:10.2214/ajr.14.12642
Houssami, N., Lång, K., Hofvind, S., Zackrisson, S., Bernardi, D., Hunter, K., . . . Skaane, P.
(2017). Effectiveness of digital breast tomosynthesis (3D-mammography) in population
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Including diagnosis related costs, 3-D mammography costs less than digital mammography.
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Summary of the Articles and Evidence Hierarchy
Title Authors Purpose Methods Findings/Conclusion Level of Evidence*
Comparative effectiveness of combined digital mammography and tomosynthesis screening for women with dense breasts Lee, C. I., Cevik, M., Alagoz, O., Sprague, B. L., Tosteson, A. N., Miglioretti, D. L., Kerlikowske, K., Stout, N. K., Jarvik, J. G., Ramsey, S. D., … Lehman, C. D. (2014)
To evaluate how effective combined digital breast tomosynthesis mammography compared to traditional digital mammography. A discrete-event simulation model was used to see how clinical and cost-effective combined mammography was compared to traditional mammography. Incremental cost for each quality-adjusted year of life by adding 3-D mammograms was $53893. 405 of 1000 were false-positives and were averted. Cost-effectiveness was most sensitive. Level III: Controlled trial without randomization
Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice Greenberg, J. S., Javitt, M. C., Katzen, J., Michael, S., & Holland, A. E. (2014) To assess the performance of combined tomosynthesis compared to standard mammography in a community. Outcomes from 14 radiologists who examined 500+ screenings to see how accurate the results were. 3-D screened patients had a 16.1% less recall rate than those with 2-D mammography. 3-D mammography found 43.8% more cancers than 2-D screenings. Increased early detection overall found by 3-D over 2-D. Level II: Randomized controlled trial
Effectiveness of digital breast tomosynthesis (3D-mammography) in population breast cancer screening: a protocol for a collaborative individual participant data (IPD) meta-analysis Houssami, N., Lång, K., Hofvind, S., Zackrisson, S., Bernardi, D., Hunter, K., . . . Skaane, P. (2017) To examine whether 3-D mammography is more effective at detecting breast cancer than standard mammography. Selected 10,000 breast cancer screenings and compared the results from combined mammography screenings to standard mammography screenings. There will be a greater detection rate using the 3-D mammography over the standard 2-D mammography. Expect that findings will help with transition to 3-D mammography in practice in population-based health programs. Level I: Systematic review with meta-analysis
Beyond the mammography debate: a moderate perspective Kaniklidis, C. (2015) To evaluate the effectiveness of 3-D mammography as well as the risks and benefits in the community. Two researchers performed a meta-analysis on eleven screening trials for consistency. 89% of women in their 40s want yearly mammograms. 38% of women believe false-positives should be considered in decisions made. “Women expressed an overwhelming preference to err on the side of caution in preferring the risk of overtreatment to the risk of undertreatment.”
Level I: Systematic review with meta-analysis
Reducing radiation doses for breast tomosynthesis? Yaffe, M. J. (2016) To examine the amount of radiation used in 3-D mammography along with determining if the radiation causes further effects. Researchers evaluated the amounts of radiation that were used in mammograms and tried to find any links to cancers later in life. 3-D mammography, when used with synthetic 2-D mammograms, provides results as good as standard 2-D mammograms. Radiologists read fewer mammograms each year and are more likely to re-screen a woman rather than dismiss a small finding. Level II: Randomized controlled trial
Knowledge and practice of doctors and nurses regarding early detection of breast cancer
Adriane, P. B., Arianne Tiemi, J. M., Arnez, A., Mara Lisiane de Moraes,dos Santos, Leila Simone, F. M., & Almeida, d. M. (2016) To compare knowledge of citizens in a city with the practice of doctors and nurses of the Family Health Strategy. Questionnaire was given to residents by doctors and nurses which assessed knowledge of early detection of breast cancer. 109 health care professionals interviewed: 72.2% of the doctors and 89.1% of the nurses had received training regarding breast cancer. 50% of the doctors 13.2% of the nurses had knowledge of mammography practices. Level V: Cross-sectional survey
Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): A prospective comparison study Ciatto, S., Houssami, N., Bernardi, D., Caumo, F., Pellegrini, M., Brunelli, S., . . . Macaskill, P. (2013). To investigate the effectiveness of 3-D mammography compared to 2-D mammography in breast cancer screenings.
Selected over 7000 women over 48 years old and performed both a standard mammogram, and a combined mammogram.
59 breast cancers were found in 57 women, including 52 invasive cancers. Combined mammography (integrated 2-D & 3-D) detected 20 cancers, while standard 2-D detected none. 2-D only screens found 5.3 cancers per 1000 screens, while 8.1 cancers per 1000 were found in combined screening. Combined screenings could have reduced false-positives by 17.2%. Level II: Randomized controlled trial
* Rating system for Hierarchy of Evidence provided by Melnyk and Fineout-Overholt