1. Practitioner Variation of applied Compression Force in Mammography Claire E. Mercer MSc, BSc(hons)

2. Structure  Myself and my role  My PhD research  Collaboration  Research findings  Impact

3. 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

4. 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

5. Collaborative working  Mammographers  Research Radiographers  Consultant Mammographers  Phycologists  Statisticians  Physicists

6. My research  I’m here to share my research with you  Breast compression  Practitioner variation  Compression force standards

7. 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.

8. First: Quality Standards  Breast Screening  Heavily reliant on service and quality standards  Yet …. No standards for breast compression

9. 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.

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

11. Programme relies on screening attendance QA recommendations - over 70% of clients invited should attend 1 Painful mammography contributes to non-re- attendance 2 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.

12. No compression standards No evidence to work with KEY RESEARCH AIM

13. Let’s get some evidence? KEY RESEARCH AIM 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

14. 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

15. Let’s get some evidence? KEY RESEARCH AIM 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

16. 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

17. 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

18. 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.

19. 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

20. Consequences to client experiences over sequential screening

21.  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

22. 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

23. Back to the start Get some evidence? 3 easy steps… KEY RESEARCH AIM

24. Back to the start Get some evidence? 3 easy steps… KEY RESEARCH AIM 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

25. Back to the start Get some evidence? 3 easy steps… KEY RESEARCH AIM 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

26. Back to the start Get some evidence? 3 easy steps… KEY RESEARCH AIM 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

27. 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

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