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Original Investigation | Association of VA Surgeons

Expansion of Screening Mammography in the Veterans Health Administration:  Implications for Breast Cancer Treatment

Charlotte L. Kvasnovsky, MD, MPH1,2,3; Susan B. Kesmodel, MD1,2; Josephine L. Gragasin, CTR1; Valsamma Punnoose, MSN4; Pamela A. Johnson, MHA1; Rakhi Goel, MD5; Srinevas K. Reddy, MD1,2; Richard N. Pierson, MD1,6; Ajay Jain, MD1,2,7,8
[+] Author Affiliations
1Baltimore Veterans Affairs Medical Center, Surgical Service, Baltimore, Maryland
2Division of General and Oncologic Surgery, University of Maryland School of Medicine, Baltimore
3Department of Colorectal Surgery, King’s College Hospital, London, England
4Nursing Service, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland
5Radiology Service, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland
6Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore
7Office of Research and Development, Research and Development Service, Baltimore Veterans Administration Medical Center, Baltimore, Maryland
8Division of General and Oncologic Surgery, University of Maryland School of Medicine, Baltimore
JAMA Surg. 2013;148(11):999-1004. doi:10.1001/jamasurg.2013.3738.
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Importance  Women represent the fastest-growing demographic in the Veterans Health Administration. In 2008, we implemented programmatic changes to expand screening mammography, develop on-site breast care resources, and better coordinate care with non–Veterans Affairs (VA) facilities.

Objective  To determine whether the programmatic changes would increase patient volumes, decrease time to definitive treatment, and increase the rate of breast conservation therapy (BCT).

Design, Setting, and Participants  We performed a retrospective cohort study of all breast cancer cases treated from January 1, 2000, to May 31, 2012, at the Baltimore VA Medical Center.

Main Outcomes and Measures  We compared process-of-care metrics before and after 2008, when programmatic changes were implemented. Metrics evaluated included the number of mammograms performed annually, sex shift, the interval from clinical suspicion to tissue diagnosis and definitive treatment, and the rate of BCT.

Results  From 2000 to 2012, a total of 7355 mammograms were performed and 76 patients with breast cancer received treatment. Most mammograms (n = 6720) were performed after 2008. A median of 1453 (interquartile range [IQR], 592-1458) mammograms were performed and 6.33 patients received cancer treatment annually after 2008, representing 1200% and 49% increases, respectively, compared with the 2000 to 2007 interval. Most patients (86.7%) received screening and diagnostic imaging, biopsy, and surgery between multiple institutions. The interval between screening mammography and tissue diagnosis was 34 days (IQR, 20-52), with no significant difference between study intervals (P = .18). Time from tissue diagnosis to initiation of definitive treatment increased from 33 days (IQR, 26-51) to 51 days (IQR, 36-75) (P = .03) between 2008 and 2012. Thirty-three patients eligible for BCT (67.3%) received it, while 16 patients (32.7%) underwent mastectomy.

Conclusions and Relevance  Our institution has rapidly and successfully expanded screening mammography. Higher mammography volumes have been associated with increased use of non-VA breast care services and increased time to definitive treatment. Appropriate counseling regarding BCT was consistently documented, and mastectomy in BCT-eligible patients was largely the result of patient preference or clinical/social factors. Our data suggest that as patient volumes increase with intensified screening, VA hospitals may benefit from acquiring a full complement of on-site breast care services rather than improving flow between VA hospitals and non-VA breast care centers having specialized resources.

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Figure 1.
Enrollment and Use of Health Care Services by Female Veterans 40 Years or Older and the Rate of Mammography

Since 2007, the year when the Women’s Health Program was elevated to a Strategic Health Care Group in the Veterans’ Health Administration, the Veterans Affairs (VA) Maryland Health System (VAMHCS) has recorded enrollment and utilization of health care services by female veterans. Enrollment and utilization data for female veterans 40 years or older (the population most likely to use screening mammography) are shown from 2007 to 2012. The VAMHCS has also recorded the number of screening and diagnostic mammograms performed at the Baltimore VA Medical Center since 2000.

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Figure 2.
Flow Diagram Describing Use of Breast Conservation Therapy (BCT) or Mastectomy in Women With Breast Cancer

This diagram illustrates surgical management in women who received a diagnosis of breast cancer during the study period. Of the 76 patients, 54 were deemed eligible for breast conservation, but not all received it because of medical concerns or patient preference.

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