Sweden: A Study in Mammography Excellence

 Breast cancer screening in Sweden is a national effort paying great dividends. Studies, most notably by Laszlo Tabar, MD, have substantiated the benefits of regular mammograms—a 40 to 50 percent decrease in breast cancer deaths nationwide. Now, further benefits are expected from the widespread use of the latest digital mammography technology.  Some 80 to 90 percent of Swedish women have bi-annual mammograms and today 40 percent of those are done on digital systems. As Sweden’s system of choice, digital mammography is helping assure continued success with diagnosis, workflow and patient care.

Since Sweden instituted the world’s first national breast cancer screening program in 1986 following Tabar’s well-known 1985 study, women have embraced mammography more so than any other country. It’s been a team effort—women, government, physicians and healthcare facilities—like-minded folks working toward efficient screening. 

“Everyone is very ambitious to take good mammography images because we know how important it is to find small breast cancers,” says Eva Edholm, a radiologic technologist at Capio Saint Göran Hospital in Stockholm.

The National Board of Health and Welfare recommends screening every 18 months for Swedish women ages 40 to 55 and every 24 months for women ages 55 to 74, although some counties use the 24-month recommendation for all age groups. “An invitation is sent to remind them,” says Edholm. And so begins the workflow.

Capio Saint Göran Hospital is one of 100 national health mammography sites, each day screening 200 women and treating 30 to 40 clinical cases, except during the summer when they take eight weeks off from screening. In August, they went fully digital, installing four Sectra MicroDose mammography systems at the hospital, providing them with the lowest radiation dose units on the market. Two systems also were installed at its sister site, Capio Diagnostic Mammography Center in Tumba, Stockholm. “We switched in one day,” says Edholm. “It was so easy.”

The installation of digital mammography furthers workflow efficiency at the Stockholm hospital. For the techs, the big differences are the user-friendly workstation and lack of film developing. “It’s easy to work with the key pad and mouse,” says Edholm. Only 20 minutes of training was required to learn to use the workstation. Information is entered and available immediately during the procedure. “You can see what you can do; it’s right here.”

Developing film is something Edholm and her 14 fellow rad techs don’t miss either. She says the rooms no longer smell like developing chemicals and are much quieter. “Now we can see the image immediately and can take a new image at once if we need it. We don’t have call backs.” 

Techs also like the adjustable mammo unit. “It is easier to work. We have to change the angle so many times a day, with this unit, you can do it automatically,” says Edholm, who added her shoulder has suffered from the physical aspect of the job over the years. Now with the touch of a button, the machine moves into place for the four images. For patient comfort, the MicroDose also features a warmer to place the patient’s breast on and rounded edges.

Radiologists in Sweden typically work very closely with techs and often spend lunch time with them. Edholm says they like the low dose of the system and the ability to send images electronically for remote access or consultation.

The new digital mammography system enhanced workflow for all in the breast unit at Capio Saint Goran Hospital. “Even the women notice. They say, you have changed,” Edhold remarks. “‘Yes, we are digital,’ we tell them.”

Lessons to learn from Swedish mammography workflow
 Sectra’s MicroDose mammography system
There are lessons the United States can learn from the Swedish approach to breast cancer screening, says Gerald R. Kolb, JD, chief knowledge officer for Solis Women’s Health, with 10 centers in the Dallas-Fort Worth area, Arizona and North Carolina. At Solis, they currently utilize Fujifilm Medical Systems USA ClearView CR digital mammogram system and Sectra PACS, and have incorporated some of the principles Kolb has learned from visits with the Swedes. He spent time observing workflow at the filmless breast unit at Helsingborg General Hospital, in southern Sweden. Kolb gathered a number of take-aways and touts how the Swedes effectively manage digital breast screening.
  • Centralized breast centers | Specified hospitals have breast centers, allowing the consolidation of resources and expertise.
  • Efficient scheduling | Women automatically receive “invitations” for a mammogram by mail with a day and time, and it is up to the recipient to reschedule the appointment if she has a conflict. Since patients are block scheduled in half-hour time slots, the first to arrive at the appointed time goes first and the rest follow for a continual flow of scanning.
  • Punctuality | From both sides, patients and the medical staff are known to be prompt. Patients show up on time and the healthcare staff begins and ends work, breaks and lunch on time.
  • Paperless workflow | Electronic records are the name of the game. At the time of registration, patient information is updated in the mammography information system. During the exam, techs enter information with a keypad and mouse for an instantaneous record.
  • Ergonomic & electronic equipment | Much emphasis is put into the efficiency and comfort of the mammography systems for the tech and the patient. Easily adjustable systems that are convenient and easy to move make work easier for the tech. Features like smooth edges on the mammography systems ease the scanning process for the patient.
  • Highly trained technologists | Radiology techs in Sweden are nurses with specialized radiology training. They focus only on breast imaging, which makes them more knowledgeable in the field.
  • Specialty radiologists | The radiologists reading mammograms are specially trained, only focusing on women’s imaging.
  • Team spirit | Look for doctors, techs and other staff members to not just collaborate on a diagnosis, but to take breaks and eat lunch together in the same dining room as a matter of course. The team approach is important to a collaborative effort of an effective, efficient exam and reading.
  • Routine conferences | As a matter of course, clinicians (including surgeons, radiologists and oncologists) and staff members meet twice-weekly to discuss cases.