Breast Cancer: Mount Sinai Hospital - Term Paper Example

4. Business Case Breast cancer is caused genetic mutation of cells that are produced within the milk-producing lobules, which results to their abnormally quick growth. This project has been hatched with the realization that breast cancer can be treated easily if the hospital is in possession of modern and more sophisticated equipment, which aids in highly accurate screening tests. Primary justification Breast cancer is a leading cause of deaths in Mount Sinai Hospital. Additionally, it is a matter of fact that breast cancer is the leading form of cancer that is killing many women in Mount Sinai Hospital as well as all other hospitals in the world. It is therefore very important for the hospital management to consider introduction of an image segmentation facility to help with early warning of breast cancer, because this is literary the key to improve breast cancer diagnosis in the hospital. Image segmentation use contours or the region they are position on to find the features of an image. Performance gap and the expected benefits One of the most common screening methods used by radiologists in analysis of the mammograms is X-ray mammography. This technique is very importance in detection of the presence or absence of lesions from the mammograms (Stems, 1996). It is, however, becomes extremely difficult to detect breast cancer during its early stages because its presence is especially restrained and unsteady. As such, if only experiences are diagnosed, radiologists and doctors can easily fail to detect the presence of abnormality. Having said that, the doctors and radiologists can rely on computer aided screening technology to get a more effective and reliable diagnosis (Sheng, Hong and Enmin, 2011). The aim of having such a computer aided imaging technique is to ensure an accurate segmentation of medical images. This process involves use of different criteria to segment different areas of an image (Chang and Teng, 2007). Use of mammography images in breast cancer image segmentation is a tasking procedure though its accuracy is essential for screening of tumors as well as classification of tissue for early discovery of breast abnormalities. Although it is not perfect, mammography imaging is recommended for this project because of it is essentially the most efficient imaging method (Guido and Nico, 1999). For women without symptoms, Mammography imaging is believed to detect between 80% and 90% of the breast cancer. A precise image segmentation of the mammography images is very crucial for a computer aided equipment to perform accurate diagnosis. Early detection benefits The type of the equipment used is one of the factors that influence early detection through mammography. Knowledge of breast radiology and advances in technology has eased detection of breast lesions. The probability of detecting tumors before they are revealed clinically, with a short preclinical phase, is very low. However, screening Morrison can be used to detect tumors with preclinical phases that have existed for a long time. Investigations have revealed that the cases in their preclinical phase, which have been diagnosed through mammography screening, have a mean duration that is longer than that of the cases that are usually detected through the manifestation of symptoms (Warren-Burhenne and Burhenne, 1992). It is also evident that tumors develop slowly during the preclinical phase and have the same character when their symptoms start manifesting themselves. However, though accurate detection of tumors that may remain unnoticed for a while or those with progressive growth, mammography screening improves the prevalence rate. Reduction of breast cancer due to mammographic screening Scientific studies have revealed that regular mammographic screening reduces the chances of dying from malignancy, especially for women aged between 50 and 70 years. This comes amidst strong opposition of screening breast cancer by critics who have questioned its value. A research carried out by the International Agency for Research on Cancer (IARC) found that a 35% reduction in mortality of women who are screened regularly is as a result of the 25% reduction in mortality that occurs in the trials of mammographic screening. Introduction of mammography screening is expected to save about 140 lives each year in Mount Sinai Hospital. Radiation Risks in Mammography The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), in its 2000 report pointed out uncertainty in risks for solid cancer and a risk in low or chronic doses. 1 The approximation of cancer identification rates are extremely high for women aged 50-64 years (NHSBSP data). According to During Young and Burch (2000), during the mammography screening, the radiation doses that are received are expressed as mean glandular dose (MGD) (United Nations Scientific Committee on the Effects of Atomic Radiation, 2000). The data for different does is presented in Tables 1, 2 and 3. The mean dose for a woman whose each breast is being performed a two-view mammography is represented by 3.65 mGy, while the doses that are above the top 2% and 0.1% of the population are represented by 11 mGy and 20 mHy – this group receive higher doses mainly because they have large breast size. Cancers discovered/ induced Age (years) 3.65 mGy (mean MGD) 11 mGy (MGD above by 2% of screened women) 20 mGy (MGD above by 0.1% of screened women) 50-63 105 33 20 55-58 121 40 21 60-63 179 61 34 Table 1. Ratio of cancers discovered to cancers induced, with 3-yearly two-view screening. Cancers discovered/induced Age (years) 3.66 mGy (mean MGD) 12 mGy (MGD above by 2% of screened women) 20 mGy (MGD above by 0.1% of screened women) 30-35 2.5 0.86 0.49 36-40 6.3 2.1 1.3 41-45 10.9 3.9 2.4 46-49 19.5 6.8 3.9 Table 2. Cancers discovered/cancers induced in younger women, with annual two-view screening, without family history. Cancers discovered/induced Age (years) Index patient age at diagnosis (the age at which the first-level relatives got their breast cancer) 3.66 mGy (mean MGD) 11 mGy (MGD above by 2% of screened women) 20 mGy (MGD level exceeded by 0.1% of screened women) 25-30 31-40 6.0 2.0 1.2 31-35 20.0 5.7 3.8 36-40 42.0 15.0 7.8 41-45 54.0 19.0 10.1 46-50 60.0 21.0 11.2 30-35 41-50 12.0 5.0 2.4 36-40 20.0 7.8 3.8 41-45 33.0 12.0 6.1 46-50 36.0 13.0 6.9 Table 3. Cancers discovered /cancers induced in younger women, with annual two-view screening and family history, 4.3 Business objective Critical success factors It will be very important if Mount Sinai Hospital could seek ways of becoming more efficient ways of implementing new technology such as the in the form of digital mammography with the aim of boosting patient volume capabilities. This is especially with consideration of the current situation of an aging mammography technologist environment and an acute shortage of breast radiologists. Furthermore, the national screening rates have reduced for the past couple of years; hence Mount Sinai Hospital will find it important to embark on an extensive awareness on the importance of undergoing breast cancer screening. In order to demystify the issues of screening, the hospital will require increasing its commitments towards educating women in matters of cancer. Essentially, as the hospital embarks on reversing the declining rate of screening, the revenue capacity will be expected to increase accordingly. This will, however, take place only if the hospital maintains high standards in all its services in order win the royalty of the clients. This will also include engagement in perception centered performance improvements such that the hospital upholds a good image to its clients as well as other stakeholders. 4.4 Key assumptions and hypothesis Implementation of the screening project in the hospital is expected to substantially reduce mortality rate from breast cancer by 2015. Despite the great expectation that the project will achieve excellent results, it is also expected that the project will introduce workload demands on the staff and this will present a major challenge to the organization. If the Hospital will find it extremely hard to recruit staff with the necessary knowledge to handle to equipment, the board members must convene a meeting to develop new ways of introducing new types of staff in order to move with the pace of the project. One of the possible ways of developing the skills of the existing staff so they could be able to operate the new screening program include sending some selected staff to training centers that specialize with screening programs. In addition, that staffs who are already working in similar screening programs will also be trained in the centers in order to develop and update their skills. cost assumptions For the women aged 50-70, breast screening using mammography costs about £70 million per year. It is expected that the program will save about 140 lives per year. Generally, the program is expected to increase the live expectancy of every woman who is screening by the program by 15 years. Therefore, the program is estimated to cost about £2500 annual for very life saved. This cost is similar to the cost of screening of cervical cancer in United Kingdom (Peto et al., 2004). . Operating and maintenance manpower requirements/costs The program will require 1-year to be set aside for the training of the manpower. The primary objective will be to increase the number of Surgeons, Gynecologists, Oncologists, Physicists, and Pathologists with concentration in Oncology. The following is a suggested balance of the manpower: Five radiation oncologist, 2 medical Oncologist and one Clinical Hematologist. One specialist to be trained in surgical oncology, Clinical Oncology, Surgical Pathology and Clinical Hematology. Every year, one Therapy Radiographers should be trained Two medical physicists to be trained. The digital screening mammogram mammography will last for about 10-years, after which it can be sold at a marginal scrap value, and replaced with a new one. The cost of purchasing and operating equipment is as shown in Table 4, which also shows comparison with a screen-film. All other costs essential in its maintenance are listed in the table. Unit Costs Screening Mammogram CPT Code(s) Cost Screen-Film 76092 £51 Digital HCPCS £81.29 Additional Imaging (Diagnostic) Diagnostic Mammogram  Digital (unilateral) G0206 £69.21  Screen-Film (unilateral) 76090 £46.45  Digital (bilateral) G0204 £85.50  Screen-Film (bilateral) 76091 £97.40 Ultrasound (unilateral or bilateral)† 76645 £58.11 MRI  unilateral 76093 £283.23  bilateral 76094 £373.23 Procedures  Ultrasound-guided 76942 £433.85  Mammography 76096 £576.61 Visit Costs Office visit with physician £27.09 Radiology (imaging) visit personal time £22.86 Procedure (biopsy) visit personal time £32.04 Table 4: Unit costs used to estimate operating costs Utilities and service requirements Running screening mammogram is will consumer relatively small amount of power, and therefore the electricity expenses will be incurred very month. Other utilities required to maintain the mammogram include water and air, which will also consume a very small portion of the budget. The budgeting committee will estimate the cost of utilities per year, which will be increased every year depending on the scale and the stage of the program. Lifecycle cost considerations A reserve will be set aside to cater for the replacement of the equipment after its useful life lapses in 10-years. This will be in consideration of the fact that the capital for the replacement is massive and if there is no reserves set aside, the hospital might experience unprecedented cash flow deficit in future when replacing the equipment, or else interrupt continuation of the program if the equipment is not be replaced immediately. 5. Project description 5.1 Project description The preferred equipment that will be installed in the hospital for is for breast cancer screening is called digital screening mammography. This x-ray equipment is supplied by different manufacturers. It functions by displaying the mammography image in digital format. The equipment will be purchased on a cash basis and then implemented in three phases. The first phase, which will take about a month, will involve the whole process of procurements and installation. After the equipment is fully installed and confirmed to be fully functional, the second the final phases will be embarked on. The second phase, which is the demo-phase, will entail subjecting a number of women to breast cancer screening with the primary aim of testing the equipment for functionality and incase any problem is detected it is fixed accordingly. The third and the final stage will involve undertaking of the real screening after the equipment has been confirm to be almost free of any issue and when all the staff will have been fully introduced into their roles. In this stage, which will take place from the fifth month, the project coordinator will be keen to identify whether there are any issues that were left unresolved during the second stage and seek ways of addressing them accordingly. During this final stage, the program will have been considered to have officially kicked off, and everything will be run as per the short-term as well as the long-term plans. 5.2 Facility Capability The introduction of a digital mammography in the hospital will be considered successful only if it will bring improvements to the existing system. In this sense, the screening program is expected to have a number of capabilities, including: decline in the necessity for recurrent images; the equipment should make a more effective use of x-rays by delivering fewer dose; the clinicians should be able to access images at any destination; the storage spaced should be reduced; manual handling by radiographers should be reduced; enhanced image manipulation; ease of consultation among clinicians; improve the clinical environment by exempting the need for chemicals; and enable instantaneous exchange of information among different departments. 5.3 Changes from the current design Currently, Mount Sinai Hospital is relying on traditional methods of screening breast cancer, which are somewhat ineffective as they are highly inaccurate. As such, the president of the hospital has proposed for the adoption of a digital screening mammogram, which will introduce an overall to the whole process of screening of cancer in the hospital. The new technique will hopefully increase the cancer detection accuracy rate by more than 50%. The new program will require changes to be introduced in the entire system of the hospital including staffing and leadership. A variety of new staff will be hired to take up new roles in the program while different existing staff will be taken through an extensive training to be able to handle new roles appropriately. The project manager, who will be charged with the responsibility of ensuring smooth implementation of the new screening program, will be required to be a person of high integrity, and strong coordination and planning capability because he will be entrusted to ensure that the whole program is a success. 5.4 Location of the equipment The screening mammography will be situated in the hospitals headquarters branch at New York City. Part of the strategic plans will propose introduction of similar equipments in the hospitals branches, but this will only come after the initial program is successfully implemented and tested within the headquarters. 6. 0 Project Alternatives Following a review of the screening equipment that are available in the market, it was found that besides digital mammography, there exists other alternatives such as computerized radiography, computer aided detection, Ultrasound, Film x-ray mammography, and Magnetic resonance imaging among other imaging techniques. 6.1.1 Film x-ray mammography Film x-ray mammography is a screening intervention that is very effective in reducing breast cancer mortality (25). This technique is expressed in randomized controlled trials. 6.1.2 Computerized radiography Like digital mammography, computerized radiography has many advantages including low cost of operation, but it comes in variety of performance and quality. (80). 6.1.3 Computer Aided Detection (CAD) Computer aided detection is applicable in digital mammographic images. This technique is mostly preferred for its reduction in the number of human readers required per film and improved sensitivity. Currently, no clear benefits have been identified from this technology. (81). 6.1.4 Ultrasound Ultrasound is a very effective method if used for breast guided biopsy and further evaluation of mammographic anomalies. Studied have revealed that Ultrasound can be used as a secondary addition to screening of the mammographically dense breast, and can also be used in the primary screening of younger women experiencing higher risk (83). Breast ultrasound is cheaper as easily available compared to other imaging techniques such as magnetic imaging resonance and nuclear medicine. However, the numbers of radiologists who can perform ultrasound screening are not easily available and the procedure is time consuming. 6.1.5 Magnetic resonance imaging Magnetic resonance imaging has the most sensitive capability of all other methods that are available for screening breast cancer. (83). However, the technique has a higher false rate compared to x-ray mammography and its equipment is very expensive. 6.2 Lease vs. purchase Although purchase of mammography equipment has been found to be very expensive, the hospital will opt to purchase rather than lease because do so will be cheaper in the long-term. An investigation into the cost of leasing mammography equipment revealed that the rental expenses will equate the purchase price after the fifth year, which is far much expensive considering that the equipment, if purchased, will be resold after the tenth year at a marginal scrap value. However, if the organization was experiencing cash flow problems currently, it could have made a lot of sense to lease the equipment and use the much needed cash in other operating activities, and only opt to purchase it in future when the cash problem is surmounted. 6.3 Potential solutions Mount Sinai is expected to leap a lot of benefits following commencement of the project. Some of the problems that are expected to be addressed by the equipment in the short-run include prevention of loss of clients to other Hospitals with sophisticated screening machines, and an increase the cancer detection accuracy rate by more than 50% and hence leading to a reduction of mortality rate as a result of breast cancer by up to 25%. Making the hospital more reliable in terms of breast cancer screening is also expected to increase the much needed revenue by the hospital, which will be used not only for the furtherance of the project its self but also other project that will see Mount Sinai Hospital expanding in terms of clients capacity by up to 50% in two-years. The growth in revenue as a result of the new venture is hoped to reach up to 15% by the end of the first year since the commencement of the project. A variety of new staff will be hired to take up new roles in the program while different existing staff will be taken through an extensive training to be able to handle new roles appropriately. 7.0 Engineering information Table 5: Screen-Film Mammography Equipment - Digital Manufacturer The following is a list of full-field-of-view digital screening mammography available in the U.K. Indirect–conversion detectors • GE Scintillator Pixel size Field of view CsI(Tl) TFT 100 microns 18*23 cm • Fischer Imaging Scintillator CsI(Tl) Pixel size CCD 24/48 microns Field of view CsI(Tl) CsI(TI) CCD 24/48 microns 22 * 30 cm (scanning) Direct–conversion detectors • Hologic/Lorad Photoconductor Pixel size Field of view amorphous selenium TFT 70 microns 24 x 29 cm 8.0 Technology basis Digital mammography is one of the most technologically sophisticated machines used for screening of early anomalies in the breast. The best opportunity to treat breast cancer is when screening is done early to detect possible anomalies, which should be followed by immediate treatment. Therefore, digital mammography is recommended in this program to help savings lives of many women who succumb to breast cancer. With this kind of technology, screening mammograms can be conducted in 10 to 12 minutes. The risk of lost films is gotten rid of because images are obtained and stored by electronic means. Pressure or compression is used to take an average of two images from each breast, a procedure that can sometimes cause discomfort. Despite this discomfort, the procedures remain very crucial because it offers quality images - the women can abstain from scheduling for mammograms one week prior to menstrual cycle because during this time the breasts are usually very sensitive, so they can avoid discomfort. In addition, patients should desist from wearing deodorant talcum powder during screening to ensure the quality of the image is enhanced. 8. Project schedule Weeks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 On agreement of the Implementation Plan xx Confirmation of release of tender document for digital mammography (DM) xx xx Installation of three read only sites and DT at one sites, xx xx xx xx xx xx Implementation plan for the picture archive and communication system xx xx xx xx xx Delivery of 2013-14 Annual Performance Report - confirmation of installation of DT at two sites xx xx xx xx xx xx xx xx xxx 9. 0 Project cost estimate Task £ On agreement of the Implementation Plan 2,000 Confirmation of release of tender document for digital mammography (DM) 4,000 Installation of three read only sites and DT at one sites, 3,500 Implementation plan for the picture archive and communication system 2,500 Delivery of 2013-14 Annual Performance Report 940 9.1 Estimate basis 10. Project execution plan 11. Funds and resources required 12. Public impacts 13. Long-term impacts References Chang, P.L .and Teng, W., 2007. Exploiting the self organizing map for medical image segmentation. In, twentieth IEEE international symposium on computer based medical systems, pp281-288 Guido, M. and Nico, K., 1999. Single and multiscale detection of masses in digital mammograms. IEEE Transations on Medical imaging, 18(7), pp. 628-638. Peto, J., Gilham, C., Fletcher, O. and Matthews, F.E., 2004. The cervical cancer epidemic that screening has prevented in the UK. Lancet, 2004, 364, pp. 249–256. Sheng, Z.X., Hong, L. and Enmin, G., 2011. Marker-controlled watershed for lesion segmentation in mammograms. J digital imaging, 24(754), pp. 763 -2011 Stems, E.E., 1996. can j. sung. 33, pp128-132 United Nations Scientific Committee on the Effects of Atomic Radiation., 2000. Sources and Effects of Ionising Radiation. UNSCEAR Warren-Burhenne, L. H. T. and Burhenne, H., 1992. The British Columbia mammography screening program: evaluation of the first 15 monrhs, Am J Roentgenol, 1(158), pp. 45– 49. Young, K.C. and Burch, A., 2000. Radiation doses received in the UK breast screening programme in 1997 and 1998. B J Radiol 73, pp. 278-287 Read More