If you thought that BreastScreen Aotearoa was just a series of clinics that shuttled women in one door, through a mammography machine and out the other door with a positive or a negative, you would be wrong. And if you had thought that its clinical leader, Madeleine Wall, was just another bureaucratic management type - a cog in the public health machine - you would be wrong there too.
A two hour plus interview with Madeleine Wall revealed a woman who is passionate about her job, and dedicated to ensuring women with breast cancer are diagnosed early enough to give them the best shot at survival.
Madeleine started out as a general radiologist, and it was while she was working as a registrar in Oxford, in the UK, that she started doing mammography. She was pregnant with her second child and couldn't continue with the intervention procedures such as barium enema and angiography that required her to be exposed to radiation. With mammographic interpretation there was no risk to her baby.
When she returned to Wellington there was, as there is now, a dearth of radiologists so she "slotted in here and kept doing it."
In 1989, a multi-disciplinary group under the auspices of the Cancer Society began the call for a national breast screening programme. The Ministry of Health convened a breast cancer screening advisory group, of which Madeleine was a member. As a result of the recommendations of that group, and the positive outcome from two pilot programmes, BreastScreen Aotearoa (BSA) was formed; they began enrolling women in December 1998 and screening started in January 1999. New Zealand's National Breast Screening programme had finally been birthed and Madeleine had been there at its conception and throughout its gestation.
She was initially the clinical director of BreastScreen Central in Lower Hutt and was appointed the Clinical Leader of BreastScreen Aotearoa in 2003. However, despite what must be a heavy work load in that role, Madeleine still works as a screen reading radiologist.
"It keeps me grounded," she says, explaining that side of her work. "And it prevents me from becoming too bureaucratic, and reminds me what I am there for - the women!"
I spoke with Madeleine about the disparities in breast cancer incidence and mortality between Māori and non-Māori, and some of the research they have done which shows that while age specific incidence rates are similar, mortality rates for Maori are significantly worse compared with Pacific Island and other New Zealand women - an issue that will be the focus of some of the articles for this and subsequent issues of Upfront. As with all areas of her work she is passionate about increasing the screening uptake by Māori and Pacific Island women. She points out that while they had reached 65% of non-Māori women between 50 and 64 years up to June 2005, only 45% of eligible Māori women were enrolled in the screening programme. And re-screening rates are also worse for Māori - only 65% of Māori women come back, against 70% of non-Māori. She believes that there are cultural barriers not for Māori women, but for providers of health care.
"This is consistent with research from the Institute of Medicine in the US, from the UK and also from New Zealand researchers," she said.
It seems from our discussion that this is something that needs to be addressed from outside of BSA as well as from within.
"Those of us who provide health care need to be aware of our own cultural issues in order to transcend them, and communicate effectively with patients who differ from us. Otherwise we cannot give every one the best care available," Madeleine explained.
Despite this, Madeleine and her colleagues have reason to celebrate their successes. She proudly tells me that BreastScreen South has recently attained 70% coverage overall and, importantly, that includes Māori and Pacific Island women, an achievement that is believed to be a world first. In part, that achievement has been possible through addressing cultural issues.
However, getting a greater number of eligible women through BSA's doors is not all that BSA is about, nor all that interests Madeleine. One of her major concerns is that not all women are getting the best possible treatment, and it is at this point that I discover how much more there is to BSA than just mammography.
BSA is involved in much of the continuum from prevention through to palliative care of those women unfortunate enough to have progressed that far with the disease. They have a role in improving women's access to treatment as the National Screening Unit funds treatment through the district health boards for women screened through BSA, and want to improve access to full multi-disciplinary care for all women with breast cancer. Madeleine says they are also contributing to work on the National Cancer Management Database as, although they collect and publish data on the treatment of BSA diagnosed women, it is impossible to improve the care other women are offered and identify high risk women when we know so little about the women with breast cancer and what type of care they currently receive.
Madeleine would like to see the development of a risk calculator for women, and BSA has commissioned the New Zealand Health Technology Assessment Unit to review the risk factors for breast cancer, particularly looking at women at high risk of the disease. The plan is to modify an existing risk calculator for the New Zealand population and develop guidelines for high risk women, to identify those women before breast cancer strikes. These guidelines will identify the best means of providing surveillance, particularly for younger women at high risk of breast cancer, as mammography alone is not ideal for picking up tumours in these women, and some will benefit from MRI.
There is simply not enough space to detail all the items on the BSA agenda, and not enough space to convey Madeleine's energy for, and involvement in, her work. For example, there are workforce issues with insufficient medical radiology technicians for the demand. Another issue is the advent of digital mammography, and immediate plans revolve around completing the implementation of the age extension for mammographic screening, to offer the service to all eligible women between 45 and 69 years. And, of course, there is coverage - raising the number of eligible New Zealand women accessing screening above 70%, while ensuring that those who enroll are aware of the limitations as well as the benefits of mammography.
I also asked her about the future for mammography.
"If we had a screening test that would outdo mammography it would be wonderful," she responded. "I think some of the emerging techniques associated with digital mammography offer the most promise at present, such as digital tomosynthesis which images different levels within the breast and produces pictures like a CT scan, essentially removing overlying tissue that can obscure a cancer. Contrast enhanced digital mammography reveals areas of abnormal vessel development associated with cancers and also promises to be more sensitive than standard mammography."
These techniques still require x-rays and Madeleine said that "technologies using different physical characteristics (such as ultrasound, radar, etc.) would have to be shown to reduce breast cancer deaths in order to prove they were an appropriate replacement for mammography."
"Just picking up breast cancers alone is not enough. For example, routine breast self examination will pick up many cancers (as well as benign lumps), but not sufficiently early to prevent breast cancer deaths compared with usual care. So, despite its limitations I think mammography will be a screening tool for some time yet," she said.
When I ask Madeleine about "preventing" breast cancer, she says she would like nothing better than to be "done out of a job". Of course, the day when prevention becomes possible is likely to be a long way off. However, I get the impression that, in the meantime, one way or another Madeleine Wall will be working to improve the outcomes for women with breast cancer, trying to save them all.
Copyright © 2006 Sue Claridge