title: Expansion of screening mammography in the Veterans Health Administration: implications for breast cancer treatment.
abstract: OBJECTIVE
  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).
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Baltimore Veterans Affairs Medical Center, Surgical Service, Baltimore, Maryland2Division of General and Oncologic Surgery, University of Maryland School of Medicine, Baltimore3Department of Colorectal Surgery, King's College Hospital, London, England.
authors.forename: Charlotte L
authors.initials: CL
authors.lastname: Kvasnovsky
authors.forename: Susan B
authors.initials: SB
authors.lastname: Kesmodel
authors.forename: Josephine L
authors.initials: JL
authors.lastname: Gragasin
authors.forename: Valsamma
authors.initials: V
authors.lastname: Punnoose
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Johnson
authors.forename: Rakhi
authors.initials: R
authors.lastname: Goel
authors.forename: Srinevas K
authors.initials: SK
authors.lastname: Reddy
authors.forename: Richard N
authors.initials: RN
authors.lastname: Pierson
authors.forename: Ajay
authors.initials: A
authors.lastname: Jain
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D055088:Early Detection of Cancer; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008327:Mammography / Q000706:statistics & numerical data*; D008403:Mass Screening / Q000458:organization & administration; D008408:Mastectomy; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D058014:Veterans Health