Better images for better outcomes

Mammographies in Macedonia

Karen Lindfors’ trip to Macedonia in 2009, also through Radiology Mammography International (RMI), provided similar challenges and insights into the communities and health-care systems of a small, developing country.

RMI had visited Macedonia once before, and both times at the invitation of the Boris Trajkovski International Foundation. The foundation is named for Trajkovski, the second president of the Republic of Macedonia who died in a plane crash in 2004. One of the foundation’s many missions is to help establish a country-wide breast cancer screening program.

Lindfors spent two weeks in the radiology department at the University of Skopje in Macedonia’s capital city. She spoke to radiologists who traveled on bus from two hours away to attend her daily lectures, as well as working one-on-one with radiologists in the reading room.

The enthusiasm was mostly there, but the equipment and techniques were lacking. The university hospital had no sterile supplies for core biopsies, no gurneys, no spinal needles for administering anesthesia, and surgical gloves in only one size. Lindfors also discovered the absence of functional guidelines for meeting a specific standard of image quality on the screenings. "We would not have accepted the quality of those screenings here in the U.S.," she says. Her team, which included a technologist and an engineer, was able to show the Macedonian radiologists how the quality of their mammograms could be improved.

But emotional barriers presented a significant obstacle. Because women were fearful about radiation, perhaps due to the proximity to Chernobyl, just 700 miles away, breast cancer screenings were also being done with ultrasound.

"We don’t use ultrasound in this country for screenings, except for some high-risk women who can’t tolerate an MRI. Ultrasound is never a substitute for high-quality screening mammography either," Lindfors says. "The clinics routinely used ancient equipment that didn’t do much. I don’t think they could pick up anything except for the largest palpable masses."

RMI sends advance teams to ensure that the host countries will be receptive — which generally they have been. "You’re a guest in their country, and you have to be diplomatic," Lindfors says. "You can’t just come in and say, ’You’re doing it all wrong.’ Sometimes it’s hard to get through." Of the group of radiologists she worked with in Skopje, for example, one doctor did not attend any of her lectures and barely spoke to her.

Lindfors recently received an email from a radiologist she met on the Macedonia trip. The radiologist indicated that she and the Macedonian technologists are working hard to implement and maintain the screening program. Lindfors adds that the Minister of Health, with whom she had communicated both by letter and in person, was receptive to the idea of improving the quality of screenings.

The next possible visit for RMI and Lindfors is Nicaragua in November.

It took about 20 men to push the new mammography machine up the stairs for installation in a hospital in Kosovo.

Karen Lindfors But the effort was worth it. In a country where most breast tumors are detected too late and where 50 percent of women with breast cancer die from their disease, the prospect of saving more lives was good motivation.

Karen Lindfors, professor of radiology and member of UC Davis Cancer Center, recently returned from a medical mission to Prishtina, capital of the Balkan republic, where she helped teach local doctors and technicians how to use the newly donated machine to screen women for breast cancer.

Lindfors says screening for breast cancer is very limited and, if available, done using ultrasound or old mammography machines that make it almost impossible to accurately detect lesions.

It was the second such trip for Lindfors through Radiology Mammography International, a nonprofit organization that provides technical assistance, donations and training in underserved parts of the world to support breast cancer prevention, detection and treatment. Lindfors made a similar trip to Macedonia in 2009.

Kosovo Hospital In a country where most breast tumors are detected too late and where 50 percent of women with breast cancer die from their disease, the prospect of saving more lives was good motivation.

Upon her return from Kosovo, Lindfors described what she saw as a system for breast cancer screening that lacks technological sophistication, clinical expertise and medical record management. Complicating matters, she says, is that patients don’t have health insurance; there are wide disparities when it comes to access to care; and radiologists in the public system earn less than $500 a month.

Lindfors says screening for breast cancer is very limited and, if available, done using ultrasound or old mammography machines that make it almost impossible to accurately detect lesions. Technicians are trained using textbooks – not in clinical practice. And because most patients are diagnosed late, they usually undergo full mastectomies rather than breast-sparing lumpectomies.

Kosovo Hospital Because the clinics do not set up appointments for screening, Lindfors says, "it’s absolute chaos because everyone is trying to get in the door. Some patients waited three days for a screening."

"What really struck me was how large the cancers were that we saw in Kosovar women who were sent in for evaluation, and how interested the radiologists were in really improving their skills," Lindfors says. "But what a tough road that is going to be because of the lack of infrastructure and support."

And because the clinics do not set up appointments for screening, Lindfors says, "it’s absolute chaos because everyone is trying to get in the door. Some patients waited three days for a screening."

In addition to daily lectures with medical personnel, Lindfors taught them how to do wire localizations, a procedure used to pinpoint breast lesions that are not palpable. She also worked with surgeons who performed the first wire-localized lumpectomy ever done in the country as well as the first sentinel lymph node biopsy.

All told, she says, in two weeks the team performed 200 mammograms and found seven cancers, five of which could be surgically removed with lumpectomy.

Mammography Demo at a Kosovo Hospital "What really struck me was how large the cancers were that we saw in Kosovar women who were sent in for evaluation, and how interested the radiologists were in really improving their skills."

~ Karen Lindfors

Lindfors says the challenge now is to keep the program sustainable in Kosovo, which requires government support and continued funding for supplies. She hopes to return to Kosovo some day, as long as those things are in place.

"I’ve received several positive e-mails from the radiologists I trained in Kosovo," Lindfors says. "They report reasonable progress on their breast cancer screening program. If that continues, I’ll return to Kosovo for a follow-up mission."