On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.103 n.3 Cape Town Mar. 2013
PinkDrive intervention 'over-rated' - experts
Breast health professionals are questioning the life-saving impact of the high profile non-profit breast cancer organisation PinkDrive. But PinkDrive founder Noelene Kotschan has roundly rejected the attack.
The multi-disciplinary Breast Interest Group of South Africa (BIGOSA) claims PinkDrive has been forced to stop its mammographic screening activities - which Izindaba showcased as temporarily eliminating public sector mammography backlogs in our December issue - due to poor imaging and interpretation as well as failure to provide work-up for positive findings. The group, a multi-disciplinary national collective of medical professionals linked to breast health, further claims that PinkDrive violated multiple scientifically sound principles and failed to operate under 'any kind of scientific scrutiny'.
Izindaba lauded PinkDrive's work in relieving pressure on overloaded and often understaffed public sector breast clinics in at least 3 provinces and in potentially saving 'thousands of lives' by screening both symptomatic and asymptomatic women. However, both Professor Justus Apffelstaedt, who heads Tygerberg Hospital's Breast Clinic, and his counterpart at Groote Schuur Hospital, Professor Eugenio Panieri, said that this was a gross overestimate of the life-saving ability of PinkDrive's mobile mammography unit (MMU).
BIGOSA, which is chaired by Apffelstaedt, said the assumption that the MMU (a highly visible feminine-themed 10 m pink truck) would solve the challenges of breast cancer services provision in South Africa was 'erroneous and counter-productive'. Definitive diagnosis requires not mammography but a pathological examination of a tissue sample from a tumor. Poor specimen acquisition and pathology services across the country are highly problematic and contribute to poor early detection, and thus poor treatment outcomes. BIGOSA gave the example of cytology samples ofbreast masses in peripheral clinics in the Western Cape, which have a less than 40% adequacy rate while waiting times for their results exceed 1 month. Additionally, waiting times for surgery and radiotherapy 'in many units' exceeded 3 months.
The case load in breast cancer at Tygerberg Hospital over the past 15 years has tripled - without any increase in resources for treatment. While welcoming the involvement of NGOs in alleviating service provision challenges in the public sector, BIGOSA said they needed to tie in with existing services, be scientifically sound and achieve defined goals. In the light of the overall challenges, they added that it's 'extremely unwise' to divert scarce resources into poorly designed and scientifically unsound mobile screening mammography services.
However, Panieri, whose breast unit offers the largest public service in the Western Cape, said PinkDrive's intervention had approximately halved his unit's waiting list while there had been 'no problems' with the quality of their radiology. 'We try for a same-day mammograph on a patient really wanting it, but they can wait between two to three weeks and three to four months, so an extra machine (they usually have only one) really does make a difference,' he said.
Initial problems eliminated -PinkDrive chief
PinkDrive's CEO and founder, Noelene Kotschan, initially appealed to several provinces for financial assistance, given that PinkDrive hugely reduced their mammography backlogs, but was turned down. She admitted to initial image quality and 'mammographic technique' problems while screening asymptomatic women at 3 Tygerberg Hospital-linked community health centres. However, she said that these had been corrected 'within months' in 2011 via the services of the Africa X-Ray and Industrial and Medical company - and that Tygerberg Hospital had acknowledged this.
She angrily denied that her outfit had ever been 'stopped' due to poor mammogram imaging and interpretation problems. The Radiation Control Board scrutinises PinkDrive on a regular basis and her non-profit organisation has been 'compliant since day one'. She described the allegations as 'unfounded and incorrect,' adding that a full 9.59% of 2 732 asymptomatic patients screened at Tygerberg's three outlying clinics between 2011 and 2012 were referred. Of these referrals a further 9,92% were positively diagnosed with breast cancer. (What was most alarming was that 88.4% of the confirmed diagnoses had a history of cancer in their family.)
Kotschan showed Izindaba letters of gratitude from Addington and Grey's hospitals in KwaZulu Natal and an e-mail from Western Cape Health Chief, Professor Craig Househam, in which he described 'issues regarding the quality of the mammograms' provided by PinkDrive as 'largely resolved'.
In his e-mailed response to her request for funding, Househam admitted that PinkDrive had heightened his department's awareness of the need to augment their current mammography capacity to ensure earlier diagnosis of breast cancer. However, he said that the preferred strategy is to secure additional mammography equipment, 'within current budget allocations,' for breast clinics at Tygerberg and Groote Schuur hospitals.
The squabble comes in the context of more than 8 000 cases of breast cancer diagnosed nationally (in the public and private sectors jointly) every year and a rapidly growing case load. Apffelstaedt said the 8 000 is a collaborative and conservative estimate with his peers, and that the Western Cape annually sees 1 500 new cases. Tygerberg's Breast Unit case load had grown from 140 new diagnoses annually 10 years ago to over 490 currently. Breast cancer is the most common cancer among women, but highly responsive to early detection and treatment.
PinkDrive rapidly allays patient fears - clinic chief
A snap survey of clinicians who worked with PinkDrive in the Western Cape elicited one overarching response: the outfit needs more 'clinical supervision and guidance', with greater control by, and forward planning with, the public sector facilities to enable optimal efficiency. Said Panieri, 'What it does do is allow you to deal with patients' concerns more rapidly. Whether it saves lives is a big debate. Timeous evaluations and investigations is what you want to do all the time - real life-saving issues need very careful evaluation and are quite complex to tease out of that context.'
Apffelstaedt said his unit's screening picked up nearly 3 times as many breast cancers as PinkDrive's did. 'Breast-cancer screening is one of the best-researched areas of medicine. It's well described and you have to keep to the protocols if you want to have effective screening,' he said.