1
Fail-safe System for Diagnosis Quality Control
in Cancer Screening Canscreen

• Contract number 125 / 2006 financed by Romanian
  Government, through CEEX 2006 - Romanian National
  Research Development Programme, VIASAN
• Research domain Health
• Duration september 2006 september 2008

2
Consortium
Canscreen

• CO - "Iuliu Hatieganu" University of Medicine and
  Pharmacy, Cluj-Napoca
• ? www.umfcluj.ro
• project manager prof. dr. Andrei Achimas-Cadariu
• P1 - "I. Chiricuta" Oncology Institute,
  Cluj-Napoca ?
  www.iocn.ro
• project responsable dr. physician Florian Nicula
• P2 - SC IPA SA Cluj Subsidiary
  
  ? www.automation.ro
• project responsable senior researcher eng. Ioan
  Stoian
• P3 - "Babes Bolyai" University, Cluj-Napoca
  ?
  www.ubbcluj.ro
• project responsable prof. dr. Liana Lupsa
• P4 - Al. Trestioreanu Oncology Institute,
  Bucuresti ?
  www.iob.ro
• project responsable physician Milena Duma

3
Project Objectives
Canscreen

• Main objective - to find an appropriate cervical
  and breast cancer screening strategy for Romania
  and thus, the reduction of incidence and
  mortality by cancer with the improvement of
  quality of life for the patients.
• Canscreen has the following scientifically and
  technological objectives
• building up of a complex fail safe system which
  will ensure the diagnosis and treatment quality
  at European Standards
• design of a database which will include the
  tested women and also registers with high risk
  women
• design of algorithms for individualized diagnosis
  and a protocol for subsequent therapeutics
  indications
• improving the smears interpretation
• analysis and selection of smears with cytological
  abnormalities
• insuring the quality of the system by random
  selection of a percent of samples of interpreted
  smears and transmitting them to an expert
  cytologist
• distance transmission of mammography and ensuring
  their quality control
• designing the cost-effectiveness study which
  allows to choose the screening strategy with the
  lowest ratio of cost-effectiveness using the
  Markov model

4
Project Phases
Canscreen

• Phase 1 Study of the actual situation in cancer
  pathology and of it's monitoring in Romania ?
  01.09.2006 30.10.2006
• Phase 2 Definition of support methodology ?
  31.10.2006 30.04.2007
• Phase 3 Designing the informatic system ?
  01.05.2007 30.10.2007
• Phase 4 Implementation and verification of the
  informatic system ? 31.10.2007 30.04.2008
• Phase 5 Evaluation of preliminary results and
  results dissemination ? 01.05.2008 30.09.2008

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System Functions
Canscreen

• Canscreen system functions
• access of Canscreen people monitoring
  administrative personnel
• defining physician dictionaries assigned to
  following medical facilities family medicine,
  sampling centers, cytological laboratory, image
  processing centers, etc
• mailing screening invitations for a number of
  persons which respect some mandatory criteria and
  generates needed documents for economical
  research of invitation process
• establishing an individual schedule of sampling
  for persons that make a reservation depending on
  availability/unavailability of the interpretation
  centers
• gathering, in electronic screening format, of
  data for each registered patient, her cross thru
  sampling center, laboratories, the result of
  investigation and the recommendation of the
  specialist physician
• recording prevailed images on the file server and
  on screening programs database
• images quality improvement and improper image
  files automatic elimination
• viewing of rounds historical, episodes and
  invitations for a participant to screening
  program
• automatic persons involve in screening programs
  planning according to the screening test result
  
• screening persons monitoring in case of HPV and
  colposcopy testing to keep the possibility of
  their reintegration in screening programs
• developing specific annual statistic reports
  according to databases post processing
• data export to other related software
  applications ?

6
Medical Screening Protocols
Canscreen

• Based on the medical protocols specific for the
  screening of cervical and breast cancer defined
  by the methodology the technical specifications
  for the database and for collecting and analyzing
  images was established.
• Medical protocols define the system technical
  specifications
• establishing external source of medical data to
  import
• establishing medical data necessary to the system
• analysis of the quantification possibilities and
  coding for medical data
• designing the hardware configuration necessary
  for the informatics system
• establishing data flow from informatics point of
  view
• establishing requirements for the
  cost-effectiveness study and algorithms

7
Screening Programs Data Collection
Canscreen

• Necessary steps in data collection process
• taking the smears
• processing the smears and images
• smears/images interpretation
• data storing

8
System Architecture
Canscreen

• Hardware architecture n-tier architecture with
  the levels
• presentation level
• logical management level
• logical data access level
• database level
• Hardware architecture is composed by
• client workstations
• WEB server
• database and application server
• files server

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System Architecture
Canscreen

• Systems software architecture contains the
  modules
• interface design module accomplishes the user
  access to the level of the medical centers
  involved in the screening program for the
  cervical and breast cancer (MPI)
• medical data quantification and representation
  module (MRCD)
• medical images acquisition module (cytological
  and mammographic images) (MAI)
• medical data generation and exploitation module
  offers the possibility of retrieving data
  according to certain criteria defined by the
  screening protocol. Another module function is
  the pacients tratament management which involves
  special investigations.(MGEBD)
• images filtering module intends to optimize the
  interpreting procedures for the cytological
  smears and mammographies, by elaborating
  recognition algorithms for extracting the
  quantifiable features (MFI)
• quality module randomly selects a percentage of
  the analyzed images, which are afterwards re-read
  and transferred to a cytology expert (MAC)
• economical analysis module decides the screening
  strategy in accordance with the cost-efficiency
  ratio, by using Markov models applied to existing
  data in the database (MAE)

10
System Architecture
Canscreen

• Software modules interaction

11
System Database
Canscreen

• Canscreen database consists of the following
  data collections
• clinical information store - high-order
  relational database - encoded medical data
  involved in the screening program in accordance
  with the guidelines for screening protocols
• images repository - low-order relational database
  - only the image address is memorised in the
  database, not the entire image
• Canscreen database is designed and implemented
  in Erwin and Microsoft SQL Server 2005.

low-order relational database
high-order relational database
12
System Database
Canscreen

• Global relational entities model

13
Application Program

• Implemented in Microsoft Visual Studio 2005
• Manages the system database and implements the
  system functions

Canscreen
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Cytological Images Interpretation
Canscreen

• Algorithms for cytological images interpretation
  
• algorithms used in automatic cellular formation
  segmentation (found in cytological images) (Otsu
  method)
• automatic cellular formation segmentation found
  in cytological images using clustering algorithms
  (Moving k means clustering algorithm)
• post-processing segmented image using clustering
  algorithms (Modified Seed Based Region Growing
  algorithm)
• automatic cellular formation segmentation found
  in cytological images using clustering algorithms
  and segmentation algorithms based on global
  segmentation limit calculation

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Mammographic Images Interpretation
Canscreen

• Algorithms for mammographic images
  interpretation
• multi scale segmentation algorithms
• microcalcifies detection algorithms based on
  crossed entropy minimization
• microcalcifies detection algorithms based on
  bidimensional simultaneous apparition matrix
• microcalcifies detection algorithms based on
  conditional entropy maximization

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Markov Model
Canscreen
State Possible transactions
W W, L, H, D, A
L W, L, H, D, A
H W, L, H, UC1, D, A
UC1 UC1, C1, UC2, D, A
UC2 UC2, C2, UC3, D, A
UC3 UC3, C3, UC4, D, A
UC4 UC4, C4, UC2, D, A
D1 D1, D2, S, DC, D, A
D2 D2, D3, S, DC, D, A
D3 D3, D4, S, DC, D, A
D4 D4, S, DC, D, A
S S, D, A
DC Absorbing state
D Absorbing state
A Absorbing state

• Canscreen database is used to do an economic
  evaluation of healthcare interventions to ensure
  the quality of the screening programs.
• Medical decision analysis using Markov model
• modeling the progression of a chronic disease
  (cervical and breast cancer)
• predict effect changes in cervical and breast
  cancer practice
• States of Markov models from which it is
  impossible the leaves are known as absorbing
  states (overfullfilment of including age in
  screening).
• All possible transitions between absorbing states
  in a Markov model are given by a transition
  matrix.
• Transaction matrix for a 15-state Markov model in
  cervical cancer screening program
• ?

17
Quantifiable Results
Canscreen

• Direct quantifiable results
• developing a model of a fail-safe system of
  diagnosis control in screening program
• developing a database of data and images that
  will contain information about identification of
  tested women, medical parameters, and also
  registers of women with high risk
• developing a study of economical analysis, a
  study of cost-effectiveness to decide the
  screening strategy
• impact on working people, specialization in
  informatics field of the medical personnel, about
  10 persons
• Indirect quantifiable results
• increasing the life expectancy of the patients,
  by elaborating individualized diagnosis
  algorithms and prognosis with consecutive
  therapeutic indications
• increasing the management capability of the
  project coordinator in leading interdisciplinary
  projects

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Expected Beneficiaries
Canscreen

• Oncology units from the public health network
• The project can be extended, as a network at the
  level of rural localities, geographically
  isolated or in the consulting rooms of family
  doctors and in health centers. Thus it will
  increase efficiency of public health system and
  it will bring the Romanian health system on
  European coordinates.
• The project offers the following benefits
• access of high risk feminine population for
  developing breast or ovarian cancer to be
  monitored according to European Community
  standards
• access of feminine population to organized
  screening for precocious identification of
  cervical cancer, using an optimal strategy
• developing of a complex system to control for the
  diagnosis quality in the cancer screening program
• developing a study of economical analysis a
  cost-effectiveness study to decide the screening
  strategy

19
Project Dissemination
Canscreen

• List of published research papers in national and
  international conferences proceedings and
  jounals
• The Role of Cancer Registries in Suveillance and
  Cancer Care, Improvement of Data Quality in
  Institutional Cancer Registry by Data Linkage,
  Luciana Neamtiu, Daniela Coza, Florian Nicula,
  Ofelia Suteu, pp. 129, Poster, Octomber 2006,
  Amsterdam (Netherlands)
• XII-th International Conference on Applied
  Stochastic Models and Data Analysis (ASMDA),
  Stochastic Fractal Interpolation Function and its
  Applications to Fractal Analysis of Normal and
  Pathological Body Temperature Graphs by Children,
  Anna Soos, May June 2007, Chania, Creta (Grece)
  
• Meditech 2007, Data Management System for
  Cervical Cancer Screening CanScreen, Teodora
  Sanislav, Ioan Stoian, Dorina Capatîna, Mihaela
  L. Dragan, Luciana Neamtiu, Florian Nicula,
  Ofelia Suteu, Liana Lupsa, September 2007,
  Cluj-Napoca (Romania)
• ENUMATH 2007, Multiple Dynamic Programming
  Applied in Cervical Screening, Luciana Neamtiu,
  Ioana Chiorean, Final Program and Abstracts,
  September 2007, Graz (Austria)
• ENUMATH 2007, Special Efficient Solutions for
  Multicriterial Transport Problems, Liana Lupsa,
  Ioana Chiorean, Dorel I. Duca, Luciana Neamtiu,
  Final Program and Abstracts, September 2007, Graz
  (Austria)
• IACR 29TH ANNUAL MEETING, The Role of Cancer
  Control Department in Our Comprehensive Cancer
  Center Oncological Institute Ion Chiricuta,
  Daniela Coza, Florian Nicula, Ofelia Suteu,
  Luciana Neamtiu, Ioana Radulescu, Mihaela Sârbu,
  Lidia Lovasz, September 2007, Ljubljana
  (Slovenia)
• Seminar of Functional Equation, Approximation and
  Convexity, Lex-Min Assignment Problem, Luciana
  Neamtiu, Radu-Lucian Lupsa, Volume 5, Septembrie
  2007, Cluj-Napoca (Romania)
• Tiberiu Popoviciu Seminar of Functional Equation,
  Approximation and Convexity, Posibilitati de
  aplicare în medicina a masurilor de
  neconvexitate, Liana Lupsa, September 2007,
  Cluj-Napoca (Romania)