Impact of a national external quality assessment scheme for breast pathology in the UK

BACKGROUND

This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology.

AIMS/METHODS

The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics.

RESULTS

Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming.

CONCLUSIONS

These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal

BACKGROUND

The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK.

AIMS/METHODS

To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed.

RESULTS/CONCLUSIONS

Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

Feasibility of familial PSA screening: psychosocial issues and screening adherence

This study examined factors that predict psychological morbidity and screening adherence in first-degree relatives (FDRs) taking part in a familial PSA screening study. Prostate cancer patients (index cases - ICs) who gave consent for their FDRs to be contacted for a familial PSA screening study to contact their FDRs were also asked permission to invite these FDRs into a linked psychosocial study. Participants were assessed on measures of psychological morbidity (including the General Health Questionnaire; Cancer Worry Scale; Health Anxiety Questionnaire; Impact of Events Scale); and perceived benefits and barriers, knowledge; perceived risk/susceptibility; family history; and socio-demographics. Of 255 ICs, 155 (61%) consented to their FDRs being contacted. Of 207 FDRs approached, 128 (62%) consented and completed questionnaires. Multivariate logistic regression revealed that health anxiety, perceived risk and subjective stress predicted higher cancer worry (P = 0.05). Measures of psychological morbidity did not predict screening adherence. Only past screening behaviour reliably predicted adherence to familial screening (P = 0.05). First-degree relatives entering the linked familial PSA screening programme do not, in general, have high levels of psychological morbidity. However, a small number of men exhibited psychological distress.

Factors influencing the radiative surface temperature of grey seal (Halichoerus grypus) pups during early and late lactation

The aim of this study was to examine the variation in body surface temperature of grey seal (Halichoerus grypus) pups throughout lactation in response to different environmental conditions. Radiative surface temperatures (T (r), degrees C) of pups were measured on the Isle of May (56 degrees 11'N, 02 degrees 33'W), southeast Scotland from 29 October to 25 November 2003. Records were obtained from a total of 60 pups (32 female and 28 male) from three different pupping sites during early and late lactation. Pups were sheltered from high wind speeds but air temperature, humidity and solar radiation at pupping sites were similar to general meteorological conditions. The mean T (r) of all pups was 15.8 degrees C (range 7.7-29.7 degrees C) at an average air temperature of 10.2 degrees C (range 6.5-13.8 degrees C). There was no difference in the mean T (r) of pups between early and late lactation. However, the T (r) varied between different regions of the body with hind flippers on average 2-6 degrees C warmer than all other areas measured. There was no difference in mean T (r) of male and female pups and pup body mass did not account for the variation in T (r) during early or late lactation. Throughout the day there was an increase in the T (r) of pups and this explained 20-28% of the variation in T (r) depending on stage of lactation. There was no difference in the mean T (r) of pups between pupping sites or associated with different substrate types. Wind speed and substrate temperature had no effect on the T (r) of pups. However, solar radiation, air temperature and relative humidity accounted for 48% of the variation in mean T (r) of pups during early lactation. During late lactation air temperature and solar radiation alone accounted for 43% of the variation in T (r). These results indicate that environmental conditions explain only some of the variation in T (r) of grey seal pups in natural conditions. Differences in T (r) however indicate that the cost of thermoregulation for pups will vary throughout lactation. Further studies examining intrinsic factors such as blubber thickness and activity levels are necessary before developing reliable biophysical models for grey seals.

The psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: 6-month follow-up

State anxiety (S-STAI-6), distress (GHQ-12), concern and quality of life (EuroQoL-EQ-5D) 6 months after human papillomavirus (HPV) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospective questionnaire study, with 6-month follow-up after the smear test result. Two centres participated in an English pilot study of HPV testing. Participants included two groups of women receiving abnormal smear test results: (tested for HPV and found to be (a) HPV positive (n=369) or (b) HPV negative (n=252)) and two groups not tested for HPV (those receiving (c) abnormal smear test results (n=102) or (d) normal smear test results (n=288)). There were no differences in anxiety, distress or health-related quality of life between the four study groups at 6 months. Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result, and were highest in the group untested for HPV. Predictors of concern across all groups receiving an abnormal smear test were perceived risk of developing cancer, being HPV positive or untested for HPV, sexual health worries and the smear being a woman's first smear test. The raised anxiety and distress observed in women immediately after being informed of an abnormal smear test result and that they are HPV positive was no longer evident at 6 months. Concern about the smear test result was however still raised in these women and those who tested negative for HPV, and particularly among those who did not undergo HPV testing.

Randomised controlled trial of mammographic screening in women from age 40: results of screening in the first 10 years

Debate continues over the effectiveness of screening by mammography in women below age 50. We report here on results of screening in the first 10 years of a randomised trial to study the effect on breast cancer mortality of invitation to annual mammography from age 40 to 41 compared to first invitation to the 3-yearly UK national programme at age 50–52. The trial is taking place in 23 NHS breast screening centres. Between 1991 and 1997, 160 921 women were randomised in the ratio 1 : 2 to intervention and control arms. Screening is by two views at first screen and single view subsequently; data on screening up to and including round five are now complete. Uptake of invitation to screening is between 68 and 70% at all but the latest screening rounds. Rates of referral for assessment are 4.6% at first screen and 3.4% at subsequent screens. Invasive cancer detection rates are 0.09% at first screen, and similar at rescreens until the sixth and later screens. There is little evidence of regular mammography in the trial control arm. The setting of this trial within the NHS breast screening programme should ensure applicability of results to a national programme.

Randomised controlled trial of mammographic screening in women from age 40: predicted mortality based on surrogate outcome measures

A trial in the UK to study the effect on mortality from breast cancer of invitation for annual mammography from the age of 40–41, has randomised a total of 160 921 women in the ratio 1 : 2 to the intervention and control arms. All breast cancers diagnosed in the two arms have been identified, and the histology reviewed. This paper presents the results of an interim analysis using surrogate outcome measures to compare predicted breast cancer mortality in the two arms based on 1287 cases diagnosed to 31.12.1999. Due to earlier diagnosis, there is currently an 8% excess of invasive breast cancers in the intervention arm. The ratio of predicted deaths at 10 years in the intervention arm relative to the control arm, adjusted for this excess diagnosis, ranges from 0.89 (95% confidence interval (CI) 0.78–1.01) to 0.90 (95% CI 0.80–1.01). Screening from age 40 may result in a lower reduction in breast cancer mortality than that observed in other trials including women below age 50. This analysis based on surrogate outcome measures suggests that a reduction in breast cancer mortality may be observed in this trial. However, a number of assumptions have been necessary and firm conclusions must await the analysis of observed mortality from breast cancer.

Should women under 50 be screened for breast cancer?

Despite some controversy in recent years, the majority of experts agree on the evidence for effectiveness of breast screening by mammography for women aged 50 years and above, but for those under 50 years, the picture is much less clear. However, the issue remains of importance both to policy makers and to individual women; although the incidence of breast cancer is lower at younger ages, the life years lost due to cancers diagnosed below 50 years amount to a third of all those lost due to the disease.

Effectiveness and cost-effectiveness of double reading of mammograms in breast cancer screening: findings of a systematic review

There is a lack of direct evidence on the effectiveness of double reading of breast screening mammograms within the context of national screening programmes even though about half of the countries that use mammography screening have implemented double reading. A systematic review was conducted to compare double reading with single reading of mammograms for screening accuracy, patient outcomes and costs. We searched an extensive range of electronic databases, bibliographies of studies were scanned and experts were contacted. Data extraction and quality assessment was undertaken independently by two reviewers. Estimates of the diagnostic accuracy were calculated for those studies with follow-up to identify interval cancers. Only 10 cohort studies met the inclusion criteria with reported extractable data on the effectiveness of double compared to single reading. The mix of methodologies meant that few conclusions could be drawn about the effect of double reading independent of number of views, or effects on size and type of tumours detected. Overall, double reading increases the cancer detection rate by 3-11 per 10,000 women screened and has a double impact on recall rates depending on the recall policy used. The benefit could be mainly in the detection of small cancers, and could be greatest where two readers have different strengths and weaknesses, or where readers are less experienced. Double reading can improve accuracy as compared with single reading. In particular, double reading by consensus or arbitration achieves an increase in cancer detection rate together with a reduction in the rate of women recalled for assessment. Further research should quantify the relative benefit from double reading according to recall policy and number of mammographic views, and estimate the impact on patient outcome.

An investigation into the number of appointment changes and queries arising as a result of extending breast screening to older women in the United Kingdom

OBJECTIVE

To compare the number of telephone queries and appointment changes requested by women aged 65-69 with women aged 50-64.

SETTING

Department of Health funded demonstration study of extending breast screening to women of 65-69.

METHODS

A survey was conducted for 1 week, each month, over the period of a year. Data were collected on the date of the query, the age of the woman, whether and why the appointment was changed, and whether the location for screening was changed.

RESULTS

The proportion of telephone queries or appointment changes was significantly more for women aged 50-64 years (p<0.001), 29.7% of women invited aged 50-64 compared with 26.5% of women invited aged 65-69. The main reason for changing the appointments was inconvenience for both age groups.

CONCLUSIONS

Administrative costs associated with inviting an older woman for breast screening are no more than those for a woman aged 50-64. The number of telephone calls was high in both age groups, which has resource implications for extending the breast screening programme. The extent of appointment queries or changes needs to be considered in the funding of future population screening programmes with preallocated appointment systems.

Evaluation of echocardiography on the neonatal unit

BACKGROUND

Echocardiography is an investigation that is being used increasingly on the neonatal unit. There is some controversy as to whether this service can be provided safely and effectively by neonatologists or whether it should only be performed by paediatric cardiologists.

AIMS

To describe (a) the indications for an echocardiogram, (b) the yield and range of positive findings, (c) the resulting changes in clinical management, and (d) the reliability of echocardiography in the hands of neonatologists when it is performed on the neonatal unit.

METHODS

Information about all echocardiograms performed on the neonatal unit was collected prospectively. Indications for performing echocardiography, echocardiographic findings, and any resulting changes in clinical management were determined. The concordance of findings in infants who underwent echocardiograms performed by both a neonatologist and a paediatric cardiologist was described.

RESULTS

A total of 157 echocardiograms were performed in 82 infants. Echocardiography identified 44 infants with a structural cardiac abnormality and a further 17 infants with a trivial abnormality. In addition, 13 babies were found to have an important functional abnormality. Echocardiography prompted a specific change in clinical management in 64 (78%) babies. In 31 of the 38 infants who had paired scans performed, there was complete concordance between the two examinations. No infants had scans that were completely different. Some discrepancy was identified in seven infants, but this did not prevent appropriate immediate clinical management.

CONCLUSIONS

Echocardiography on the neonatal unit has a high yield for the diagnosis of structural and functional cardiac abnormalities, often results in a change in clinical management, and can be a reliable tool in the hands of neonatologists.

Antidepressants for the treatment of depression in people with schizophrenia: a systematic review

BACKGROUND

Depression is common in people with schizophrenia and is associated with substantial morbidity and an increased risk of suicide. Our aim was to review systematically all the randomized controlled trials that have investigated the clinical effectiveness of antidepressant medication in the treatment of depression in people who also suffer with schizophrenia.

METHOD

Electronic searches of ClinPsych, the Cochrane Library, the Cochrane Schizophrenia Group's Register of Trials, EMBASE and Medline were completed. Reference lists from identified articles were hand searched.

RESULTS

Eleven small studies were identified and all randomized fewer than 30 subjects to each group. We could only perform analyses on a subset of the trials. For five trials (aggregate N = 209) the proportion improved in the antidepressant group was 26% (95% CI 10% to 42%) higher than in the placebo group. In six studies (aggregate N = 267) the standardized mean difference on the Hamilton Rating Scale for Depression at the end of the trial was -0.27 (95 % CI -0.7 to 0.2). There was no evidence that antidepressant treatment given during the stable phase of illness led to a deterioration of psychotic symptoms in the included trials.

CONCLUSIONS

The literature reviewed was, overall, of poor quality and only a small number of trials could contribute towards the meta-analysis. The results provide weak evidence for the effectiveness of antidepressants in those with schizophrenia and depression and could be explained by publication bias. We need further research to determine the best approach towards treating depression in people with schizophrenia.

Impact of skin cancer education on medical students' diagnostic skills

Skin cancer is increasingly common, and the skills involved in its diagnosis should be promoted in UK medical schools. However, there has been no scientific evaluation of the teaching methods employed by dermatology departments. The aim of this study was to evaluate, using traditional audiovisual methods, the impact of an illustrated booklet on skin cancer, coupled with a lecture, on undergraduates' diagnostic skills. The ability of 27 final-year medical students to recognize a variety of skin lesions, using projected images from clinical slides, was assessed. They were tested without warning on two occasions. Immediately after the first test, students were given an illustrated booklet on skin tumours and pigmented lesions which was supplemented with a lecture based on the booklet. Two weeks later, a second test was employed using a series of slides deemed to be of equal diagnostic difficulty. Our results showed a significant increase in the median number of correct diagnoses between the first and second tests (P < 0.001). However, there remained wide variation at the second test in the percentage of correct answers (30 to 80%) amongst students. Our study highlights the need to develop effective methods for improving the diagnostic skills of undergraduates in dermatology, and the importance of evaluating teaching methods. The methods of evaluation, such as ours, can be simple and inexpensive.

PCR detection of Clostridium chauvoei in pure cultures and in formalin-fixed, paraffin-embedded tissues

The polymerase chain reaction (PCR) was used to amplify specific segments of the 16S ribosomal RNA gene of Clostridium chauvoei, a major pathogen of ruminants. Three sets of primers were used to produce amplicons of 159, 836 and 959 base pairs (bp), respectively. The PCR was evaluated by testing clinically important strains of Clostridium, including 21 strains of C. chauvoei, five strains each of Clostridium septicum and Clostridium perfringens and two strains each of Clostridium novyi, Clostridium histolyticum and Clostridium sordellii. Both purified DNA and biomass from pure cultures of each of these microorganisms were evaluated as templates in the PCR. In addition, extracts of formalin-fixed, paraffin-embedded tissues of eight sheep experimentally inoculated with C. chauvoei or C. septicum (four animals each) were also tested by the PCR using the three sets of primers. Purified DNA template of all C. chauvoei strains produced PCR amplicons of the expected size for all three primer pairs. However, when biomass from pure cultures of C. chauvoei or tissue extracts were used as templates, only the primer pair designed to produce the 159bp amplicon gave consistently positive results. No positive results were obtained with any primer pair when purified DNA or biomass from pure cultures of non-target clostridial species were used as templates. Therefore, the PCR primer sets appear to be very specific for identifying C. chauvoei in both cultures and tissues.

Magnetic endoscope imaging: a new technique for localizing colonic lesions

BACKGROUND AND STUDY AIMS

The precise localization of advanced colorectal lesions preoperatively directs the appropriate surgical management. The use of internal landmarks at colonoscopy can be inaccurate, and other methods are therefore necessary to localize lesions precisely. Magnetic endoscope imaging (MEI), a real-time, nonradiographic technique for imaging of the colonoscope, may assist in determining the location of lesions found at colonoscopy.

PATIENTS AND METHODS

A prospective study was carried out to determine the accuracy of MEI for localizing the colonoscope tip anatomically. The MEI system was used to identify one of four predetermined locations within the colon. Once identified, two endoscopic marking clips were attached to the colonic mucosa, and 400 - 500 ml of Urografin radiographic contrast medium was injected to produce an air-contrast "enema." The clips were subsequently localized using plain abdominal radiography, assessed by a single experienced radiologist who was blinded to the colonoscopic findings.

RESULTS

Twenty-nine consecutive patients were enrolled in the study. The overall accuracy of MEI in comparison with the air-contrast "enema" was 90 % (26 of 29 cases). There were three slight errors of localization - clips localized to the descending rather than the sigmoid-descending colon junction (n = 1), or to either side of the mid-transverse (n = 1) and hepatic flexure (n = 1) - but these were not considered to be of surgical or clinical importance.

CONCLUSIONS

MEI is a reliable and accurate method for determining the anatomical position of the endoscope tip during colonoscopy. When it becomes commercially available, we believe the use of MEI will avoid the need for unnecessary barium enemas for localization of lesions prior to definitive surgery.

An investigation into the effect of extending routine mammographic screening to older women in the United Kingdom on the time it takes to screen

OBJECTIVE

To compare the time it takes to screen women aged 65-69 with women age 50-64.

SETTING

Screening centres participating in the Department of Health funded demonstration study of extending breast screening to women aged 65-69.

METHODS

Consecutive women of all ages were timed during November 1999 to February 2000, until about 50 women aged 65-69 had been screened at each of the sites. For each woman screened, her age, whether she had been screened before, the times when she checked in, started to get undressed, started screening, finished screening, and when she left the screening unit were recorded. The radiographers also recorded any difficulties associated with screening any of the women in the survey.

RESULTS

The total mean time spent at the centres and the time being screened was not significantly different between the two age groups overall or within each of the demonstration sites (p>0.05). The distribution of screen time was similar between the age groups within each of the sites. The proportion of screens reported as difficult by the radiographers differed between sites, with two out of the three sites reporting more problems screening older women.

CONCLUSIONS

Despite some radiographers reporting more difficulties associated with screening older women, screening a woman aged 65-69 was found, on average, to take no longer than screening a women aged 50-64 years. Thus, when the NHS breast screening programme is extended to include older women, the same time interval for an appointment can be scheduled regardless of the woman's age.

Development of a protocol for evaluation of mammographic surveillance services in women under 50 with a family history of breast cancer

BACKGROUND

Preliminary retrospective data suggest it is possible to identify impalpable breast cancer in women presenting with a family history of breast cancer under the age of 50, by using regular mammography. In consequence, this service is offered in a number of centres in the UK. The effectiveness of such a service, however, has not been fully evaluated.

METHODS

We propose to perform such an evaluation in a cohort of 20000 women under the age of 50 with a significant family history of breast cancer, given regular mammographic surveillance over 5 years. Comparison of surgical and pathological data with completed and ongoing population screening trials using analysis techniques of varying complexity will be performed to obtain an accurate prediction of future breast-cancer mortality reduction. The formal aims are: i) to estimate the difference in breast-cancer mortality in women under the age of 50 with a significant family history of breast cancer having regular mammography, compared with those not being screened; ii) to estimate the cost-effectiveness of regular mammography in this group of women, compared with no screening. The increase in health service resource use attributable to such a policy will be compared with no screening, and costed. Incremental cost-effectiveness ratios of implementing the standardised mammography strategy compared with no screening will be presented in terms of the additional cost per cancer detected, per life saved and per life-year saved.

Effect of faecal occult blood screening on mortality from colorectal cancer: results from a randomised controlled trial

BACKGROUND

Three large randomised trials have shown that screening for colorectal cancer using faecal occult blood (FOB) tests can reduce the mortality from this disease. Two national pilot studies have recently been launched in the UK to investigate the feasibility of population screening for colorectal cancer in the National Health Service. The largest of the randomised trials was conducted in Nottingham and randomised 152 850 individuals between the ages of 45 and 74 years to receive biennial Haemoccult (FOB) test kit (intervention group) or to a control group.

AIMS

We have compared the mortality in the intervention group compared with the control group.

METHODS

The 152 850 randomised individuals were followed up through local health records and central flagging (Office for National Statistics) over a median follow up period of 11 years.

RESULTS

At a median follow up of 11 years there was a 13% reduction in colorectal cancer mortality (95% confidence interval 3-22%) in the intervention group despite an uptake at first invitation of only approximately 50%. The mortality reduction for those accepting screening was 27%. The reduction in mortality was independent of sex and site of tumour. There was no significant difference in mortality from causes other than colorectal cancer between the intervention and control groups.

CONCLUSIONS

Although the reduction in colorectal cancer mortality was sustained, further follow up of this population is required to determine whether a significant reduction in the incidence of colorectal cancer will be achieved.