Biennial Versus Annual Mammography and the Risk of Late-Stage Breast Cancer

Prediction of higher mortality reduction for the UK Breast Screening Frequency Trial: a model-based approach on screening intervals

Background:

The optimal interval between two consecutive mammograms is uncertain. The UK Frequency Trial did not show a significant difference in breast cancer mortality between screening every year (study group) and screening every 3 years (control group). In this study, the trial is simulated in order to gain insight into the results of the trial and to predict the effect of different screening intervals on breast cancer mortality.

Methods:

UK incidence, life tables and information from the trial were used in the microsimulation model MISCAN–Fadia to simulate the trial and predict the number of breast cancer deaths in each group. To be able to replicate the trial, a relatively low sensitivity had to be assumed.

Results:

The model simulated a larger difference in tumour size distribution between the two groups than observed and a relative risk (RR) of 0.83 of dying from breast cancer in the study group compared with the control group. The predicted RR is lower than that reported from the trial (RR 0.93), but within its 95% confidence interval (0.63–1.37).

Conclusion:

The present study suggests that there is benefit of shortening the screening interval, although the benefit is probably not large enough to start annual screening.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms

BACKGROUND

Despite trials of mammography and widespread use, optimal screening policy is controversial.

OBJECTIVE

To evaluate U.S. breast cancer screening strategies.

DESIGN

6 models using common data elements.

DATA SOURCES

National data on age-specific incidence, competing mortality, mammography characteristics, and treatment effects.

TARGET POPULATION

A contemporary population cohort.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTIONS

20 screening strategies with varying initiation and cessation ages applied annually or biennially.

OUTCOME MEASURES

Number of mammograms, reduction in deaths from breast cancer or life-years gained (vs. no screening), false-positive results, unnecessary biopsies, and overdiagnosis.

RESULTS OF BASE-CASE ANALYSIS

The 6 models produced consistent rankings of screening strategies. Screening biennially maintained an average of 81% (range across strategies and models, 67% to 99%) of the benefit of annual screening with almost half the number of false-positive results. Screening biennially from ages 50 to 69 years achieved a median 16.5% (range, 15% to 23%) reduction in breast cancer deaths versus no screening. Initiating biennial screening at age 40 years (vs. 50 years) reduced mortality by an additional 3% (range, 1% to 6%), consumed more resources, and yielded more false-positive results. Biennial screening after age 69 years yielded some additional mortality reduction in all models, but overdiagnosis increased most substantially at older ages.

RESULTS OF SENSITIVITY ANALYSIS

Varying test sensitivity or treatment patterns did not change conclusions.

LIMITATION

Results do not include morbidity from false-positive results, patient knowledge of earlier diagnosis, or unnecessary treatment.

CONCLUSION

Biennial screening achieves most of the benefit of annual screening with less harm. Decisions about the best strategy depend on program and individual objectives and the weight placed on benefits, harms, and resource considerations.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Finding the minimal intervention needed for sustained mammography adherence

BACKGROUND

Regular adherence to mammography screening saves lives, yet few women receive regular mammograms.

DESIGN

RCT.

SETTING/PARTICIPANTS

Participants were recruited through a state employee health plan. All were women aged 40-75 years and had recent mammograms prior to enrollment (n=3547). Data were collected from 2004 to 2009.

INTERVENTION

Trial tested efficacy of a two-step adaptively-designed intervention to increase mammography adherence over 4 years. The first intervention step consisted of three reminder types: enhanced usual care reminders (EUCR); enhanced letter reminders (ELR); both delivered by mail, and automated telephone reminders (ATR). After delivery of reminders, women who became off-schedule in any of the 4 years received a second step of supplemental interventions. Three supplemental intervention arms contained priming letters and telephone counseling: barriers only (BarriCall); barriers plus positive consequences of getting mammograms (BarriConCall+); and barriers plus negative consequences of not getting mammograms (BarriConCall-).

MAIN OUTCOME MEASURES

Average cumulative number of days non-adherent to mammography over 4 years based on annual screening guidelines (analyses conducted in 2009).

RESULTS

All reminders performed equally well in reducing number of days of non-adherence. Women randomized to receive supplemental interventions had significantly fewer days of non-adherence compared to women who received EUCR (p=0.0003). BarrConCall+ and BarrConCall- conditions did not significantly differ in days non-adherent compared to women in the barriers-only condition (BarriCon).

CONCLUSIONS

The minimal intervention needed for sustained mammography use is a combination of a reminder followed by a priming letter and barrier-specific telephone counseling for women who become off-schedule. Additional costs associated with supplemental interventions should be considered by organizations deciding which interventions to use.

TRIAL REGISTRATION NUMBER

NCT01148875.

Longitudinal predictors of nonadherence to maintenance of mammography

BACKGROUND

Regular adherence to screening mammography, also known as maintenance of mammography, reduces breast cancer morbidity and mortality. However, mammography maintenance is uncommon and little is known about why women do not maintain regular screening schedules. We investigated longitudinal predictors of women not maintaining adherence.

METHODS

Participants were insured women enrolled in an intervention trial who had screening mammograms 8 to 9 months before study enrollment (n = 1,493). Data were collected from 2003 to 2008. We used discrete event history analysis to model nonadherence to mammography maintenance over three successive annual screening intervals (+ 2 months).

RESULTS

Most (54%) women did not maintain screening adherence over 3 years. Women who did not maintain adherence were more likely to be ages 40 to 49 years, rate their health fair or poor, be less satisfied with their last mammography experiences, report one or more barriers to getting mammograms, be less than completely confident about getting their next mammograms (lower self-efficacy), or have weaker behavioral intentions. The odds of not maintaining adherence decreased over time.

DISCUSSION

Although great strides have been achieved in increasing the proportion of women who have received mammograms, most women still are not maintaining regular mammography use over time. Our findings provide insights into targets for future mammography maintenance interventions.

Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms

BACKGROUND

Despite trials of mammography and widespread use, optimal screening policy is controversial.

OBJECTIVE

To evaluate U.S. breast cancer screening strategies.

DESIGN

6 models using common data elements.

DATA SOURCES

National data on age-specific incidence, competing mortality, mammography characteristics, and treatment effects.

TARGET POPULATION

A contemporary population cohort.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTIONS

20 screening strategies with varying initiation and cessation ages applied annually or biennially.

OUTCOME MEASURES

Number of mammograms, reduction in deaths from breast cancer or life-years gained (vs. no screening), false-positive results, unnecessary biopsies, and overdiagnosis.

RESULTS OF BASE-CASE ANALYSIS

The 6 models produced consistent rankings of screening strategies. Screening biennially maintained an average of 81% (range across strategies and models, 67% to 99%) of the benefit of annual screening with almost half the number of false-positive results. Screening biennially from ages 50 to 69 years achieved a median 16.5% (range, 15% to 23%) reduction in breast cancer deaths versus no screening. Initiating biennial screening at age 40 years (vs. 50 years) reduced mortality by an additional 3% (range, 1% to 6%), consumed more resources, and yielded more false-positive results. Biennial screening after age 69 years yielded some additional mortality reduction in all models, but overdiagnosis increased most substantially at older ages.

RESULTS OF SENSITIVITY ANALYSIS

Varying test sensitivity or treatment patterns did not change conclusions.

LIMITATION

Results do not include morbidity from false-positive results, patient knowledge of earlier diagnosis, or unnecessary treatment.

CONCLUSION

Biennial screening achieves most of the benefit of annual screening with less harm. Decisions about the best strategy depend on program and individual objectives and the weight placed on benefits, harms, and resource considerations.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Overuse of mammography during the first round of an organized breast cancer screening programme

OBJECTIVES

We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination.

METHODS

A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals.

RESULTS

The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0-26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7-5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6-12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months.

CONCLUSIONS

Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.

Impact of mailed and automated telephone reminders on receipt of repeat mammograms: a randomized controlled trial

BACKGROUND

This study compares the efficacy of three types of reminders in promoting annual repeat mammography screening.

DESIGN

RCT.

SETTING AND PARTICIPANTS

Study recruitment occurred in 2004-2005. Participants were recruited through the North Carolina State Health Plan for Teachers and State Employees. All were aged 40-75 years and had a screening mammogram prior to study enrollment. A total of 3547 women completed baseline telephone interviews.

INTERVENTION

Prior to study recruitment, women were assigned randomly to one of three reminder groups: (1) printed enhanced usual care reminders (EUCRs); (2) automated telephone reminders (ATRs) identical in content to EUCRs; or (3) enhanced letter reminders that included additional information guided by behavioral theory. Interventions were delivered 2-3 months prior to women's mammography due dates.

MAIN OUTCOME MEASURES

Repeat mammography adherence, defined as having a mammogram no sooner than 10 months and no later than 14 months after the enrollment mammogram.

RESULTS

Each intervention produced adherence proportions that ranged from 72% to 76%. Post-intervention adherence rates increased by an absolute 17.8% from baseline. Women assigned to ATRs were significantly more likely to have had mammograms than women assigned to EUCRs (p=0.014). Comparisons of reminder efficacy did not vary across key subgroups.

CONCLUSIONS

Although all reminders were effective in promoting repeat mammography adherence, ATRs were the most effective and lowest in cost. Health organizations should consider using ATRs to maximize proportions of members who receive mammograms at annual intervals.

Factors associated with annual-interval mammography for women in their 40s

BACKGROUND

Evidence is mounting that annual mammography for women in their 40s may be the optimal schedule to reduce morbidity and mortality from breast cancer. Few studies have assessed predictors of repeat mammography on an annual interval among these women.

METHODS

We assessed mammography screening status among 596 insured Black and Non-Hispanic white women ages 43-49. Adherence was defined as having a second mammogram 10-14 months after a previous mammogram. We examined socio-demographic, medical and healthcare-related variables on receipt of annual-interval repeat mammograms. We also assessed barriers associated with screening.

RESULTS

44.8% of the sample were adherent to annual-interval mammography. A history of self-reported abnormal mammograms, family history of breast cancer and never having smoked were associated with adherence. Saying they had not received mammography reminders and reporting barriers to mammography were associated with non-adherence. Four barrier categories were associated with women's non-adherence: lack of knowledge/not thinking mammograms are needed, cost, being too busy, and forgetting to make/keep appointments.

CONCLUSIONS

Barriers we identified are similar to those found in other studies. Health professionals may need to take extra care in discussing mammography screening risk and benefits due to ambiguity about screening guidelines for women in their 40s, especially for women without family histories of breast cancer or histories of abnormal mammograms. Reminders are important in promoting mammography and should be coupled with other strategies to help women maintain adherence to regular mammography.

Cancer screenings, diagnostic technology evolution, and cancer control

Screening should allow for the anticipation of cancer diagnosis at an earlier stage, when curative treatment is possible. Screening for cervical, large bowel, and breast cancer were shown to be effective in reducing mortality. The wide acceptance of the screening concept led to the wide diffusion also of screening of uncertain benefit against prostate cancer and skin melanoma. Diagnostic technologies are continuously evolving, and new tests are proposed to improve existing screenings or as screening tests for additional cancer sites (e.g., lung cancer). Cancer screening, however, is a complex and costly intervention that does not result only in benefits but also may cause harm. A major emerging problem of screening is overdiagnosis, or the detection of cases that would have not progressed to the symptomatic phase in the absence of screening. Thus, both experimental and observational evaluation studies are needed to reduce harm caused by screenings and to select effective interventions among many proposed innovations. Finally, the research of markers to assess the aggressive nature of screen-detected lesions is of great importance to improve screenings ' harm/benefit ratio.

Impact of changing from annual to biennial mammographic screening on breast cancer outcomes in women aged 50–79 in British Columbia

Objectives

The objective of this study was to compare breast cancer outcomes among women subject to different policies on mammography screening frequency.

Setting

Data were obtained for women participating in the Screening Mammography Programme of British Columbia (SMPBC) for 1988–2005. The SMPBC changed its policy for women aged 50–79 years from annual to biennial mammography in 1997, but retained an annual recommendation for women aged 40–49 years.

Methods

Breast cancer outcomes were compared for women participating in the programme before and after 1997 for two groups: ages 40–49 and 50–79 years.

Results

There were data on 658,151 women. Comparing pre-1997 and post-1997, the median interscreen interval increased by 11.1 months in women 50–79 but by only 0.3 months in women aged 40–49. Excluding those detected at initial screen, 6291 breast cancers were identified. Comparing pre-1997 and post-1997: the relative rates (RR) of screen detected cancer increased in women aged 40–49 (RR = 1.32) and the rate of invasive cancers ≥20 mm at diagnosis decreased (RR = 0.83); the rate of cancers with axillary node involvement increased in women aged 50–79 (RR = 1.23). Cancer survival improved after 1997 for women diagnosed at ages 40–49 (hazard ratio = 0.62), but was unchanged for women aged 50–79. Breast cancer mortality rates did not change between the periods in either age group.

Conclusion

The proximal cancer outcomes considered (staging and survival) improved in women aged 40–49 but this was offset in women aged 50–79 associated with the change in screen frequency. These changes did not result in alterations in breast cancer mortality rates in either age group.

Annual or biennial mammography screening for women at a higher risk with a family history of breast cancer: prognostic indicators of screen-detected cancers in New South Wales, Australia

OBJECTIVE

This study examined whether offering annual mammography screening for women with the risk factor of a family history of breast cancer resulted in more favorable prognostic indicators of diagnosed cancers than the usual approach of biennial screening.

METHODS

The study involved women aged 50-69 years with a family history of breast cancer, defined as having > or = 1 first-degree relative diagnosed with breast cancer, who were diagnosed with a screen-detected invasive breast cancer between 1998 and 2004 in BreastScreen New South Wales (n = 590). The women were grouped according to whether they screened in an area offering annual screening to women with a family history, or were offered the standard biennial screening. The odds of having favorable tumor size, grade, and nodal status prognosis were compared between these screening groups using logistic regression. A comparison group of women without a family history, all offered biennial screening, was also evaluated based on the same area groupings to examine whether any differences were due to the area, rather than the screening interval policy.

RESULTS

Women with a family history who were offered annual screening at BreastScreen NSW were significantly more likely than those who were offered biennial screening to be diagnosed with a tumor < or = 20 mm in size (adjusted odds ratio (AOR) = 1.91, 95% CI: 1.21-3.02), and to have a node-negative tumor (AOR = 1.61, 95% CI: 1.03-2.50). There were also significantly higher odds of being diagnosed with tumors < or = 15 mm (p < 0.001) and < or = 10 mm in size (p = 0.011) in women offered annual screening. There was no significant difference in the odds of a Grade 1 tumor being detected (AOR = 1.26, 95% CI: 0.87-1.81), although the direction of the effect was consistent with that seen for size and nodal status. No significant differences were found in the comparison group of women without a family history.

CONCLUSIONS

Offering annual screening for women aged 50-69 years with a family history of breast cancer significantly increased the odds of being diagnosed with a smaller, node-negative tumors. Further investigation is required to assess whether the improved prognostic indicators translate into significantly better mortality outcomes for women with a family history offered annually screening.

Comparing screening mammography for early breast cancer detection in Vermont and Norway

BACKGROUND

Most screening mammography in the United States differs from that in countries with formal screening programs by having a shorter screening interval and interpretation by a single reader vs independent double reading. We examined how these differences affect early detection of breast cancer by comparing performance measures and histopathologic outcomes in women undergoing opportunistic screening in Vermont and organized screening in Norway.

METHODS

We evaluated recall, screen detection, and interval cancer rates and prognostic tumor characteristics for women aged 50-69 years who underwent screening mammography in Vermont (n = 45 050) and in Norway (n = 194 430) from 1997 through 2003. Rates were directly adjusted for age by weighting the rates within 5-year age intervals to reflect the age distribution in the combined data and were compared using two-sided Z tests.

RESULTS

The age-adjusted recall rate was 9.8% in Vermont and 2.7% in Norway (P < .001). The age-adjusted screen detection rate per 1000 woman-years after 2 years of follow-up was 2.77 in Vermont and 2.57 in Norway (P = .12), whereas the interval cancer rate per 1000 woman-years was 1.24 and 0.86, respectively (P < .001). Larger proportions of invasive interval cancers in Vermont than in Norway were 15 mm or smaller (55.9% vs 38.2%, P < .001) and had no lymph node involvement (67.5% vs 57%, P = .01). The prognostic characteristics of all invasive cancers (screen-detected and interval cancer) were similar in Vermont and Norway.

CONCLUSION

Screening mammography detected cancer at about the same rate and at the same prognostic stage in Norway and Vermont, with a statistically significantly lower recall rate in Norway. The interval cancer rate was higher in Vermont than in Norway, but tumors that were diagnosed in the Vermont women tended to be at an earlier stage than those diagnosed in the Norwegian women.

Mammography screening of women in their 40s: impact of changes in screening guidelines

BACKGROUND

: In March 1997, the American Cancer Society (ACS) updated its recommended mammography screening interval for women ages 40-49 years from once every 1 to 2 years to once every year. At the same time, the National Cancer Institute (NCI), which had previously not recommended routine screening of women in their 40s, began recommending screening at 1 to 2-year intervals. These events occurred during the data collection phase of a prospective study of mammography screening and, thereby, provided an unexpected opportunity to examine the potential influences of changing guidelines on women's beliefs about how frequently they should obtain screening exams.

METHODS

: This analysis included 1451 African American and white women ages 40-79 years, who obtained an "index" screening exam between October 1996 and January 1998. In baseline and 2-year follow-up telephone interviews, respondents provided information on demographic, socioeconomic, health history, medical care, behavioral and psychosocial factors, and on how frequently they believed women of their age should obtain screening mammograms.

RESULTS

: After the ACS and NCI announcements of new screening guidelines for women in their 40s, a significant increase in endorsement of annual screening among women ages 40-49 years was observed, consistent with the ACS recommendation for annual screening in that age group. No increase in endorsement of annual screening among women ages 50 years and older was evident during the same time period.

CONCLUSIONS

: Women's beliefs about how frequently they should obtain mammography screenings appear to change in response to changes in recommendations of high-profile health organizations, particularly when those recommendations call for an increase in screening.

Surveillance mammography and the risk of death among elderly breast cancer patients

PURPOSE

To examine the benefits of mammography for elderly breast cancer survivors in community settings.

METHODS

Using the 1991-1999 linked SEER-Medicare data, we examined if mammography reduced the risk of breast-cancer-specific and all-cause mortality among women age 66 or older who were diagnosed with first primary breast cancer (FPBC) at stages 0-III and survived at least 30 months. To analyze the influence of mammography (both within one year and within two years prior to death/censoring) on the risk of breast-cancer-specific mortality, we compared women who died of breast cancer (cases) with women who died of other causes or were censored (controls). For an analysis of all-cause mortality, we compared women who died from any cause (cases) with women who were censored (controls). Propensity scores were used to adjust for tumor-related, treatment-related, and sociodemographic confounders.

RESULTS

Among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period in propensity-score-adjusted analysis (within one year odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.72-0.95; within two years OR: 0.80, 95% CI: 0.70-0.92). Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals.

CONCLUSIONS

In community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.

The effect of telephone versus print tailoring for mammography adherence

OBJECTIVE

The purpose of this intervention was to increase mammography adherence in women who had not had a mammogram in the last 15 months.

METHODS

A prospective randomized intervention trial used four groups: (1) usual care, (2) tailored telephone counseling, (3) tailored print, (4) tailored telephone counseling and print. Participants included a total of 1244 women from two sites-a general medicine clinic setting serving predominately low-income clientele and a Health Maintenance Organization (HMO). Computer-tailored interventions addressed each woman's perceived risk of breast cancer, benefits and/or barriers and self-efficacy related to mammography screening comparing delivery by telephone and mail.

RESULTS

Compared to usual care all intervention groups increased mammography adherence significantly (odds ratio 1.60-1.91) when the entire sample was included.

CONCLUSIONS

All interventions groups demonstrated efficacy in increasing mammography adherence as compared to a usual care group. When the intervention analysis considered baseline stage, pre contemplators (women who did not intend to get a mammogram) did not significantly increase in mammography adherence as compared to usual care.

PRACTICE IMPLICATIONS

Women who are in pre contemplation stage may need a more intensive intervention.

The association between the pre-diagnosis mammography screening interval and advanced breast cancer

BACKGROUND

While screening has been demonstrated to reduce breast cancer mortality, the optimal screening interval is unknown. We designed a study to determine the risk of an advanced breast cancer diagnosis by varying the interval between mammograms.

METHODS

We reviewed a single state's mammography records of women diagnosed with breast cancer between 1994 and 2002. The pre-diagnosis screening interval was the number of days between the last two eligible mammograms preceding a cancer diagnosis. The interval was classified as annual (0.75-1.49 years), biennial (1.5-2.49 years) or longer (exceeding 2.49 years). Advanced breast cancer was >or=stage IIB, tumor size >2 cm, or >or=one lymph node with cancer.

RESULTS

The probability of an advanced breast cancer diagnosis did not differ between women with an annual pre-diagnosis screening interval and women with a biennial interval (21.1% vs. 23.7%, P=0.262). A longer pre-diagnosis screening interval was weakly associated with advanced breast cancer (21.8% for intervals 0.75-2.49 years vs. 26.8% for longer intervals, P=0.070). In multivariate analysis, we found an interaction between the pre-diagnosis screening interval and age. Among women 50 years or older, the risk of an advanced breast cancer diagnosis risk was higher for women with a pre-diagnosis screening interval exceeding 2.49 years compared to women with shorter screening intervals (OR 1.99 [1.02-3.90]).

CONCLUSIONS

We found no difference in advanced breast cancer rates between women using mammography annually or biennially. Among women 50 years or older, the advanced breast cancer rate increased when the pre-diagnosis screening interval exceeded 2.49 years.

Disease-Specific Survival in Patient-Detected Breast Cancer

BACKGROUND

Patient-detected breast cancer is not well described, and its association with survival is not known.

PATIENTS AND METHODS

Initial breast cancer detection methods were extracted from patient chart notes in a registry cohort of women aged 40-93 with primary invasive breast cancer seen at the community-based regional cancer center between 1990 and 1999 (N = 2228). Patients were followed for vital status and recurrence (current as of 2003/2004) with a mean follow-up of 7.6 years. Physician-detected breast cancers were excluded from the analysis (n = 231).

RESULTS

Forty-six percent of cases were patient detected (n = 1019), and 54% were mammography detected (n = 1209). Those with patient-detected disease received more aggressive treatment (combined radiation and chemotherapy; 49% vs. 23%; P < 0.001) and were twice as likely to have a modified radical mastectomy (41% vs. 20%; P < 0.001). Patient-detected cases were more likely to have a disease recurrence (5-year recurrence rate: 13% vs. 6%; log-rank test, 30.51; P < 0.001) and were more likely to die of disease (5-year disease-specific mortality rate: 8% vs. 3%; log-rank test, 34.7; P < 0.001). In a Cox proportional hazards model, detection method was not associated with risk of breast cancer-related death.

CONCLUSION

Patient-detected breast cancer appears to be a more virulent form of breast cancer than mammography-detected breast cancer with higher recurrence and mortality risk despite more aggressive treatment.