The impact of breast cancer screening on survival. A 5- to 10-year follow-up study

Variability Among Breast Cancer Risk Classification Models When Applied at the Level of the Individual Woman

BACKGROUND

Breast cancer risk models guide screening and chemoprevention decisions, but the extent and effect of variability among models, particularly at the individual level, is uncertain.

OBJECTIVE

To quantify the accuracy and disagreement between commonly used risk models in categorizing individual women as average vs. high risk for developing invasive breast cancer.

DESIGN

Comparison of three risk prediction models: Breast Cancer Risk Assessment Tool (BCRAT), Breast Cancer Surveillance Consortium (BCSC) model, and International Breast Intervention Study (IBIS) model.

SUBJECTS

Women 40 to 74 years of age presenting for screening mammography at a multisite health system between 2011 and 2015, with 5-year follow-up for cancer outcome.

MAIN MEASURES

Comparison of model discrimination and calibration at the population level and inter-model agreement for 5-year breast cancer risk at the individual level using two cutoffs (≥ 1.67% and ≥ 3.0%).

KEY RESULTS

A total of 31,115 women were included. When using the ≥ 1.67% threshold, more than 21% of women were classified as high risk for developing breast cancer in the next 5 years by one model, but average risk by another model. When using the ≥ 3.0% threshold, more than 5% of women had disagreements in risk severity between models. Almost half of the women (46.6%) were classified as high risk by at least one of the three models (e.g., if all three models were applied) for the threshold of ≥ 1.67%, and 11.1% were classified as high risk for ≥ 3.0%. All three models had similar accuracy at the population level.

CONCLUSIONS

Breast cancer risk estimates for individual women vary substantially, depending on which risk assessment model is used. The choice of cutoff used to define high risk can lead to adverse effects for screening, preventive care, and quality of life for misidentified individuals. Clinicians need to be aware of the high false-positive and false-negative rates and variation between models when talking with patients.

The Global and Regional Survival Rate of Women With Breast Cancer: A Systematic Review and Meta-analysis

Breast cancer is the most common cancer among women in the world. The aim of this study was to measure the global and regional survival rates of women with breast cancer. We searched Medline/PubMed, Web of Science, Scopus, and Google Scholar to identify cohort studies on the survival rate of women with primary invasive breast cancer until the end of June 2017. We used random effect models to estimate the pooled 1-, 3-, 5-, and 10-year survival rates. Subgroup analysis and meta-regression models were used to investigate the potential sources of heterogeneity. One hundred twenty-six studies were included in the meta-analysis. Between-study heterogeneities in the 1-, 3-, 5-, and 10-year survival rates were significantly high (all I²s > 50%; P = .001). The global 1-, 3-, 5-, and 10-year pooled survival rates in women with breast cancer were 0.92 (95% confidence interval [CI], 0.90-0.94), 0.75 (95% CI, 0.71-0.79), 0.73 (95% CI, 0.71-0.75), and 0.61% (95% CI, 0.54-0.67), respectively. Subgroup analysis revealed that survival rates varied in different World Health Organization regions, age and stage at diagnosis, year of the studies, and degree of development of countries. Meta-regression indicated that year of the study (β = 0.07; P = .002) and development of country (β = -0.1; P = .0001) were potential sources of heterogeneity. The survival rate was improved in recent decades; however, it is lower in developing regions than developed ones.

Accuracy of the "triple test" in the diagnosis of palpable breast masses in Saudi females

BACKGROUND

For patients who present to clinicians with palpable breast lesions, the triple test: (physical examination, mammography and fine-needle aspiration cytology) can be employed to provide accurate diagnosis. In this study, the sensitivity, specificity and predictive values of triple test components were studied separately and in combination.

MATERIAL AND METHODS

During the study period (from January 1998 to December 1999), 140 patients with palpable breast masses were subjected to all components of the triple test followed by confirmatory open biopsy.

RESULTS

Physical examination showed 82.6% sensitivity, 97.3% specificity and 86.4% positive predictive value. Mammography showed 87.5% sensitivity, 97.3% specificity and 87.5% positive predictive value and fine-needle aspiration cytology (FNAC) showed 91.7% sensitivity, 100% specificity and 100% positive predictive value in concordant cases (elements had either all malignant or all benign results).

CONCLUSION

The triple test was 100% accurate in the diagnosis of palpable breast lesions when all three elements were concordant. Based on these results, we recommend elimination of the confirmatory open biopsy, which will result in reduced expenses and morbidity compared with open biopsy.

Palpable breast cancers are inherently different from nonpalpable breast cancers

BACKGROUND

We examined the clinicopathologic profile of T1 cancers to determine whether palpable cancers are different from nonpalpable cancers.

METHODS

A prospective database was reviewed. Palpable T1 cancers were compared with nonpalpable T1 cancers. Initial significance was determined by chi2 analysis. Factors found to be significant were then reanalyzed. controlling for tumor size by logistic or linear regression, as appropriate.

RESULTS

Of 1263 T1 cancers treated between 1981 and 2000, 857 (68%) were palpable and 401 (32%) were nonpalpable. Palpability correlated with pathologic tumor size, mitotic grade, nuclear grade, high S-phase, lymphovascular invasion, nodal positivity, and lack of extensive intraductal component, multifocality, and multicentricity. There was no significant difference in estrogen receptor, progesterone receptor or Her-2/neu status, ploidy, or DNA index. Breast cancer-specific survival was worse for patients with palpable cancers.

CONCLUSIONS

Palpable cancers are inherently different from nonpalpable cancers, with a less diffuse growth pattern, higher metastatic potential, higher proliferative activity, more nuclear abnormalities, and a worse prognosis.

The operative management of screen-detected breast cancers

BACKGROUND

Mammographic screening for breast cancer not only reduces the overall mortality from breast cancer but allows greater opportunities for breast-conserving operations. The predicted degree of breast conservation is not being realized, but is increasing in centres that have published their results.

METHODS

The operative management of breast cancers diagnosed by BreastScreen Central and Eastern Sydney Screening and Assessment Service were compared between two time periods: January 1988-December 1992 (group 1) and January 1993-December 1995 (group 2). The rate of breast conservation, and other data were compared between the two periods. An attempt was made with multivariate analysis to identify some of the factors that made mastectomy rather than conservation more likely.

RESULTS

There were 723 cancers detected that were suitable for analysis (group 1, n = 273; group 2, n = 450). In group 1 the breast conservation rate was 42.9%; this increased significantly to 60.4% in group 2 (P < 0.001). The data were examined to determine if there was any other factor that had changed over the time periods which might account for the increased rate of breast conservation. The use of pre-operative diagnostic techniques such as fine needle aspirate cytology and core biopsy increased significantly. Multivariate analysis comparing the differences in patient age, diagnostic technique, tumour type, grade, size, location and lymph node status, both independently and compositely did not account for the increase in breast conservation in group 2.

CONCLUSION

The increase in breast conservation is due to other factors such as the surgeons' approach and patient attitude. The use of pre-operative, minimally invasive tissue sampling techniques is increasing.

Interval breast cancers are not biologically distinct--just more difficult to diagnose

BACKGROUND

Breast cancer diagnosed within 1 year of a negative annual screening examination is called interval breast cancer (IBC) and is considered to be a more virulent subtype of disease.

METHODS

We reviewed clinical data on 24 women who were diagnosed as having IBC while participating in the Breast Cancer Detection Demonstration Project at Ellis Fischel Cancer Hospital and the Women's Cancer Control Program screening project in Columbia, Missouri, between 1974 and 1992. We reinterpreted mammograms from the visit prior to the diagnosis of IBC for possible misdiagnosis, changes suggestive of malignancy, and Wolfe's patterns. Archival paraffin blocks from 19 patients were used to determine qualitative expression of tumor markers.

RESULTS

Observed 5-, 8-, and 10-year survival rates were identical to published data for patients with non-IBC. Seventy-four percent of the mammograms evidenced dysplastic Wolfe's patterns (P2 and DY), and one patient was found retrospectively to have shown evidence of cancer which was missed. Compared to breast cancers in general, fewer IBC tumors expressed tumor markers associated with poor prognosis.

CONCLUSIONS

Survival rates and tumor marker expressions in this retrospective cohort suggest that IBC tumors are not more biologically aggressive than noninterval tumors. They are more difficult to diagnose both by physical examination and mammography.

Management of in situ and minimally invasive breast carcinoma

In situ breast carcinoma represents an early localized stage in the transition to invasive breast carcinoma and has an especially favorable prognosis with appropriate management. The widespread use of mammography has contributed to its increased rate of diagnosis. The two histologic forms of this entity have distinct pathologic and biologic characteristics, with different therapeutic implications. Lobular carcinoma in situ is considered a marker of increased risk for subsequent invasive carcinoma and is most commonly managed by nonoperative surveillance. Ductal carcinoma in situ behaves more as a true anatomic precursor of invasive disease and has the same therapeutic options as invasive breast carcinoma. Minimally invasive breast carcinoma should be considered a fundamentally different entity, primarily because of its potential for systemic metastasis that in situ lesions do not theoretically have. There are still many outstanding issues and dilemmas to be resolved by scientific investigation before the intriguing potential of these early forms of breast malignancy are fully understood.

A comparison of breast cancers detected by mass screening and those found in out-patient clinics

We evaluated the results of a mass screening study on breast cancer detection by physical examination alone conducted in Ishikawa Prefecture from 1978 to 1990. The number of cases of breast cancer detected by mass screening was then compared with that found in out-patient clinics during the same period. Breast cancer was detected in 88 of 152,969 women by mass screening, the detection rate being 0.06% for the total study: 0.08% at the initial screening and 0.04% at periodic screenings. Early stage breast cancer was more frequently detected during periodic screenings than at the initial screening or in out-patient clinics. Moreover, although the initial screenings may have identified patients with breast cancer at more advanced stages, the survival was not significantly different. The results of this series led us to conclude that mass screening by physical examination alone may have no impact on the mortality rate of breast cancer.

The effect of mass screening for breast cancer: results of a multivariate analysis

To evaluate the life-prolonging effect of mass screening for breast cancer, we compared the risk of death for the patients detected by mass screening with that for the patients diagnosed in out-patient clinics, after adjusting for other relevant factors simultaneously by using the Cox regression model. A multivariate analysis using the Cox regression model in which clinical staging of disease was taken as one of the independent variables, showed that the risk of death for patients detected by mass screening was smaller by 0.765 times than that for patients found in out-patient clinics although the reduction was not statistically significant. This small reduction might be partly due to the effect of mass screening through early detection even within the same stage, and partly due to length bias, lead time bias and self-selection bias. When clinical staging of disease was removed from the independent variables, the risk of death for patients detected by mass screening was reduced from 0.765 times to 0.677 times that for patients diagnosed in out-patient clinics, which was statistically significant (P greater than 0.01). For asymptomatic patients detected by mass screening, such as reduction of the risk of death was from 0.789 times to 0.555 times that for patients found in out-patient clinics (P less than 0.05). These results suggest that mass screening for breast cancer may contribute to the reduction of the risk of death, although the effect of biases inherent in periodic screening was not removed completely in the present analysis.

Steroid-hormone receptors in nonpalpable and more advanced stages of breast cancer. A contribution to the biology and natural history of carcinoma of the female breast

Tumors of five groups of patients, with (1) nonpalpable primary breast cancer, (2) palpable operable primary breast cancer, (3) loco-regionally advanced primary breast cancer, (4) first and (5) late metastatic breast cancer, were studied in respect to their steroid receptor content. A statistically significant decrease of progesterone receptor positive tumors and of tumors positive for estradiol and progesterone receptors, was found with increasing advance of the disease. A reversed extrapolation of these figures supports the hypothesis that every breast cancer contains steroid receptors and is hormone-dependent from its inception.

Breast cancer detection: experience in a suburban community

Six hundred sixty-nine breast biopsies performed at the Methodist Hospital of Southern California and the Arcadia Outpatient Surgery Center during 1987 and 1988 were reviewed. Three hundred twenty-eight biopsies were performed for clinical indications (lump, thickening, or nipple discharge). Three hundred forty-one biopsies (51%) were performed because of mammographic abnormalities and required preoperative x-ray localization. Of the 341 localized biopsy specimens, 261 were varieties of fibrocystic mastopathy, fibroadenoma, papilloma, or hyperplasia. An additional 31 cases showed atypical ductal or lobular hyperplasia. One hundred fifty-one breast cancers were detected in this series of 669 breast biopsies. One hundred two (68%) of these were detected as a result of a clinical finding, and 49 were detected as a result of mammographic abnormalities (a 32% incidence of occult breast cancers). Among the 341 x-ray localization biopsies performed, breast cancer was detected in 14%.

The impact of mammography on the patterns of patients referred for definitive breast irradiation

To evaluate the impact of mammography on the patterns of patients referred for definitive breast irradiation, the records of 1507 cases of carcinoma of the breast in 1468 women treated between 1977 and 1988 with breast-conserving surgery and definitive irradiation were reviewed. All patients had undergone complete excision of the primary tumor with or without axillary staging. All patients had either noninvasive, intraductal carcinoma (American Joint Committee [AJC] Stage Tis, N0) or invasive carcinoma (AJC Stage T1 or T2, N0 or N1). The use of a mammographic needle localization breast biopsy for diagnosis of a nonpalpable carcinoma steadily increased over time from 3% (one of 32) in in 1977-78 to 26% (111/421) in 1987-88 (P less than 0.0001). The percentage of intraductal carcinomas was significantly increased for the cases in which a mammographic needle localization was used for biopsy of a nonpalpable carcinoma (P less than 0.0001). There was an increase in the incidence of intraductal carcinomas in patients referred for definitive breast irradiation over time from 6% (two of 32) in 1977-78 to 13% (53/421) in 1987-88 (P = 0.0004). These results demonstrate that the use of mammography has had a significant impact on the patterns of patients referred for breast conservation and definitive irradiation with an increase in the percentage of nonpalpable cancers diagnosed using mammographic needle localization and with an increase in the percentage of intraductal carcinomas referred over time.

Mass screening for breast cancer: comparison of the clinical stages and prognosis of breast cancer detected by mass screening and in out-patient clinics

To establish the criteria for assessing the life-prolonging effect of mass screening for breast cancer, clinical stage and prognosis of breast cancer detected by mass screening in 11 regions of Japan were compared with those for matched patients in out-patient clinics. A total of 728 patients detected by mass screening and 1,450 found in the out-patient clinics were reviewed. The stage of the disease was Tis or I in 40.9% of the patients detected by mass screening, and 28.7% of those found in the out-patient clinics. In contrast, stage III was found in 9.3% and 14.6%, respectively, indicating that early stages were significantly more common in the patients detected by mass screening. The overall survival curve for the patients detected by mass screening was compared with that for those found in the out-patient clinics. The 5-year survival rate was significantly higher in the patients detected by mass screening (91.7% vs. 85.6%; P less than 0.01), while the 10-year survival rate was slightly higher in the same group of patients, but the difference from the other group was not significant (80.5% vs. 78.1%). Women who had conducted breast self-examination (BSE) showed a higher survival rate than those who had not conducted BSE.

The use of oncofetal ferritin-bearing lymphocytes as a marker for the screening, diagnosis, and follow-up of patients with early breast malignancy screening of 3400 women

The potential of using a blood test enumerating oncofetal ferritin-bearing lymphocytes (FBL) as a biomarker for early breast cancer was further explored. Nine hundred women attending a high-risk breast cancer clinic and 2500 normal-risk women were physically examined and their blood drawn for FBL determination using a newly developed radioimmunoassay. The FBL test results were compared to clinically or histopathologically diagnosed breast disease and to known breast cancer risk factors. A gradual increase in the mean FBL ratio was seen from normal risk disease-free women to those with in situ or early stage breast cancer. The percentage of women with positive FBL was 13.6% for the normal risk group, 19% and 25.7% for clinically and histopathologically diagnosed benign breast disease, respectively, and 100, 77.8, and 66.7% for in situ, Stage I, and Stage II breast cancer, respectively. In locally advanced disease (Stage III) the percentage of positive women was only 17.2%. It was further found that a negative FBL result in known breast cancer patients at Stage I, II of the disease was a bad prognostic marker indicating a shorter disease-free survival. The follow-up of patients after surgery by periodical clinical examination and the FBL test revealed that the positive FBL was declining after removal of the precancerous or malignant tumor and that it was highly sensitive (100%) in predicting tumor development and recurrence. Using a logistic regression analysis, an FBL-positive test indicated a significant association with risk of early breast cancer (odds ratio = 2.9; 95% confidence interval = 1.4-5.8). Being a measure of the immune response the positive FBL was associated with early breast cancer and good prognosis. Since patients with locally advanced cancer and poor prognosis were FBL negative but such patients were shown to have increased serum ferritin levels. It is suggested to use the FBL and serum ferritin assays for screening and diagnosis of breast cancer.

Enhanced detection of preinvasive breast cancer: combined role of mammography and needle localization biopsy

Several recent reports have described an increase in the incidence of preinvasive carcinoma of the breast. To determine the incidence of preinvasive breast cancer at our institution, the results of 469 consecutive outpatient breast biopsies performed at Walter Reed Army Medical Center between July 1, 1985, and January 1, 1987, were reviewed. During this time period, 256 biopsies were performed on palpable masses, and 213 needle localization biopsies were performed on mammographically suspicious lesions. The overall incidence of cancer was 15.4%. Needle localization biopsies yielded a diagnosis of cancer in 17.8% of cases, as did 13.3% of biopsies performed on palpable masses. Eight of 38 (21.1%) carcinomas identified by mammography were preinvasive at the time of diagnosis. Only one of 34 (2.9%) cancers identified because of a breast mass was preinvasive. We conclude that screening mammography is an invaluable tool for the detection of preinvasive carcinoma of the breast and that the increased use of mammography will result in an increase in the incidence of detection of this lesion.

Treatment and survival of female patients with nonpalpable breast carcinoma

Since 1971, 151 nonpalpable breast cancers (100 invasive carcinomas, 39 in situ ductal carcinomas, and twelve lobular carcinomas in situ) have been diagnosed and treated at the St. Radboud University Hospital. Of the 100 clinically occult invasive carcinomas, 53 had pathologic diameters of more than 10 mm, 29 were of sizes between 6 and 10 mm, and 18 were tumors of 5 mm or less. Residual tumor outside the "excisional" biopsy cavity was encountered in 76 of the 118 mastectomy specimens (64.4%) fully capable of evaluation. Invasive residual tumor would have been left behind in 34 of 86 mastectomy specimens (39.5%). Of 27 axillas studied, no patient with in situ carcinoma had evidence of axillary lymph node metastases. Invasive carcinoma, however, showed axillary lymph node involvement in 7.7% of mastectomy specimens when the size of the primary tumor was not more than 5 mm, in 12.5% when the size was between 6 and 10 mm, and in 29.5% when the primary tumor was more than 10 mm in diameter. The 10-year recurrence-free survival (RFS) of patients with clinically occult invasive carcinomas greater than 10 mm in size was 71.9% and differed significantly from the 90.9% for patients with the invasive tumors less than or equal to 5 mm, as well as from the 100% RFS of patients with invasive tumors of between 6 and 10 mm and noninvasive tumors. Although the 10-year RFS was 92.6% for the patients with negative axillary nodes and 80.0% for the patients with positive axillary nodes, this difference did not reach statistical significance. However, the disease-specific overall survival after 10 years was significantly different between node-negative patients (96.4%) and node-positive patients (78.8%). Multivariate analysis disclosed that the relationship between size of the primary tumor and RFS was independent of the presence of axillary lymph node metastases. In conclusion, the validity of the concept of minimal breast cancer has been re-enforced. However, the results of this study suggest that the upper limit of the original definition of minimal breast cancer is too narrow and should be extended, so that, apart from the noninvasive tumors--regardless of their size--all invasive tumors having a maximum diameter less than or equal to 10 mm should be regarded as minimal breast cancers.

An expert system for early detection of cancer of the breast

In order to study the relevancy of exploring complex expert systems for use by the lay public, an expert system for the early detection of cancer of the breast has been developed. The system consists of a conversion between a microcomputer and a woman who is anxious about breast cancer. The conversation is divided into two parts: one is listening to the woman's symptoms regarding the breast then giving advice, the other is an explanation of breast cancer and how to detect it in its early stages. After listening to the woman's symptoms, the computer presents its conclusion and suggests courses of action the woman should take. The system is written in Prolog. It was tried by women in a small town at a festival for health, by female patients who visit our hospital, and received a positive reaction.

Breast diseases and the internist

Benign breast disease affects almost all women, although only one out of 11 will eventually develop breast cancer. Fibrocystic disease or benign breast mastopathies have been associated with an increased propensity to progress to malignancy. However, the increased relative risk for women with benign breast disease developing breast cancer appears to be associated with proliferative benign disease in association with atypia. Their cumulative risk may be as high as 30%. These women represent 3-5% of women with benign disease. They clearly warrant more careful screening and follow-up. The etiology of benign breast mastopathies is unknown, but its incidence and relationship to hormonal events suggests that many of the histologic entities represent an endocrine response. Many hormonal manipulations have been shown to decrease mastodynia and reduce the incidence of breast aspirations and biopsies. However, these and other therapeutic interventions have not been shown to reduce the incidence of breast cancer in women who are at high risk.

Management of nonpalpable breast abnormalities

From January 1982 to June 1986, 444 patients had localization of 500 nonpalpable mammographically suspicious lesions using the Kopans hook wire technique. Four hundred ninety-nine biopsies were performed in 443 patients. Cancer was identified in 12% of the biopsies performed for a suspicious mass or density and in 20% of biopsies performed for suspicious calcifications. Carcinoma was identified in a total of 72 biopsies (14%) performed in 65 patients; 82% of the malignant lesions were invasive. All lesions were small; 76% of the cancers were 1.0 cm or less in diameter. Sixty-two axillary dissections were performed of which seven (11%) had positive nodes. Advantages of preoperative needle localization include precise localization of the lesion, a small incision, and removal of a small amount of breast tissue with no cosmetic deformity. Outpatient biopsy of these lesions can be easily performed under local anesthesia. Identification and treatment of these small preclinical cancers should lead to improved survival from breast cancer.