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Katsika L, Boureka E, Kalogiannidis I, Tsakiridis I, Tirodimos I, Lallas K, Tsimtsiou Z, Dagklis T. Screening for Breast Cancer: A Comparative Review of Guidelines. Life (Basel) 2024; 14:777. [PMID: 38929759 PMCID: PMC11204612 DOI: 10.3390/life14060777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Breast cancer is the most common malignancy diagnosed in the female population worldwide and the leading cause of death among perimenopausal women. Screening is essential, since earlier detection in combination with improvements in breast cancer treatment can reduce the associated mortality. The aim of this study was to review and compare the recommendations from published guidelines on breast cancer screening. A total of 14 guidelines on breast cancer screening issued between 2014 and 2022 were identified. A descriptive review of relevant guidelines by the World Health Organization (WHO), the U.S. Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN), the American College of Obstetricians and Gynecologists (ACOG), the American Society of Breast Surgeons (ASBrS), the American College of Radiology (ACR), the Task Force on Preventive Health Care (CTFPHC), the European Commission Initiative on Breast Cancer (ECIBC), the European Society for Medical Oncology (ESMO), the Royal Australian College of General Practitioners (RACGP) and the Japanese Journal of Clinical Oncology (JJCO) for women both at average and high-risk was carried out. There is a consensus among all the reviewed guidelines that mammography is the gold standard screening modality for average-risk women. For this risk group, most of the guidelines suggest annual or biennial mammographic screening at 40-74 years, while screening should particularly focus at 50-69 years. Most of the guidelines suggest that the age limit to stop screening should be determined based on the women's health status and life expectancy. For women at high-risk, most guidelines recommend the use of annual mammography or magnetic resonance imaging, while the starting age should be earlier than the average-risk group, depending on the risk factor. There is discrepancy among the recommendations regarding the age at onset of screening in the various high-risk categories. The development of consistent international practice protocols for the most appropriate breast cancer screening programs seems of major importance to reduce mortality rates and safely guide everyday clinical practice.
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Affiliation(s)
- Laskarina Katsika
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (L.K.); (I.T.); (Z.T.)
| | - Eirini Boureka
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.B.); (I.K.); (T.D.)
| | - Ioannis Kalogiannidis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.B.); (I.K.); (T.D.)
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.B.); (I.K.); (T.D.)
| | - Ilias Tirodimos
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (L.K.); (I.T.); (Z.T.)
| | - Konstantinos Lallas
- Department of Medical Oncology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Zoi Tsimtsiou
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (L.K.); (I.T.); (Z.T.)
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.B.); (I.K.); (T.D.)
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Eijkelboom AH, Larsen M, Siesling S, Nygård JF, Hofvind S, de Munck L. Prolonged screening interval due to the COVID-19 pandemic and its association with tumor characteristics and treatment; a register-based study from BreastScreen Norway. Prev Med 2023; 175:107723. [PMID: 37820746 DOI: 10.1016/j.ypmed.2023.107723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE During the COVID-19 pandemic Norway had to suspend its national breast cancer screening program. We aimed to investigate the effect of the pandemic-induced suspension on the screening interval, and its subsequent association with the tumor characteristics and treatment of screen-detected (SDC) and interval breast cancer (IC). METHODS Information about women aged 50-69, participating in BreastScreen Norway, and diagnosed with a SDC (N = 3799) or IC (N = 1806) between 2018 and 2021 was extracted from the Cancer Registry of Norway. Logistic regression was used to investigate the association between COVID-19 induced prolonged screening intervals and tumor characteristics and treatment. RESULTS Women with a SDC and their last screening exam before the pandemic had a median screening interval of 24.0 months (interquartile range: 23.8-24.5), compared to 27.0 months (interquartile range: 25.8-28.5) for those with their last screening during the pandemic. The tumor characteristics and treatment of women with a SDC, last screening during the pandemic, and a screening interval of 29-31 months, did not differ from those of women with a SDC, last screening before the pandemic, and a screening interval of 23-25 months. ICs detected 24-31 months after screening, were more likely to be histological grade 3 compared to ICs detected 0-23 months after screening (odds ratio: 1.40, 95% confidence interval: 1.06-1.84). CONCLUSIONS Pandemic-induced prolonged screening intervals were not associated with the tumor characteristics and treatment of SDCs, but did increase the risk of a histopathological grade 3 IC. This study provides insights into the possible effects of extending the screening interval.
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Affiliation(s)
- Anouk H Eijkelboom
- Department of Health Technology and Services Research, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands.
| | - Marthe Larsen
- Section for Breast Cancer Screening, Cancer Registry of Norway, P.O. Box 5313, 0304, Oslo, Norway.
| | - Sabine Siesling
- Department of Health Technology and Services Research, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands.
| | - Jan F Nygård
- Department of Register Informatics, Cancer Registry Norway, P.O. Box 5313, 0304 Oslo, Norway.
| | - Solveig Hofvind
- Section for Breast Cancer Screening, Cancer Registry of Norway, P.O. Box 5313, 0304, Oslo, Norway; Department of Health and Care Sciences, UiT The Arctic University of Norway, P.O. 6050, 9037, Tromsø, Norway.
| | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands.
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Kerlikowske K, Chen S, Golmakani MK, Sprague BL, Tice JA, Tosteson ANA, Rauscher GH, Henderson LM, Buist DSM, Lee JM, Gard CC, Miglioretti DL. Cumulative Advanced Breast Cancer Risk Prediction Model Developed in a Screening Mammography Population. J Natl Cancer Inst 2022; 114:676-685. [PMID: 35026019 PMCID: PMC9086807 DOI: 10.1093/jnci/djac008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/14/2021] [Accepted: 01/10/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Estimating advanced breast cancer risk in women undergoing annual or biennial mammography could identify women who may benefit from less or more intensive screening. We developed an actionable model to predict cumulative 6-year advanced cancer (prognostic pathologic stage II or higher) risk according to screening interval. METHODS We included 931 186 women aged 40-74 years in the Breast Cancer Surveillance Consortium undergoing 2 542 382 annual (prior mammogram within 11-18 months) or 752 049 biennial (prior within 19-30 months) screening mammograms. The prediction model includes age, race and ethnicity, body mass index, breast density, family history of breast cancer, and prior breast biopsy subdivided by menopausal status and screening interval. We used fivefold cross-validation to internally validate model performance. We defined higher than 95th percentile as high risk (>0.658%), higher than 75th percentile to 95th or less percentile as intermediate risk (0.380%-0.658%), and 75th or less percentile as low to average risk (<0.380%). RESULTS Obesity, high breast density, and proliferative disease with atypia were strongly associated with advanced cancer. The model is well calibrated and has an area under the receiver operating characteristics curve of 0.682 (95% confidence interval = 0.670 to 0.694). Based on women's predicted advanced cancer risk under annual and biennial screening, 69.1% had low or average risk regardless of screening interval, 12.4% intermediate risk with biennial screening and average risk with annual screening, and 17.4% intermediate or high risk regardless of screening interval. CONCLUSION Most women have low or average advanced cancer risk and can undergo biennial screening. Intermediate-risk women may consider annual screening, and high-risk women may consider supplemental imaging in addition to annual screening.
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Affiliation(s)
- Karla Kerlikowske
- Department of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA, USA
| | - Shuai Chen
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | | | - Brian L Sprague
- Department of Surgery and Radiology, University of Vermont, Burlington, VT, USA
| | - Jeffrey A Tice
- Department of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Garth H Rauscher
- School of Public Health, Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL, USA
| | - Louise M Henderson
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Janie M Lee
- Department of Radiology, University of Washington, and Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Charlotte C Gard
- Department of Economics, Applied Statistics, and International Business, New Mexico State University, Las Cruces, NM, USA
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis, CA, USA
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
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Benefits and harms of annual, biennial, or triennial breast cancer mammography screening for women at average risk of breast cancer: a systematic review for the European Commission Initiative on Breast Cancer (ECIBC). Br J Cancer 2022; 126:673-688. [PMID: 34837076 PMCID: PMC8854566 DOI: 10.1038/s41416-021-01521-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 06/20/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although mammography screening is recommended in most European countries, the balance between the benefits and harms of different screening intervals is still a matter of debate. This review informed the European Commission Initiative on Breast Cancer (BC) recommendations. METHODS We searched PubMed, EMBASE, and the Cochrane Library to identify RCTs, observational or modelling studies, comparing desirable (BC deaths averted, QALYs, BC stage, interval cancer) and undesirable (overdiagnosis, false positive related, radiation related) effects from annual, biennial, or triennial mammography screening in women of average risk for BC. We assessed the certainty of the evidence using the GRADE approach. RESULTS We included one RCT, 13 observational, and 11 modelling studies. In women 50-69, annual compared to biennial screening may have small additional benefits but an important increase in false positive results; triennial compared to biennial screening may have smaller benefits while avoiding some harms. In younger women (aged 45-49), annual compared to biennial screening had a smaller gain in benefits and larger harms, showing a less favourable balance in this age group than in women 50-69. In women 70-74, there were fewer additional harms and similar benefits with shorter screening intervals. The overall certainty of the evidence for each of these comparisons was very low. CONCLUSIONS In women of average BC risk, screening intervals have different trade-offs for each age group. The balance probably favours biennial screening in women 50-69. In younger women, annual screening may have a less favourable balance, while in women aged 70-74 years longer screening intervals may be more favourable.
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Ho TQH, Bissell MCS, Kerlikowske K, Hubbard RA, Sprague BL, Lee CI, Tice JA, Tosteson ANA, Miglioretti DL. Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography. JAMA Netw Open 2022; 5:e222440. [PMID: 35333365 PMCID: PMC8956976 DOI: 10.1001/jamanetworkopen.2022.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022] Open
Abstract
Importance Breast cancer screening with digital breast tomosynthesis may decrease false-positive results compared with digital mammography. Objective To estimate the probability of receiving at least 1 false-positive result after 10 years of screening with digital breast tomosynthesis vs digital mammography in the US. Design, Setting, and Participants An observational comparative effectiveness study with data collected prospectively for screening examinations was performed between January 1, 2005, and December 31, 2018, at 126 radiology facilities in the Breast Cancer Surveillance Consortium. Analysis included 903 495 individuals aged 40 to 79 years. Data analysis was conducted from February 9 to September 7, 2021. Exposures Screening modality, screening interval, age, and Breast Imaging Reporting and Data System breast density. Main Outcomes and Measures Cumulative risk of at least 1 false-positive recall for further imaging, short-interval follow-up recommendation, and biopsy recommendation after 10 years of annual or biennial screening with digital breast tomosynthesis vs digital mammography, accounting for competing risks of breast cancer diagnosis and death. Results In this study of 903 495 women, 2 969 055 nonbaseline screening examinations were performed with interpretation by 699 radiologists. Mean (SD) age of the women at the time of the screening examinations was 57.6 (9.9) years, and 58% of the examinations were in individuals younger than 60 years and 46% were performed in women with dense breasts. A total of 15% of examinations used tomosynthesis. For annual screening, the 10-year cumulative probability of at least 1 false-positive result was significantly lower with tomosynthesis vs digital mammography for all outcomes: 49.6% vs 56.3% (difference, -6.7; 95% CI, -7.4 to -6.1) for recall, 16.6% vs 17.8% (difference, -1.1; 95% CI, -1.7 to -0.6) for short-interval follow-up recommendation, and 11.2% vs 11.7% (difference, -0.5; 95% CI, -1.0 to -0.1) for biopsy recommendation. For biennial screening, the cumulative probability of a false-positive recall was significantly lower for tomosynthesis vs digital mammography (35.7% vs 38.1%; difference, -2.4; 95% CI, -3.4 to -1.5), but cumulative probabilities did not differ significantly by modality for short-interval follow-up recommendation (10.3% vs 10.5%; difference, -0.1; 95% CI, -0.7 to 0.5) or biopsy recommendation (6.6% vs 6.7%; difference, -0.1; 95% CI, -0.5 to 0.4). Decreases in cumulative probabilities of false-positive results with tomosynthesis vs digital mammography were largest for annual screening in women with nondense breasts (differences for recall, -6.5 to -12.8; short-interval follow-up, 0.1 to -5.2; and biopsy recommendation, -0.5 to -3.1). Regardless of modality, cumulative probabilities of false-positive results were substantially lower for biennial vs annual screening (overall recall, 35.7 to 38.1 vs 49.6 to 56.3; short-interval follow-up, 10.3 to 10.5 vs 16.6 to 17.8; and biopsy recommendation, 6.6 to 6.7 vs 11.2 to 11.7); older vs younger age groups (eg, among annual screening in women ages 70-79 vs 40-49, recall, 39.8 to 47.0 vs 60.8 to 68.0; short-interval follow-up, 13.3 to 14.2 vs 20.7 to 20.9; and biopsy recommendation, 9.1 to 9.3 vs 13.2 to 13.4); and women with entirely fatty vs extremely dense breasts (eg, among annual screening in women aged 50-59 years, recall, 29.1 to 36.3 vs 58.8 to 60.4; short-interval follow-up, 8.9 to 11.6 vs 19.5 to 19.8; and biopsy recommendation, 4.9 to 8.0 vs 15.1 to 15.3). Conclusions and Relevance In this comparative effectiveness study, 10-year cumulative probabilities of false-positive results were lower on digital breast tomosynthesis vs digital mammography. Biennial screening interval, older age, and nondense breasts were associated with larger reductions in false-positive probabilities than screening modality.
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Affiliation(s)
- Thao-Quyen H. Ho
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
- Department of Training and Scientific Research, University Medical Center, Ho Chi Minh City, Vietnam
| | - Michael C. S. Bissell
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
| | - Karla Kerlikowske
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brian L. Sprague
- Department of Surgery, Office of Health Promotion Research, Larner College of Medicine at the University of Vermont and University of Vermont Cancer Center, Burlington, Vermont
| | - Christoph I. Lee
- Department of Radiology, University of Washington School of Medicine, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Hutchinson Institute for Cancer Outcomes Research, Seattle, Washington
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | - Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, Lebanon, New Hampshire
- Department of Oncology, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Diana L. Miglioretti
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
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Schünemann HJ, Lerda D, Quinn C, Follmann M, Alonso-Coello P, Rossi PG, Lebeau A, Nyström L, Broeders M, Ioannidou-Mouzaka L, Duffy SW, Borisch B, Fitzpatrick P, Hofvind S, Castells X, Giordano L, Canelo-Aybar C, Warman S, Mansel R, Sardanelli F, Parmelli E, Gräwingholt A, Saz-Parkinson Z. Breast Cancer Screening and Diagnosis: A Synopsis of the European Breast Guidelines. Ann Intern Med 2020; 172:46-56. [PMID: 31766052 DOI: 10.7326/m19-2125] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The European Commission Initiative for Breast Cancer Screening and Diagnosis guidelines (European Breast Guidelines) are coordinated by the European Commission's Joint Research Centre. The target audience for the guidelines includes women, health professionals, and policymakers. METHODS An international guideline panel of 28 multidisciplinary members, including patients, developed questions and corresponding recommendations that were informed by systematic reviews of the evidence conducted between March 2016 and December 2018. GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests by enhancing transparency. Questions and recommendations, expressed as strong or conditional, focused on outcomes that matter to women and provided a rating of the certainty of evidence. RECOMMENDATIONS This synopsis of the European Breast Guidelines provides recommendations regarding organized screening programs for women aged 40 to 75 years who are at average risk. The recommendations address digital mammography screening and the addition of hand-held ultrasonography, automated breast ultrasonography, or magnetic resonance imaging compared with mammography alone. The recommendations also discuss the frequency of screening and inform decision making for women at average risk who are recalled for suspicious lesions or who have high breast density.
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Affiliation(s)
| | - Donata Lerda
- European Commission, Joint Research Centre, Ispra, Italy (D.L., E.P., Z.S.)
| | - Cecily Quinn
- St. Vincent's University Hospital, Dublin, Ireland (C.Q.)
| | | | | | - Paolo Giorgi Rossi
- Azienda Unitá Sanitaria Locale-IRCCS di Reggio Emilia, Reggia Emilia, Italy (P.G.R.)
| | - Annette Lebeau
- Private Group Practice for Pathology, Lübeck, Germany (A.L.)
| | | | | | | | - Stephen W Duffy
- Queen Mary University of London, London, United Kingdom (S.W.D.)
| | | | | | | | - Xavier Castells
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain (X.C.)
| | - Livia Giordano
- CPO-Piedmont - AOU Cittá della Salute e della Scienza, Torino, Italy (L.G.)
| | | | - Sue Warman
- Langford, North Somerset, United Kingdom (S.W.)
| | | | | | - Elena Parmelli
- European Commission, Joint Research Centre, Ispra, Italy (D.L., E.P., Z.S.)
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Age to Begin and Intervals for Breast Cancer Screening: Balancing Benefits and Harms. AJR Am J Roentgenol 2018; 210:279-284. [DOI: 10.2214/ajr.17.18730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Le MT, Mothersill CE, Seymour CB, McNeill FE. Is the false-positive rate in mammography in North America too high? Br J Radiol 2016; 89:20160045. [PMID: 27187600 PMCID: PMC5124917 DOI: 10.1259/bjr.20160045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/04/2016] [Accepted: 05/16/2016] [Indexed: 01/23/2023] Open
Abstract
The practice of investigating pathological abnormalities in the breasts of females who are asymptomatic is primarily employed using X-ray mammography. The importance of breast screening is reflected in the mortality-based benefits observed among females who are found to possess invasive breast carcinoma prior to the manifestation of clinical symptoms. It is estimated that population-based screening constitutes a 17% reduction in the breast cancer mortality rate among females affected by invasive breast carcinoma. In spite of the significant utility that screening confers in those affected by invasive cancer, limitations associated with screening manifest as potential harms affecting individuals who are free of invasive disease. Disease-free and benign tumour-bearing individuals who are subjected to diagnostic work-up following a screening examination constitute a population of cases referred to as false positives (FPs). This article discusses factors contributing to the FP rate in mammography and extends the discussion to an assessment of the consequences associated with FP reporting. We conclude that the mammography FP rate in North America is in excess based upon the observation of overtreatment of in situ lesions and the disproportionate distribution of detriment and benefit among the population of individuals recalled for diagnostic work-up subsequent to screening. To address the excessive incidence of FPs in mammography, we investigate solutions that may be employed to remediate the current status of the FP rate. Subsequently, it can be suggested that improvements in the breast-screening protocol, medical litigation risk, image interpretation software and the implementation of image acquisition modalities that overcome superimposition effects are promising solutions.
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Affiliation(s)
- Michelle T Le
- Medical Physics & Applied Radiation Sciences Department, McMaster University, Hamilton, ON, Canada
| | - Carmel E Mothersill
- Medical Physics & Applied Radiation Sciences Department, McMaster University, Hamilton, ON, Canada
| | - Colin B Seymour
- Medical Physics & Applied Radiation Sciences Department, McMaster University, Hamilton, ON, Canada
| | - Fiona E McNeill
- Medical Physics & Applied Radiation Sciences Department, McMaster University, Hamilton, ON, Canada
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Miglioretti DL, Zhu W, Kerlikowske K, Sprague BL, Onega T, Buist DSM, Henderson LM, Smith RA. Breast Tumor Prognostic Characteristics and Biennial vs Annual Mammography, Age, and Menopausal Status. JAMA Oncol 2016; 1:1069-77. [PMID: 26501844 DOI: 10.1001/jamaoncol.2015.3084] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Screening mammography intervals remain under debate in the United States. OBJECTIVE To compare the proportion of breast cancers with less vs more favorable prognostic characteristics in women screening annually vs biennially by age, menopausal status, and postmenopausal hormone therapy (HT) use. DESIGN, SETTING, AND PARTICIPANTS This was a study of a prospective cohort from 1996 to 2012 at Breast Cancer Surveillance Consortium facilities. A total of 15,440 women ages 40 to 85 years with breast cancer diagnosed within 1 year of an annual or within 2 years of a biennial screening mammogram. EXPOSURES We updated previous analyses by using narrower intervals for defining annual (11-14 months) and biennial (23-26 months) screening. MAIN OUTCOMES AND MEASURES We defined less favorable prognostic characteristics as tumors that were stage IIB or higher, size greater than 15 mm, positive nodes, and any 1 or more of these characteristics. We used log-binomial regression to model the proportion of breast cancers with less favorable characteristics following a biennial vs annual screen by 10-year age groups and by menopausal status and current postmenopausal HT use. RESULTS Among 15,440 women with breast cancer, most were 50 years or older (13,182 [85.4%]), white (12,063 [78.1%]), and postmenopausal (9823 [63.6%]). Among 2027 premenopausal women (13.1%), biennial screeners had higher proportions of tumors that were stage IIB or higher (relative risk [RR], 1.28 [95% CI, 1.01-1.63]; P=.04), size greater than 15 mm (RR, 1.21 [95% CI, 1.07-1.37]; P=.002), and with any less favorable prognostic characteristic (RR, 1.11 [95% CI, 1.00-1.22]; P=.047) compared with annual screeners. Among women currently taking postmenopausal HT, biennial screeners tended to have tumors with less favorable prognostic characteristics compared with annual screeners; however, 95% CIs were wide, and differences were not statistically significant (for stage 2B+, RR, 1.14 [95% CI, 0.89-1.47], P=.29; size>15 mm, RR, 1.13 [95% CI, 0.98-1.31], P=.09; node positive, RR, 1.18 [95% CI, 0.98-1.42], P=.09; any less favorable characteristic, RR, 1.12 [95% CI, 1.00-1.25], P=.053). The proportions of tumors with less favorable prognostic characteristics were not significantly larger for biennial vs annual screeners among postmenopausal women not taking HT (eg, any characteristic: RR, 1.03 [95% CI, 0.95-1.12]; P=.45), postmenopausal HT users after subdividing by type of hormone use (eg, any characteristic: estrogen+progestogen users, RR, 1.16 [95% CI, 0.91-1.47]; P=.22; estrogen-only users, RR, 1.14 [95% CI, 0.94-1.37]; P=.18), or any 10-year age group (eg, any characteristic: ages 40-49 years, RR, .1.04 [95% CI, 0.94-1.14]; P=.48; ages 50-59 years, RR, 1.03 [95% CI, 0.94-1.12]; P=.58; ages 60-69 years, RR, 1.07 [95% CI, 0.97-1.19]; P=.18; ages 70-85 years, RR, 1.05 [95% CI, 0.94-1.18]; P=.35). CONCLUSIONS AND RELEVANCE Premenopausal women diagnosed as having breast cancer following biennial vs annual screening mammography are more likely to have tumors with less favorable prognostic characteristics. Postmenopausal women not using HT who are diagnosed as having breast cancer following a biennial or annual screen have similar proportions of tumors with less favorable prognostic characteristics.
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Affiliation(s)
- Diana L Miglioretti
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis2Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | - Weiwei Zhu
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California-San Francisco, San Francisco,4General Internal Medicine Section, Department of Veterans Affairs, University of California-San Francisco, San Francisco
| | - Brian L Sprague
- Department of Surgery, Office of Health Promotion Research, University of Vermont College of Medicine, Burlington6University of Vermont Cancer Center, University of Vermont College of Medicine, Burlington
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire8Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | | | - Robert A Smith
- Cancer Control Science Department, American Cancer Society, Atlanta, Georgia
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Smith RA, Andrews K, Brooks D, DeSantis CE, Fedewa SA, Lortet-Tieulent J, Manassaram-Baptiste D, Brawley OW, Wender RC. Cancer screening in the United States, 2016: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin 2016; 66:96-114. [PMID: 26797525 DOI: 10.3322/caac.21336] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 12/11/2022] Open
Abstract
Each year the American Cancer Society (ACS) publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current ACS cancer screening guidelines, including the update of the breast cancer screening guideline, discuss quality issues in colorectal cancer screening and new developments in lung cancer screening, and provide the latest data on utilization of cancer screening from the National Health Interview Survey.
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Affiliation(s)
- Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society Atlanta, GA
| | - Kimberly Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Managing Director, Cancer Control Intervention, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Carol E DeSantis
- Senior Epidemiologist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Director for Risk Factor Screening and Surveillance, Department of Epidemiology and Research Surveillance, American Cancer Society, Atlanta, GA
| | - Joannie Lortet-Tieulent
- Senior Epidemiologist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | | | - Otis W Brawley
- Chief Medical Officer, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
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Nelson HD, O’Meara ES, Kerlikowske K, Balch S, Miglioretti D. Factors Associated With Rates of False-Positive and False-Negative Results From Digital Mammography Screening: An Analysis of Registry Data. Ann Intern Med 2016; 164:226-35. [PMID: 26756902 PMCID: PMC5091936 DOI: 10.7326/m15-0971] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Women screened with digital mammography may receive false-positive and false-negative results and subsequent imaging and biopsies. How these outcomes vary by age, time since the last screening, and individual risk factors is unclear. OBJECTIVE To determine factors associated with false-positive and false-negative digital mammography results, additional imaging, and biopsies among a general population of women screened for breast cancer. DESIGN Analysis of registry data. SETTING Participating facilities at 5 U.S. Breast Cancer Surveillance Consortium breast imaging registries with linkages to pathology databases and tumor registries. PATIENTS 405,191 women aged 40 to 89 years screened with digital mammography between 2003 and 2011. A total of 2963 were diagnosed with invasive cancer or ductal carcinoma in situ within 12 months of screening. MEASUREMENTS Rates of false-positive and false-negative results and recommendations for additional imaging and biopsies from a single screening round; comparisons by age, time since the last screening, and risk factors. RESULTS Rates of false-positive results (121.2 per 1000 women [95% CI, 105.6 to 138.7]) and recommendations for additional imaging (124.9 per 1000 women [CI, 109.3 to 142.3]) were highest among women aged 40 to 49 years and decreased with increasing age. Rates of false-negative results (1.0 to 1.5 per 1000 women) and recommendations for biopsy (15.6 to 17.5 per 1000 women) did not differ greatly by age. Results did not differ by time since the last screening. False-positive rates were higher for women with risk factors, particularly family history of breast cancer; previous benign breast biopsy result; high breast density; and, for younger women, low body mass index. LIMITATIONS Confounding by variation in patient-level characteristics and outcomes across registries and regions may have been present. Some factors, such as numbers of first- and second-degree relatives with breast cancer and diagnoses associated with previous benign biopsy results, were not examined. CONCLUSION False-positive mammography results and additional imaging are common, particularly for younger women and those with risk factors, whereas biopsies occur less often. Rates of false-negative results are low. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and National Cancer Institute.
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Affiliation(s)
- Heidi D. Nelson
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University; Portland, OR
- Providence Cancer Center, Providence Health & Services; Portland, OR
| | - Ellen S. O’Meara
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Karla Kerlikowske
- General Internal Medicine Section, University of California; San Francisco, CA
| | - Steven Balch
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Diana Miglioretti
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
- Department of Public Health Sciences, University of California, Davis, CA
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Racial differences in false-positive mammogram rates: results from the ACRIN Digital Mammographic Imaging Screening Trial (DMIST). Med Care 2015; 53:673-8. [PMID: 26125419 DOI: 10.1097/mlr.0000000000000393] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mammography screening reduces breast cancer mortality, but false-positive tests are common. Few studies have assessed racial differences in false-positive rates. OBJECTIVES We compared false-positive mammography rates for black and white women, and the effect of patient and facility characteristics on false positives. RESEARCH DESIGN AND SUBJECTS A prospective cohort study. From a sample of the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), we identified black/African American (N=3176) or white (N=26,446) women with no prior breast surgery or breast cancer. MEASURES Race, demographics, and breast cancer risk factors were self-reported. Results of initial digital and film mammograms were assessed. False positives were defined as a positive mammogram (Breast Imaging Reporting and Data System category 0, 4, 5) with no cancer diagnosis within 15 months. RESULTS The false-positive rate for digital mammograms was 9.2% for black women compared with 7.8% for white women (P=0.009). After adjusting for age, black women had 17% increased odds of false-positive digital mammogram compared with whites (OR=1.17; 95% CI, 1.01-1.35; P=0.033). This association was attenuated after adjusting for patient factors, prior films, and study site (OR=1.04; 95% CI, 0.91-1.20; P=0.561). There was no difference in the occurrence of false positives by race for film mammography. CONCLUSIONS Black women had higher frequency of false-positive digital mammograms explained by lack of prior films and study site.The variation in the disparity between the established technique (film) and the new technology (digital) raises the possibility that racial differences in screening quality may be greatest for new technologies.
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Comparison of cumulative false-positive risk of screening mammography in the United States and Denmark. Cancer Epidemiol 2015; 39:656-63. [PMID: 26013768 DOI: 10.1016/j.canep.2015.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/04/2015] [Accepted: 05/10/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION In the United States (US), about one-half of women screened with annual mammography have at least one false-positive test after ten screens. The estimate for European women screened ten times biennially is much lower. We evaluate to what extent screening interval, mammogram type, and statistical methods, can explain the reported differences. METHODS We included all screens from women first screened at age 50-69 years in the US Breast Cancer Surveillance Consortium (BCSC) (n=99,455) between 1996-2010, and from two population-based mammography screening programs in Denmark (n=230,452 and n=400,204), between 1991-2012 and 1993-2013, respectively. Model-based cumulative false-positive risks were computed for the entire sample, using two statistical methods (Hubbard Njor) previously used to estimate false-positive risks in the US and Europe. RESULTS Empirical cumulative risk of at least one false-positive test after eight (annual or biennial) screens was 41.9% in BCSC, 16.1% in Copenhagen, and 7.4% in Funen. Variation in screening interval and mammogram type did not explain the differences by country. Using the Hubbard method, the model-based cumulative risks after eight screens was 45.1% in BCSC, 9.6% in Copenhagen, and 8.8% in Funen. Using the Njor method, these risks were estimated to be 43.6, 10.9 and 8.0%. CONCLUSION Choice of statistical method, screening interval and mammogram type does not explain the substantial differences in cumulative false-positive risk between the US and Europe.
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Is mammography screening history a predictor of future breast cancer risk? Eur J Epidemiol 2014; 30:143-9. [PMID: 25421784 DOI: 10.1007/s10654-014-9972-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
Abstract
Inspired by the model by Walter and Day for risk of cervical cancer following negative screens, one might hypothesize that women in a mammography screening programme with a certain number of negative screens had a lower remaining breast cancer risk than that of women in general. We studied whether number of negative screens was a predictor for a low remaining breast cancer risk in women participating in the mammography screening programmes in Stockholm, Copenhagen and Funen. Data were collected from the mammography screening programmes in Stockholm, Sweden (1989-2012), Copenhagen, Denmark (1991-2009) and Funen, Denmark (1993-2009), and linked to the respective cancer registries. We calculated cumulative hazard rates for breast cancer in women in cohorts defined by age at entry and number of negative screens for the maximum follow-up period in each screening centre. For all centres and cohorts, the cumulative hazard were parallel for all number of negative screens, from after the time, when the women were scheduled to be invited for the next screen. This means that the remaining breast cancer risk is similar no matter how many negative screens a woman have had. Number of negative screens was not a predictor of a low remaining breast cancer risk in women participating in the mammography screening programmes in Stockholm, Sweden, Copenhagen and Funen, Denmark. The history of previous negative screens is therefore not suitable for personalisation of mammography screening.
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