A decade of breast cancer screening in The Netherlands: trends in the preoperative diagnosis of breast cancer

Trends in delayed breast cancer diagnosis after recall at screening mammography

OBJECTIVES

To determine the extent and characteristics of delay in breast cancer diagnosis in women recalled at screening mammography.

METHODS

We included a consecutive series of 817,656 screens of women who received biennial screening mammography in a Dutch breast cancer screening region between 1997 and 2016. During at least 3.5 years follow-up, radiological reports and biopsy reports were collected of all recalled women. The inclusion period was divided into four cohorts of four years each. We determined the number of screen-detected cancers and their characteristics, and assessed the proportion of recalled women who experienced a diagnostic delay of at least 4 months in breast cancer confirmation.

RESULTS

The proportion of recalled women who experienced diagnostic delay decreased from 7.5 % in 1997-2001 (47/623) to 3.0 % in 2012-2016 (67/2223, P < 0.001). The proportion of women with a delay of at least two years increased from 27.7 % (13/47) in 1997-2001 to 75.7 % (53/70) in 2012-2016 (P < 0.001). Cancers with a diagnostic delay > 2 years were more frequently invasive (P = 0.009) than cancers with a diagnostic delay of 4-24 months. The most frequent cause of diagnostic delays was incorrect radiological classifications by clinical radiologists (55.2 % overall) after recall.

CONCLUSIONS

The proportion of recalled women with a delayed breast cancer diagnosis has more than halved during two decades of screening mammography. Delays in breast cancer diagnosis are characterized by longer delay intervals, although the proportion of these delays among all screen-detected cancers has not increased. Preventing longer delays in breast cancer confirmation may help improve breast cancer survival.

Does fine-needle aspiration biopsy still have a place in the diagnosis of breast lesions?

Introduction

Core needle biopsy is a preferable breast biopsy technique under ultrasound guidance. However, fine-needle biopsy is considered equally popular.

Aim of the study

To redefine the role of fine-needle aspiration biopsy (FNAB) in the diagnosis of breast lesions.

Material and methods

We retrospectively analysed the medical records of 680 patients who underwent breast ultrasound examination. In most cases, no pathologic structures were observed within the mammary glands. In 321 patients, the presence of focal lesions was revealed, and 107 patients in this group qualified for FNAB according to current recommendations. Patients with suspicious smears were referred for core needle or surgical biopsy. Patients with benign cytological smears underwent repeated ultrasound checks at 6-month intervals during the following year.

Results

All the smears were diagnostic. The vast majority of the results were categorised as benign lesions. Cancer cells were detected in six women. In one patient the lesion was classified as suspicious, probably malignant. In all of these cases, open biopsy was performed, and histopathological examination confirmed the presence of a malignant tumour. The patients were given appropriate oncological treatment. For women with benign or suspicious, but probably benign, lesions, breast ultrasound was performed twice at six-month intervals. Control tests showed no significant changes compared to the baseline examination. None of the patients required extensive additional diagnostic tests.

Conclusions

FNAB is a reliable method of assessing pathologic lesions in mammary glands.

Comparative evaluation of various cytomorphological grading systems in breast carcinoma

BACKGROUND

The diagnosis of breast carcinoma can be reliably made by fine needle aspiration cytology (FNAC). Grading usually done in histological samples for the selection of therapy but not in cytology. Various cytological grading systems have been proposed; however, none of them is presently considered the gold standard to predict the prognosis.

AIM

This study was undertaken to evaluate various 3-tier cytological grading systems and to determine the best possible system corresponds to the histological grading proposed by Elston and Ellis based on the method by Nottingham modification of Scarff-Bloom-Richardson (SBR) method.

MATERIALS AND METHODS

In this retrospective study, 94 cases of breast carcinoma FNACs were graded using six cytological grading systems and compared with SBR method. Concordance, association, and correlation studies were done to select best possible cytological grading system. The interobserver reproducibility among the six grading systems was also assessed.

RESULTS

Robinson method showed best correlation (ρ = 0.801; P = 0.0001 and τ = 0.783; P = 0.0001), maximum percent agreement (83/94 cases; 88.3%), and a substantial kappa value of agreement (κ = 0.737) with the Nottingham modification of SBR grading system followed by Mouriguand method. Taniguchi system showed better interobserver agreement (87.2%; κ = 0.738).

CONCLUSIONS

This study showed that all six cytological grading systems correlated positively with SBR method. However, Robinson's grading system demonstrated the best concordance, correlation, and substantial Kappa value of the agreement with the histological grading by SBR method in comparison to other 3-tier cytological grading systems. Hence, in conclusion, this grading should be routinely incorporated in the cytology reports as it correlates well with histological grade. Despite various cytological grading systems, Robinson's method is simple, more objective, and reproducible, hence being preferable for routine use.

Core needle biopsy of breast cancer tumors increases distant metastases in a mouse model

INTRODUCTION: Incisional biopsies, including the diagnostic core needle biopsy (CNB), routinely performed before surgical excision of breast cancer tumors are hypothesized to increase the risk of metastatic disease. In this study, we experimentally determined whether CNB of breast cancer tumors results in increased distant metastases and examine important resultant changes in the primary tumor and tumor microenvironment associated with this outcome. METHOD: To evaluate the effect of CNB on metastasis development, we implanted murine mammary 4T1 tumor cells in BALB/c mice and performed CNB on palpable tumors in half the mice. Subsequently, emulating the human scenario, all mice underwent complete tumor excision and were allowed to recover, with attendant metastasis development. Tumor growth, lung metastasis, circulating tumor cell (CTC) levels, variation in gene expression, composition of the tumor microenvironment, and changes in immunologic markers were compared in biopsied and non-biopsied mice. RESULTS: Mice with biopsied tumors developed significantly more lung metastases compared to non-biopsied mice. Tumors from biopsied mice contained a higher frequency of myeloid-derived suppressor cells (MDSCs) accompanied by reduced CD4 + T cells, CD8 + T cells, and macrophages, suggesting biopsy-mediated development of an increasingly immunosuppressive tumor microenvironment. We also observed a CNB-dependent up-regulation in the expression of SOX4, Ezh2, and other key epithelial-mesenchymal transition (EMT) genes, as well as increased CTC levels among the biopsy group. CONCLUSION: CNB creates an immunosuppressive tumor microenvironment, increases EMT, and facilitates release of CTCs, all of which likely contribute to the observed increase in development of distant metastases.

Trends in surgery for screen-detected and interval breast cancers in a national screening programme

Background

This population-based study aimed to evaluate trends in surgical approach for screen-detected cancer versus interval breast cancer, and to determine the factors associated with positive resection margins.

Methods

Screening mammograms of women aged 50–75 years, who underwent biennial screening in a Dutch breast-screening region between 1997 and 2011, were included. Patient and tumour characteristics were compared between women who underwent mastectomy or breast-conserving surgery (BCS) for screen-detected or interval cancer, and women with a negative or positive resection margin after BCS.

Results

Some 417 013 consecutive screening mammograms were included. A total of 2224 screen-detected and 825 interval cancers were diagnosed. The BCS rate remained stable (mean 6·1 per 1000 screened women; P = 0·099), whereas mastectomy rates increased significantly during the study from 0·9 (1997–1998) to 1·9 (2009–2010) per 1000 screened women (P &lt; 0·001). The proportion of positive resection margins for invasive cancer was 19·6 and 7·6 per cent in 1997–1998 and 2009–2010 respectively (P &lt; 0·001), with significant variation between hospitals. Dense breasts, preoperative magnetic resonance imaging, microcalcifications, architectural distortion, tumour size over 20 mm, axillary lymph node metastasis and treating hospital were independent risk factors for mastectomy. Interval cancer, image-guided tumour localization, microcalcifications, breast parenchyma asymmetry, tumour size greater than 20 mm, lobular tumour histology, low tumour grade, extensive invasive component and treating hospital were independent risk factors for positive resection margins.

Conclusion

Mastectomy rates doubled during a 14-year period of screening mammography and the proportion of positive resection margins decreased, with variation among hospitals. The latter observation stresses the importance of quality control programmes for hospitals treating women with breast cancer.

Variations in screening outcome among pairs of screening radiologists at non-blinded double reading of screening mammograms: a population-based study

OBJECTIVES

Substantial inter-observer variability in screening mammography interpretation has been reported at single reading. However, screening results of pairs of screening radiologists have not yet been published. We determined variations in screening performances among pairs of screening radiologists at non-blinded double reading.

METHODS

We included pairs of screening radiologists with at least 7,500 screening examinations per pair, obtained between 1997 and 2011. During 2-year follow-up, breast imaging reports, surgical reports and pathology results were collected of all referred women and interval cancers. Referral rate, cancer detection rate, positive predictive value and sensitivity were calculated for each pair.

RESULTS

A total of 310,906 screening mammograms, read by 26 pairs of screening radiologists, were included for analysis. The referral rate ranged from 1.0 % (95 % CI 0.8 %-1.2 %) to 1.5 % (95 % CI 1.3 %-1.8 %), the cancer detection rate from 4.0 (95 % CI 2.8-5.2) to 6.3 (95 % CI 4.5-8.0) per 1,000 screens. The programme sensitivity and positive predictive value of referral ranged from 55.1 % (95 % CI 45.1 %-65.1 %) to 81.5 % (95 % CI 73.4 %-89.6 %) and from 28.7 % (95 % CI 20.8 %-36.6 %) to 49.5 % (95 % CI 39.7 %-59.3 %), respectively.

CONCLUSION

We found significant variations in screening outcomes among pairs of screening radiologists at non-blinded double reading. This stresses the importance of monitoring screening results on a local scale.

KEY POINTS

• Substantial inter-observer variability in screening mammography interpretation is known at single reading • Population-based study showed significant variations in outcomes among pairs of screening radiologists • Local monitoring and regular feedback are important to optimise screening outcome.

Fine-needle aspiration cytology can play a role in neoadjuvant chemotherapy in operable breast cancer

Despite the fact that CNB has been progressively replaced by FNAC in the investigation of nonpalpable lesions or microcalcifications without a clinical or radiological mass lesion, FNAC has yet a role in palpable lesions provided it is associated with the triple diagnosis and experienced cytologist. In these conditions, FNAC is a safe, effective, economical, and accurate technique for breast cancer evaluation. Numerous literature reviews and meta-analyses illustrated the advantages and disadvantages of both methods CNB and FNAC. The difference does not seem significant when noninformative and unsatisfactory FNAC was excluded. Recently, cytological methods using liquid-based cytology (LBC) technology improve immunocytological and molecular tests with the same efficiency as classical immunohistochemistry. The indications of FNAC were, for palpable lesions, relative contraindication of CNB (elderly or frailty), staging of multiple nodules in conjunction or not with CNB, staging of lymph node status, newly appearing lesion in patient under neoadjuvant treatment, decreasing of anxiety with a rapid diagnosis, evaluation of biomarkers and new biomarkers, and chronological evaluation of biomarker following the neoadjuvant therapy response.

Trends in breast biopsies for abnormalities detected at screening mammography: a population-based study in the Netherlands

Background:

Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used with hesitation. We determined time trends in types of breast biopsies for the workup of abnormalities detected at screening mammography. We also examined diagnostic delays.

Methods:

In a Dutch breast cancer screening region 6230 women were referred for an abnormal screening mammogram between 1 January 1997 and 1 January 2011. During two year follow-up clinical data, breast imaging-, biopsy-, surgery- and pathology-reports were collected of these women. Furthermore, breast cancers diagnosed >3 months after referral (delays) were examined, this included review of mammograms and pathology specimens to determine the cause of the delays.

Results:

In 41.1% (1997–1998) and in 44.8% (2009–2010) of referred women imaging was sufficient for making the diagnosis (P<0.0001). Fine-needle aspiration cytology decreased from 12.7% (1997–1998) to 4.7% (2009–2010) (P<0.0001), percutaneous core-needle biopsies (CBs) increased from 8.0 to 49.1% (P<0.0001) and surgical biopsies decreased from 37.8 to 1.4% (P<0.0001). Delays in breast cancer diagnosis decreased from 6.7 to 1.8% (P=0.003).

Conclusion:

The use of diagnostic surgical breast biopsies has decreased substantially. They have mostly been replaced by percutaneous CBs and this replacement did not result in an increase of diagnostic delays.

Characteristics and screening outcome of women referred twice at screening mammography

OBJECTIVES

To determine the characteristics and screening outcome of women referred twice at screening mammography.

METHODS

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

RESULTS

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P = 0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P = 0.004).

CONCLUSIONS

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

KEY POINTS

Cancer risk was 36% for lesions referred twice at screening mammography. The cancer risk was similar for lesions referred only once at screening. Densities at first referral were associated with increased cancer risk at second referral. No biopsy at first referral was associated with increased cancer risk at second referral. Patient and tumour characteristics were similar for women with and without diagnostic delay.

Anxiety after an abnormal screening mammogram is a serious problem

PURPOSE

The aim of this study was to analyze the possible negative psychological consequences of a false positive screening mammogram (FPSM). We compared anxiety evoked by first (FSM) versus repeat screening mammogram (RSM). Questionnaires were completed prior to the diagnosis and during follow up.

RESULTS

No differences in anxiety, depressive symptoms, and Quality of Life (QoL) were found between FSM (N = 186) or RSM (N = 296) groups. All women experienced high anxiety before diagnosis was known. High trait anxiety was predictive for more anxiety, depressive symptoms, and lower QoL. Women with low score on trait anxiety were more momentary anxious in FSM group compared with RSM group (p = 0.048).

CONCLUSION

Negative psychological consequences after an FPSM are seen in all women. These effects are strengthened by personality and timing of the screening mammogram. All women should receive correct information concerning the negative psychological effects and should be offered psychosocial support if needed.

Triple negativity and young age as prognostic factors in lymph node-negative invasive ductal carcinoma of 1 cm or less

BACKGROUND

Whether a systemic adjuvant treatment is needed is an area of controversy in patients with node-negative early breast cancer with tumor size of ≤1 cm, including T1mic.

METHODS

We performed a retrospective analysis of clinical and pathology data of all consecutive patients with node-negative T1mic, T1a, and T1b invasive ductal carcinoma who received surgery between Jan 2000 and Dec 2006. The recurrence free survival (RFS) and risk factors for recurrence were identified.

RESULTS

Out of 3889 patients diagnosed with breast cancer, 375 patients were enrolled (T1mic:120, T1a:93, T1b:162). Median age at diagnosis was 49. After a median follow up of 60.8 months, 12 patients developed recurrences (T1mic:4 (3.3%), T1a:2 (2.2%), T1b:6 (3.7%)), with a five-year cumulative RFS rate of 97.2%. Distant recurrence was identified in three patients. Age younger than 35 years (HR 4.91; 95% CI 1.014-23.763, p = 0.048) and triple negative disease (HR 4.93; 95% CI 1.312-18.519, p = 0.018) were significantly associated with a higher rate of recurrence. HER2 overexpression, Ki-67, and p53 status did not affect RFS.

CONCLUSIONS

Prognosis of node-negative breast cancer with T1mic, T1a and T1b is excellent, but patients under 35 years of age or with triple negative disease have a relatively high risk of recurrence.

The state of the art of cancer control in 30 European countries in 2008

Inequalities in cancer incidence, mortality and survival represent a major challenge for public health. Addressing this challenge requires complex and multidisciplinary approaches. Sharing successful experiences from across Europe may therefore be of benefit. We describe the state of the art of cancer control structures in the 27 European Union countries, plus Iceland, Norway and Switzerland, at the beginning of 2008. Information on cancer plans, cancer registries, cancer screening, Human Papillomavirus (HPV) vaccination and smoking restrictions in each country was identified through PubMed, the official websites of national and international organizations and Google searches. Experts and/or health authorities from each country completed and validated the information. Sixteen countries had implemented national cancer plans in 2008. Twenty four countries had population-based cancer registries with 100% coverage. The exceptions were Greece and Luxembourg (no population-based registry yet), France, Italy and Spain (<50%), and Switzerland (62%). In 9 countries, population coverage of breast cancer screening was 100% with participation ranging from 26 to 87%; 8 countries did not have organized programmes. Seven countries had cervical cancer screening programmes with 100% coverage with participation ranging from 10 to 80%; 8 countries had no organized programme. Nine countries had announced national HPV vaccination policies by early 2008. Six countries had organized colorectal cancer screening programmes. Five countries had complete bans on smoking in public places. There is wide international heterogeneity in cancer control structures in Europe. This provides considerable scope and motivation for cooperation and sharing of experience.

Delayed diagnosis of breast cancer in women recalled for suspicious screening mammography

PURPOSE

To determine the frequency, pathology and causes of a delay in cancer diagnosis in women recalled for suspicious screening mammography.

METHODS

We included all 290,943 screening mammograms of women aged 50-75 years, who underwent biennial screening mammography between 1st January 1995 and 1st January 2006. During a follow-up period of at least 2 years, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all 3513 women with a positive screening result. Tumour stages of breast cancers with a diagnostic delay (defined as breast cancer confirmation more than 3 months following a positive mammography screen) were compared with those of cancers diagnosed within 3 months following referral and with interval cancers.

RESULTS

A diagnostic delay occurred in 97 (6.5%) of 1503 screen-detected cancers. These 97 false-negative assessments comprised significantly more ductal cancers in situ (26.8%) than did cancers with an adequate assessment after recall (15.5%, p=0.004) or interval cancers (3.7%, p<0.001). Compared with interval cancers, cancers with a false-negative assessment had a more favourable tumour size (T1a-c, 87.3% versus T1a-c, 46.4%; p<0.001) and showed significantly fewer cases with axillary lymph node metastases (22.5% versus 48.2%; p<0.001). Between hospitals having performed the workup of at least 500 referred women each, the percentage of women with a false-negative assessment varied from 5.0% to 9.1% (p=0.03). In these hospitals, improper classification of lesions at diagnostic mammography comprised 64.4% of false-negative assessments.

CONCLUSION

We found that 6.5% of recalled women experienced a delay in breast cancer diagnosis, with significant performance variations between hospitals.

Utilization and cost of diagnostic imaging and biopsies following positive screening mammography in the southern breast cancer screening region of the Netherlands, 2000-2005

We prospectively assessed trends in utilization and costs of diagnostic services of screen-positive women in a biennial breast cancer screening program for women aged 50-75 years. All 2,062 women with suspicious findings at screening mammography in the southern region of the Netherlands between 1 January 2000 and 1 July 2005 (158,997 screens) were included. Data were collected on any diagnostic examinations, interventional procedures, and surgical consultations with two-year follow-up. We used national reimbursement rates to estimate imaging costs and percutaneous biopsy costs. Cost prices, charged by hospitals, were used to estimate open surgical biopsy costs and surgical consultation costs. The largest increase in utilization of diagnostic procedures per 100 referrals was observed for axillary ultrasound (from 3.9 in 2000 to 33.5 in 2005) and for stereotactic core biopsy (from 2.1 in 2000 to 26.8 in 2005). Per 100 referrals, the open surgical biopsy rate decreased from 34.7 (2000) to 4.6 (2005) and the number of outpatient surgical consultations fluctuated between 269.8 (2000) and 309.7 (2004). Mean costs for the diagnosis of one cancer were Euro1,501 and ranged from Euro1,223 (2002) to Euro1,647 (2003). Surgical biopsies comprised 54.1% of total diagnostic costs for women screened in 2000, but decreased to 9.9% for women screened in 2005. Imaging costs increased from 23.7 to 43.8%, percutaneous biopsy costs from 9.9 to 27.2%, and consultation costs from 12.3 to 19.1%. We conclude that diagnostic costs per screen-detected cancer remained fairly stable through the years, although huge changes in the use of different diagnostic procedures were observed.

Clinical epidemiology of breast cancer in the elderly

Breast cancer will increasingly become a disease affecting the lives of older women, especially in more developed countries, the prevalence rising up to 7% over age 70 in the near future. A review of the population-based literature and an analysis of the data of the Eindhoven Cancer Registry and European data regarding the diagnosis, treatment and prognosis showed that the proportion with unstaged and advanced disease (stages III and IV) is higher among elderly patients compared to younger ones and that their treatment is generally less aggressive, although the proportion receiving chemotherapy is increasing since the early 1990s. Disease specific (or relative) survival of elderly breast cancer patients is generally lower and the prevalence of serious (life expectancy affecting) co-morbidity is higher (>50% in patients over age 70). Because of large individual variations in physical and mental conditions, limited evidence from RCTs and personal preferences prevailing in the decision-making process, treatment of older breast cancer patients seems difficult to fit into guidelines. Therefore, alternative research strategies are needed to understand and improve the care for the elderly breast cancer population, such as descriptive (registry-based) studies and a qualitative, individual-based approach.