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Duijm LEM, Broeders MJM, Setz-Pels W, van Breest Smallenburg V, van Beek HC, Donkers-van Rossum AB, Slob MJ, Kuipers TP, Mann RM, Voogd AC. Effects of nonparticipation at previous screening rounds on the characteristics of screen-detected breast cancers. Eur J Radiol 2022; 154:110391. [PMID: 35679699 DOI: 10.1016/j.ejrad.2022.110391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/15/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE We determined the incidence and effects of different screening intervals prior to a true positive recall on the tumour characteristics of screen-detected cancers (SDC) and interval cancers (ICs) at biennial screening mammography. METHODS A consecutive series of 553020 subsequent screens was included, obtained in a Dutch screening region between January 2009 and July 2019. During 2-year follow-up, we obtained data on radiological procedures, pathology and surgical interventions of all recalled women. RESULTS A total of 13,221 women were recalled (2.4% recall rate), yielding 3662 women with a SDC (6.6 SDCs per 1000 screen). Of these, 3477 (94.9%) had attended their two most recent screens as scheduled (i.e., 2-year screening interval), whereas the interval between the two most recent screens was four years or at least six years in respectively 132 (3.6%) and 53 (1.4%) women. There was a trend of higher cancer detection rates in case of longer screening intervals. The proportions of DCIS versus invasive cancer, as well as tumour histology, tumour size, axillary lymph node status, B&R grading, hormone receptor status and type of surgical treatment (breast conserving surgery or mastectomy) were comparable for women with a 2-year or 4-year interval between their two latest screens. SDCs in women with at least six years between their two latest screens were more frequently estrogen receptor negative or triple negative and were more frequently treated by mastectomy. All tumour characteristics mentioned above were less favourable for ICs than SDCs. CONCLUSIONS A vast majority of women with a SDC had a 2-year screening interval between their two latest screens. A screening interval of at least six years had a slight negative influence on the tumour characteristics and treatment of SDCs.
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Affiliation(s)
- Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands.
| | - Mireille J M Broeders
- Dutch Expert Centre for Screening (LRCB), Wijchenseweg 101, 6538 SW Nijmegen, the Netherlands; Radboud University Medical Center, Department for Health Evidence, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, the Netherlands
| | - Wikke Setz-Pels
- Department of Radiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | | | - Hermen C van Beek
- Department of Radiology, Maxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | | | - Marjan J Slob
- Department of Radiology, St Anna Hospital, Bogardeind 2, 5664 EH Geldrop, the Netherlands
| | - Toon P Kuipers
- Department of Radiology, Bernhoven Hospital, Nistelrodeseweg 10, 5406 PT Uden, the Netherlands
| | - Ritse M Mann
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, the Netherlands; Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University Medical Center, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
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Schermers B, van Riet YE, Schipper RJ, Vrancken Peeters MJ, Voogd AC, Nieuwenhuijzen GAP, Ten Haken B, Ruers TJM. Nationwide registry study on trends in localization techniques and reoperation rates in non-palpable ductal carcinoma in situ and invasive breast cancer. Br J Surg 2021; 109:53-60. [PMID: 34642736 DOI: 10.1093/bjs/znab339] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is a transition from wire-guided localization (WGL) of non-palpable breast cancer to other localization techniques. Multiple prospective studies have sought to establish superior clinical outcomes for radioactive-seed localization (RSL), but consistent and congruent evidence is missing. METHODS In this study, female patients with breast cancer operated with breast-conserving surgery after tumour localization of a non-palpable breast cancer or ductal carcinoma in situ (DCIS) were included. The cohort was identified from the nationwide Netherlands Breast Cancer Audit conducted between 2013 and 2018. Trends in localization techniques were analysed. Univariable and multivariable analyses were performed to assess the association between the localization technique and the probability of a reoperation. RESULTS A total of 28 370 patients were included in the study cohort. The use of RSL increased from 15.7 to 61.1 per cent during the study years, while WGL decreased from 75.4 to 31.6 per cent. The localization technique used (RSL versus WGL) was not significantly associated with the odds of a reoperation, regardless of whether the lesion was DCIS (odds ratio 0.96 (95 per cent c.i. 0.89 to 1.03; P = 0.281)) or invasive breast cancer (OR 1.02 (95 per cent c.i. 0.96 to 1.10; P = 0.518)). CONCLUSION RSL is rapidly replacing WGL as the preoperative localization technique in breast surgery. This large nationwide registry study found no association between the type of localization technique and the odds of having a reoperation, thus confirming the results of previous prospective cohort studies.
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Affiliation(s)
- Bram Schermers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,University of Twente, Faculty TNW, The Netherlands
| | - Yvonne E van Riet
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - R J Schipper
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Adri C Voogd
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | | | - Bennie Ten Haken
- Magnetic Detection & Imaging Group, University of Twente, The Netherlands
| | - Theo J M Ruers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,University of Twente, Faculty TNW, The Netherlands
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Lameijer JRC, Voogd AC, Broeders MJM, Pijnappel RM, Setz-Pels W, Strobbe LJ, Jansen FH, Tjan-Heijnen VCG, Duijm LEM. Trends in delayed breast cancer diagnosis after recall at screening mammography. Eur J Radiol 2021; 136:109517. [PMID: 33421886 DOI: 10.1016/j.ejrad.2020.109517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- J R C Lameijer
- Department of Radiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands.
| | - A C Voogd
- Department of Epidemiology, Maastricht University, GROW, P Debyelaan 1, 6229 HA, Maastricht, the Netherlands; Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - M J M Broeders
- Dutch Expert Centre for Screening, Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department for Health Evidence, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - R M Pijnappel
- Dutch Expert Centre for Screening, Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - W Setz-Pels
- Department of Radiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - L J Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands; Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, P Debyelaan 1, 6229 HA, Maastricht, the Netherlands
| | - F H Jansen
- Department of Radiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - V C G Tjan-Heijnen
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands; Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, P Debyelaan 1, 6229 HA, Maastricht, the Netherlands
| | - L E M Duijm
- Dutch Expert Centre for Screening, Wijchenseweg 101, 6538 SW, Nijmegen, the Netherlands; Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands; Department of Radiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
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Whitworth P, Hogan A, Ferko N, Son D, Wang F, Xiong Y, Suri H, Barclay B. Reduced Hospital Costs for Ultrasound-guided Vacuum-assisted Excision Compared with Open Surgery in Patients with Benign Breast Masses and High-risk Lesions. JOURNAL OF BREAST IMAGING 2020; 2:452-461. [PMID: 38424905 DOI: 10.1093/jbi/wbaa055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Benign breast masses represent a substantial proportion of breast cancer screening results and may require multiple follow-up visits and biopsy. Even with a preceding benign core biopsy, benign masses have been excised via open surgery for a variety of reasons. This study compared the procedural costs of US-guided vacuum-assisted excision (US-VAE) versus open surgical excisions for benign breast masses and high-risk lesions (HRL). METHODS In this retrospective cohort study, female outpatients receiving US-VAE or open excision of benign breast masses between 2015 and 2018 were identified within the Premier Healthcare Database. A secondary analysis was conducted for patients with HRLs. Propensity score matching and multivariate regression adjusted for patient demographics, encounter level covariates, and hospital characteristics. The total procedural costs were reported from a hospital perspective. RESULTS A total of 33 724 patients underwent excisions for benign breast masses (8481 US-VAE and 25 242 open surgery). Procedural costs were significantly lower in unmatched patients who received US-VAE ($1350) versus open surgery ($3045) (P < 0.0001). After matching, a total of 5499 discharges were included in each group, with similar findings for US-VAE ($1348) versus open surgery ($3101) (P < 0.0001). A secondary analysis of matched HRL patients (41 discharges in each group) also showed significantly lower procedural costs with US-VAE ($1620) versus open surgery ($3870) (P < 0.0001). CONCLUSION Among patients with benign breast masses or HRLs, US-VAE was associated with significantly lower procedural costs versus open surgery. If excision is performed and expected clinical outcomes are equal, US-VAE is preferable to reduce costs without compromising the quality of care.
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Affiliation(s)
| | | | | | | | - Faye Wang
- Becton, Dickinson and Company, Tempe, AZ
| | - Yan Xiong
- Becton, Dickinson and Company, Franklin Lakes, NJ
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Luiten JD, Voogd AC, Luiten EJT, Broeders MJM, Roes KCB, Tjan-Heijnen VCG, Duijm LEM. Recall and Outcome of Screen-detected Microcalcifications during 2 Decades of Mammography Screening in the Netherlands National Breast Screening Program. Radiology 2020; 294:528-537. [PMID: 31990268 DOI: 10.1148/radiol.2020191266] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Trends in the detection of suspicious microcalcifications at mammography screening and the yield of these lesions after recall are unknown. Purpose To determine trends in recall and outcome of screen-detected microcalcifications during 20 years of mammography screening. Materials and Methods The authors performed a retrospective analysis of a consecutive series of 817 656 screening examinations (January 1997 to January 2017) in a national breast screening program. In 2009-2010 (transition period), screen-film mammography (SFM) was gradually replaced by full-field digital mammography (FFDM). The recalls of suspicious microcalcifications from all radiology reports and pathologic outcome of recalled women with 2-year follow-up were analyzed. Screening outcome in the era of SFM (1997-2008), the transition period (2009-2010), and the era of FFDM (2011-2016) were compared. Trends over time and variations between the SFM and FFDM periods were expressed by using proportions with 95% confidence intervals (CIs). In cases where the analysis based on the CI confirmed clear periods (eg, before and after introduction of FFDM), pre- and postchange outcomes were compared by using χ2 tests. Results A total of 18 592 women (median age, 59 years; interquartile range, 14 years) were recalled at mammography screening, 3556 of whom had suspicious microcalcifications. The recall rate for microcalcifications increased from 0.1% in 1997-1998 to 0.5% in 2015-2016 (P < .001). This was temporally associated with the change from SFM to FFDM. The recalls yielding ductal carcinoma in situ (DCIS) increased from 0.3 per 1000 screening examinations with SFM to 1.1 per 1000 screening examinations with FFDM (P < .001), resulting in a decrease in the positive predictive value for recall for suspicious microcalcifications from 51% to 33% (P < .001). More than half of all DCIS lesions were high grade (52.6%; 393 of 747). The distribution of DCIS grades was stable during the 20-year screening period (P = .36). Conclusion The recall rate for suspicious microcalcifications at mammographic screening increased during the past 2 decades, whereas the ductal carcinoma in situ detection rate increased less rapidly, resulting in a lower positive predictive value for recall. © RSNA, 2020.
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Affiliation(s)
- Jacky D Luiten
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Adri C Voogd
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Ernest J T Luiten
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Mireille J M Broeders
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Kit C B Roes
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Vivianne C G Tjan-Heijnen
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
| | - Lucien E M Duijm
- From the Department of Surgery, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands (J.D.L.); School for Oncology and Developmental Biology, GROW Research Institute (J.D.L., V.C.G.T.), and Department of Epidemiology (A.C.V.), Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands (A.C.V.); Department of Breast Surgery, Amphia Hospital, Breda, the Netherlands (E.J.T.L.); Department of Health Evidence, Biostatistics Section, Radboud University Medical Centre, Nijmegen, the Netherlands (M.J.M.B., K.C.B.R.); Dutch Expert Centre for Screening, Nijmegen, the Netherlands (M.J.M.B., L.E.M.D.); Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands (V.C.G.T.); and Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands (L.E.M.D.)
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