[Population-based breast cancer screening: certainties, controversies, and future perspectives]

[Socioeconomic inequalities in mammography screening in Spanish women aged 45 to 69]

OBJECTIVE

To analyse mammography screening in Spanish women aged 45 to 69 according sociodemographic variables and to describe the role of population-based breast cancer screening programmes in terms of variability of said screening.

METHODS

Cross-sectional study of the 2011 National Health Survey. The study population includes women living in Spain between late 2011 and early 2012. The weighted sample analysed corresponds to 3,086 women aged 45 to 69. The dependent variables were mammograms and when the last mammogram was performed and why. Independent variables were age, social class, occupational status, country of origin, area of origin (rural/urban), health cover and years the programme had been in place. Logistic regression models were performed, with odds ratio (OR) adjusted according to age and 95% confidence intervals (95% CI).

RESULTS

Approximately 91.9% indicated that they had had a mammogram before. The women who had had their last mammography screening in the previous 1 to 2 years were associated with the highest social class (OR: 1.69; 95% CI: 1.03-2.75). The reason for performing the last periodic mammogram via a population-based programme was associated with women aged between 60 and 69 years (OR: 1.51; 95% CI: 1.04-2.19).

CONCLUSIONS

The results show that there are still inequalities in preventive practices. Possible risk groups need to be identified in order to promote the implementation of specific actions.

[An audit of breast cancer screening mammograms and the variability of radiological practice]

OBJECTIVE

To audit the breast cancer screening mammograms performed in a general hospital and to assess the variation in medical practice in the diagnostic process.

MATERIAL AND METHODS

A review was carried out on the screening mammograms performed between 1 May 2010 and 30 April 2011, with clinical follow up for two years, and a comparison with the published standards.

RESULTS

Of the 3,878 women examined, 368 (9.48%) were called back to complete the study (97 [16.1%] in the initial screening and 271 [8.2%] in revisions). Forty three biopsies (1.1%) were indicated, of which 24 were diagnosed with cancer. The positive predictive value (PPV) in screening studies (PPV1) was 6.52%. For the recommended biopsy (PPV2) it was 55%, with a sensitivity of 100%, a specificity of 91% and a cancer detection rate of 6.1/1,000. There were no false negatives. Twenty tumours were invasive; with no axillary lymph node infiltration was observed 15 of them. In 6 cases, the size of the tumour was less than or equal to 10mm, and in 17 it was less than 15mm. There were a higher percentage of new appointments by two radiologists (12% and 17.2% versus 7.3%) (P<.001). In 217 cases (58.96%; P<.001) only one radiologist indicated new appointments. Of this group, 73% were discharged in the first visit, compared to 47.6% in the non-discrepant group (P<.001). Four of the cancers were detected in these 217 patients.

CONCLUSIONS

The observed results are adjusted to the reference values. The discordant data are the new appointments rate, both in the initial screening and in the review, with a significant variation depending on the radiology reader.

Mammography screening in less developed countries

Less developed countries (LDCs) are struggling with an increasing burden of breast cancer. It is important to identify what interventions might be most effective and feasible in reducing overall breast cancer mortality in a resource constrained settings. Mammography screening (MS) utilized in developed countries cannot be equally applied to LDCs. We provide a summary of the status of existing and past MS program attempts in LDCs, and try to determine the prerequisites under which any developing country is ready to benefit from a MS program. We make the case for a “mixed” portfolio of tools to reduce breast cancer mortality with MS reserved only for those sub-populations that meet the criteria. We hope our review will provide a background for policy makers to apply rigorous criteria before attempting to implement costly MS program and before judiciously evaluating additional competed programs in their countries.

Screening mammography: update and review of publications since our report in the New England Journal of Medicine on the magnitude of the problem in the United States

RATIONALE AND OBJECTIVES

After a half century of clinical trials, expansive observations, vigorous advocacy and debate, screening mammography could not be in a more controversial condition, especially the potential harm of overdiagnosis. Despite a simple rationale (catch the cancer early and either prevent death or at least decrease the amount of therapy needed for cure), the estimates to date of overdiagnosis rates are conflicting and the interpretations complex.

MATERIALS AND METHODS

Since the author's 2012 publication in the New England Journal of Medicine (NEJM), the peer-reviewed publications on overdiagnosis caused by screening mammography are reviewed and the NEJM analyses updated with three additional calendar years of results.

RESULTS

The recent peer-reviewed medical literature on screening mammography induced overdiagnosis of breast cancer has increased exponentially, nearly 10-fold in 10 years. The average estimate of overdiagnosis is about 30%, but the range extends from 0% to 70+%. An update of the NEJM report estimates that in the US, 78,000 women and 30%-31% of those diagnosed with breast cancer at the age of 40 years or older during 2011 were overdiagnosed.

CONCLUSIONS

Until we have better screening procedures that identify who really has cancer and needs to be treated, the risk of overdiagnosis relative to the benefit of screening merits more effective public and professional education. Radiologists, pathologists, and other professionals involved with screening mammography should recognize that the potential harm of overdiagnosis is downplayed or not discussed with the patient and family, despite agreement that the objective is informed choice.

[Serpiginous calcifications in breast filariasis: A descriptor not included in the BI-RADS classification system]

Filariasis is a parasitic disease with a benign course caused by nematodes. Filariasis is endemic in some tropical regions, and immigration has made it increasingly common in some centers in Spain. The death of the parasites can lead to calcifications that are visible in mammograms; these calcifications have specific characteristics and should not be confused with those arising in other diseases. However, the appearance of calcifications due to filariasis is not included in the most common systems used for the classification of calcifications on mammograms (BI-RADS), and this can lead to confusion. In this article, we discuss the need to update classification systems and warn radiologists about the appearance of these calcifications to ensure their correct diagnosis and avoid confusion with other diseases.

Evaluation of the interval cancer rate and its determinants on the Girona Health Region's early breast cancer detection program

BACKGROUND

The main aim of this study is to estimate the rate of false negative and true IC on the Program for the Early Detection of Breast Cancer (PEDBC) run by the Girona Health Region (GHR) and compare the clinicopathological characteristics of these tumors with those detected within the same program.

METHODS

A retrospective cohort study including all women participating on the Girona PEDBC between 2000 and 2006, with negative mammography screening. The IC included are those detected between the first and second round of screening and between the second and third round.

RESULTS

We identified a total of 43 IC, representing an incidence rate of 0.70 cases per 1,000 screened women. Of the 43 probable IC, we were able to classify a total of 22 (51.2%) cases. Of these 22 cases, 54.5% were classified as true interval tumors, 13.6% false negatives, 18.2% occult tumors and the remaining 13.6% minimal sign.We found significant differences in some clinicopathological characteristics of the IC comparing with the tumors detected within the program during the same period.

CONCLUSIONS

The IC rate for the PEDBC is within the expected parameters, with a high proportion of cases of true interval cancers (54.5%) and a low proportion of false negatives (13.6%). The results show that the proportional incidence of IC is within the limits set by European Guidelines. Furthermore, it has been confirmed that IC display more aggressive clinicopathological characteristics than screening breast cancers.