Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review

[Analysis of the effect of mammography allocation on women's health indicators]

The early detection of breast cancer enables more effective forms of treatment. However, widespread access to its main screening tool, mammography, remains a challenge for the Brazilian public health system. This study aimed to analyze the effect of allocating mammography equipment on women's health indicators. In 2013, of the 4,557 municipalities that lacked the equipment, 260 received it up to 2019. The main hypothesis of this study suggests that receiving the mammography device would show a heterogeneous effect between locations and that such receival would depend on observable (propensity score matching) and non-observable variables (fixed effects model). Results indicate that the Brazilian municipalities that had mammography equipment in use from 2014 onward increased their number of exams without short-term effects to diagnoses and deaths due to malignant breast neoplasia. In addition to equipment, a more complex structure involving other factors (such as access to consultations, qualified professionals, waiting time, etc.) is important to improve women's health indicators in the analyzed municipalities.

Rethinking screening mammography in Japan: next-generation breast cancer screening through breast awareness and supplemental ultrasonography

Breast cancer mortality has not been reduced in Japan despite more than 20 years of population-based screening mammography. Screening mammography might not be suitable for Japanese women who often have dense breasts, thus decreasing mammography sensitivity because of masking. The J-START study showed that breast ultrasonography increases the sensitivity and the detection rate for early invasive cancers and lowers the rate of interval cancers for Japanese women in their 40 s. Breast awareness and breast cancer survival are directly correlated; however, breast awareness is not widely known in Japan. Next-generation breast cancer screening in Japan should consist of breast awareness campaigns for improving breast cancer literacy and supplemental breast ultrasonography to address the problem of false-negative mammograms attributable to dense breasts.

Breast cancer outcomes based on method of detection in community-based breast cancer registry

PURPOSE

The impact of opportunistic screening mammography in the United States is difficult to quantify, partially due to lack of inclusion regarding method of detection (MOD) in national registries. This study sought to determine the feasibility of MOD collection in a multicenter community registry and to compare outcomes and characteristics of breast cancer based on MOD.

METHODS

We conducted a retrospective study of breast cancer patients from a multicenter tumor registry in Missouri from January 2004 - December 2018. Registry data were extracted by certified tumor registrars and included MOD, clinicopathologic information, and treatment. MOD was assigned as screen-detected or clinically detected. Data were analyzed at the patient level. Chi-squared tests were used for categorical variable comparison and Mann-Whitney-U test was used for numerical variable comparison.

RESULTS

5351 women (median age, 63 years; interquartile range, 53-73 years) were included. Screen-detected cancers were smaller than clinically detected cancers (median size 12 mm vs. 25 mm; P < .001) and more likely node-negative (81% vs. 54%; P < .001), lower grade (P < .001), and lower stage (P < .001). Screen-detected cancers were more likely treated with lumpectomy vs. mastectomy (73% vs. 41%; P < .001) and less likely to require chemotherapy (24% vs. 52%; P < .001). Overall survival for patients with invasive breast cancer was higher for screen-detected cancers (89% vs. 74%, P < .0001).

CONCLUSION

MOD can be routinely collected and linked to breast cancer outcomes through tumor registries, with demonstration of significant differences in outcome and characteristics of breast cancers based on MOD. Routine inclusion of MOD in US tumor registries would help quantify the impact of opportunistic screening mammography in the US.

Overcoming the limitations of screening mammography in Japan and Korea: a paradigm shift to personalized breast cancer screening based on ultrasonography

Screening mammography programs have been implemented in numerous Western countries with the aim of reducing breast cancer mortality. However, despite over 20 years of population-based screening mammography, the mortality rates in Japan and Korea continue to rise. This may be due to the fact that screening mammography is not as effective for Japanese and Korean women, who often have dense breasts. This density decreases the sensitivity of mammography due to a masking effect. Therefore, the early detection of small invasive cancers requires more than just mammography, particularly for women in their 40s. This review discusses the limitations and challenges of screening mammography, as well as the keys to successful population-based breast cancer screening in Japan and Korea. This includes a focus on breast ultrasonography techniques, which are based on histopathologic anatomical knowledge, and personalized screening strategies that are based on risk assessments measured by glandular tissue components.

Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations

BACKGROUND

Health inequities lead to low rates of cancer screening in certain populations, such as low-income and ethnic minority groups. Different interventions to address this have been developed with mixed results. However, interventions are not always developed in collaboration with the people they target. The aim of our article is to present the viewpoint of patients, survivors, advocates, and lay persons on interventions to increase cancer screening from a health inequity perspective.

METHODS

We prepared talking points to guide discussions between coauthors, who included representatives from nine patient and survivor advocacy groups, organizations working for citizen/patient empowerment, and health equity experts. Perspectives and opinions were first collected through video conferencing meetings and a first draft of the paper was prepared. All authors, read through, revised, and discussed the contents to reach an agreement on the final perspectives to be presented.

RESULTS

Several themes were identified: it is important to not view screening as a discrete event; barriers underlying an individual's access and willingness to undergo screening span across a continuum; individually tailored interventions are likely to be more effective than a one-size fits-all approach because they may better accommodate the person's personal beliefs, knowledge, behaviors, and preferences; targeting people who are unknown to medical services and largely unreachable is a major challenge; including professional patient advocacy groups and relevant lay persons in the cocreation of interventions at all stages of design, implementation, and evaluation is essential along with relevant stakeholders (healthcare professionals, researchers, local government and community organizations etc).

CONCLUSIONS

Interventions to address cancer screening inequity currently do not adequately solve the issue, especially from the viewpoint of patients, survivors, and lay persons. Several core pathways should be focused on when designing and implementing interventions: advancing individually tailored interventions; digital tools and social media; peer-based approaches; empowerment; addressing policy and system barriers; better design of interventions; and collaboration, including the involvement of patients and patient advocacy organizations.

Interpreting Breast Cancer Mortality Trends Related to Introduction of Mammography Screening: A Simulation Study

Background. Several studies have evaluated the effect of mammography screening on breast cancer mortality based on overall breast cancer mortality trends, with varied conclusions. The statistical power of such trend analyses is, however, not carefully studied. Methods. We estimated how the effect of screening on overall breast cancer mortality is likely to unfold. Because a screening effect is based on earlier treatment, screening can affect only new incident cases after screening introduction. To evaluate the likelihood of detecting screening effects on overall breast cancer mortality time trends, we calculated the statistical power of joinpoint regression analysis on breast cancer mortality trends around screening introduction using simulations. Results. We found that a very gradual increase in population-level screening effect is expected due to prescreening incident cases. Assuming 25% effectiveness of a biennial screening program in reducing breast cancer mortality among women 50 to 69 y of age, the expected reduction in overall breast cancer mortality was 3% after 2 y and reached a long-term effect of 18% after 20 y. In common settings, the statistical power to detect any screening effects using joinpoint regression analysis is very low (<50%), even in an artificial setting of constant risk of baseline breast cancer mortality over time. Conclusions. Population effects of screening on breast cancer mortality emerge very gradually and are expected to be considerably lower than the effects reported in trials excluding women diagnosed before screening. Studies of overall breast cancer mortality time trends have too low statistical power to reliably detect screening effects in most populations. Implications. Researchers and policy makers evaluating mammography screening should avoid using breast cancer mortality trend analysis that does not separate pre- and postscreening incident cases.

HIGHLIGHTS

Population-level mammography screening effects on breast cancer mortality emerge gradually following screening introduction, resulting in very low statistical power of trend analysis.Researchers and policy makers evaluating mammography screening should avoid relying on population-wide breast cancer mortality trends.Expected mammography screening effects at population level are lower than those from screening trials, as many cases of breast cancer fall outside the screening age range.

Misinformation and Facts about Breast Cancer Screening

Quality medical practice is based on science and evidence. For over a half-century, the efficacy of breast cancer screening has been challenged, particularly for women aged 40–49. As each false claim has been raised, it has been addressed and refuted based on science and evidence. Nevertheless, misinformation continues to be promoted, resulting in confusion for women and their physicians. Early detection has been proven to save lives for women aged 40–74 in randomized controlled trials of mammography screening. Observational studies, failure analyses, and incidence of death studies have provided evidence that there is a major benefit when screening is introduced to the general population. In large part due to screening, there has been an over 40% decline in deaths from breast cancer since 1990. Nevertheless, misinformation about screening continues to be promoted, adding to the confusion. Despite claims to the contrary, a careful reading of the guidelines issued by major groups such as the U.S. Preventive Services Task Force and the American College of Physicians shows that they all agree that most lives are saved by screening starting at the age of 40. There is no scientific support for using the age of 50 as a threshold for screening. All women should be provided with the facts and not false information about breast cancer screening so that they can make “informed decisions” for themselves about whether to participate.

BI-RADS-Based Classification of Mammographic Soft Tissue Opacities Using a Deep Convolutional Neural Network

The aim of this study was to investigate the potential of a machine learning algorithm to classify breast cancer solely by the presence of soft tissue opacities in mammograms, independent of other morphological features, using a deep convolutional neural network (dCNN). Soft tissue opacities were classified based on their radiological appearance using the ACR BI-RADS atlas. We included 1744 mammograms from 438 patients to create 7242 icons by manual labeling. The icons were sorted into three categories: “no opacities” (BI-RADS 1), “probably benign opacities” (BI-RADS 2/3) and “suspicious opacities” (BI-RADS 4/5). A dCNN was trained (70% of data), validated (20%) and finally tested (10%). A sliding window approach was applied to create colored probability maps for visual impression. Diagnostic performance of the dCNN was compared to human readout by experienced radiologists on a “real-world” dataset. The accuracies of the models on the test dataset ranged between 73.8% and 89.8%. Compared to human readout, our dCNN achieved a higher specificity (100%, 95% CI: 85.4–100%; reader 1: 86.2%, 95% CI: 67.4–95.5%; reader 2: 79.3%, 95% CI: 59.7–91.3%), and the sensitivity (84.0%, 95% CI: 63.9–95.5%) was lower than that of human readers (reader 1:88.0%, 95% CI: 67.4–95.4%; reader 2:88.0%, 95% CI: 67.7–96.8%). In conclusion, a dCNN can be used for the automatic detection as well as the standardized and observer-independent classification of soft tissue opacities in mammograms independent of the presence of microcalcifications. Human decision making in accordance with the BI-RADS classification can be mimicked by artificial intelligence.

Are there employment and income gains of a national breast cancer screening program?

BACKGROUND

The Dutch national breast cancer screening program invites women aged 50-75 for screening. By detecting the disease in an early phase, the program aims to achieve lower breast cancer mortality and improve breast cancer survivors' health. Arguably, the latter also improves the employability of diagnosed women.

OBJECTIVE

This study investigates the effects of the Dutch national breast cancer screening program on diagnosed women's employment and income.

METHODS

The empirical analysis uses data of 229,357 women aged 40-59, of whom 10,515 were diagnosed with breast cancer at an age in the range 47-53. A regression-based difference-in-differences estimator is used to identify program effects by comparing outcomes for women diagnosed at ages 47-49 with the outcomes for those diagnosed at ages 50-53. The empirical models account for individual fixed effects, and for age and year fixed effects by using a control group of women who were not diagnosed with breast cancer.

RESULTS

Women's employment rates declined in the six-year period after a breast cancer diagnosis with, on average, about 3 percentage points and their incomes declined with, on average, about 5% over this period. The empirical evidence, based on a comparison of outcomes for women diagnosed at ages 47-49 with the outcomes for those diagnosed at ages 50-53 when covered by the breast cancer screening program, does not support that these declines in employment and income were affected by the program. The evidence also does not support short or medium-term survival gains of the program.

CONCLUSIONS

The findings of this study suggest that the Dutch national breast cancer screening program yields no discernible short or medium-term employment and income gains for women diagnosed with breast cancer.

Breast magnetic resonance imaging as a problem solving tool in women recalled at biennial screening mammography: A population-based study in the Netherlands

Purpose

Problem solving magnetic resonance imaging (MRI) is used to exclude malignancy in women with equivocal findings on conventional imaging. However, recommendations on its use for women recalled after screening are lacking. This study evaluates the impact of problem solving MRI on diagnostic workup among women recalled from the Dutch screening program, as well as time trends and inter-hospital variation in its use.

Methods

Women who were recalled at screening mammography in the South of the Netherlands (2008–2017) were included. Two-year follow-up data were collected. Diagnostic-workup and accuracy of problem solving MRI were evaluated and time trends and inter-hospital variation in its use were examined.

Results

In the study period 16,175 women were recalled, of whom 906 underwent problem solving MRI. Almost half of the women (45.4%) who underwent problem solving MRI were referred back to the screening program without further workup. The sensitivity, specificity, and positive and negative predictive values of problem solving MRI were 98.2%, 70.0%, 31.1%, and 99.6%, respectively. The percentage of recalled women receiving problem solving MRI fluctuated over time (4.7%–7.2%) and significantly varied among hospitals (2.2%–7.0%).

Conclusion

The use of problem solving MRI may exclude malignancy in recalled women. The use of problem solving MRI varied over time and among hospitals, which indicates the need for guidelines on problem solving MRI.

•

Problem solving MRI did correctly refer back women to the screening program.

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The sensitivity and specificity of problem solving MRI were 98.2% and 70.0%.

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Positive and negative predictive values of problem solving MRI were 31.1% and 99.6%.

•

By excluding malignancy, problem solving MRI may reduce invasive diagnostic workup.

A Novel Seven Gene Signature-Based Prognostic Model to Predict Distant Metastasis of Lymph Node-Negative Triple-Negative Breast Cancer

Background

The prognosis of lymph node-negative triple-negative breast cancer (TNBC) is still worse than that of other subtypes despite adjuvant chemotherapy. Reliable prognostic biomarkers are required to identify lymph node-negative TNBC patients at a high risk of distant metastasis and optimize individual treatment.

Methods

We analyzed the RNA sequencing data of primary tumor tissue and the clinicopathological data of 202 lymph node-negative TNBC patients. The cohort was randomly divided into training and validation sets. Least absolute shrinkage and selection operator Cox regression and multivariate Cox regression were used to construct the prognostic model.

Results

A clinical prognostic model, seven-gene signature, and combined model were constructed using the training set and validated using the validation set. The seven-gene signature was established based on the genomic variables associated with distant metastasis after shrinkage correction. The difference in the risk of distant metastasis between the low- and high-risk groups was statistically significant using the seven-gene signature (training set: P < 0.001; validation set: P = 0.039). The combined model showed significance in the training set (P < 0.001) and trended toward significance in the validation set (P = 0.071). The seven-gene signature showed improved prognostic accuracy relative to the clinical signature in the training data (AUC value of 4-year ROC, 0.879 vs. 0.699, P = 0.046). Moreover, the composite clinical and gene signature also showed improved prognostic accuracy relative to the clinical signature (AUC value of 4-year ROC: 0.888 vs. 0.699, P = 0.029; AUC value of 5-year ROC: 0.882 vs. 0.693, P = 0.038). A nomogram model was constructed with the seven-gene signature, patient age, and tumor size.

Conclusions

The proposed signature may improve the risk stratification of lymph node-negative TNBC patients. High-risk lymph node-negative TNBC patients may benefit from treatment escalation.

Design, implementation, and pitfalls of TMIST

The early detection of breast cancer has been shown to reduce deaths through randomized, controlled trials. Numerous observational studies, failure analyses, and "incidence of death" studies have confirmed that screening reduces deaths in the general population. Digital Breast Tomosynthesis (DBT) which collects mammographic images from different angles and uses them to synthesize planes through the breast is simply another advance in mammography among others that have been made over the years. DBT "absolutely" detects more cancers at a time when cure is more likely while also having the advantage of reducing recall rates. The Tomosynthesis Mammographic Imaging Screening Trial (TMIST) has been designed to compare DBT with 2-Dimensional Full Field Digital Mammography (FFDM), but it's major design issues may provide misleading results. Instead of using a reduction in deaths as the endpoint, benefit in TMIST is predicated on a reduction in advanced cancers in the DBT group. This is a questionable "endpoint" (a reduction in advanced cancers is not necessary as proof of benefit). In addition, the trial may be underpowered so that even if DBT shows a benefit it may not be able to achieve "statistical significance". The six CISNET models of the National Cancer Institute have shown that annual mammography beginning at the age of 40 will save the most lives. Yet TMIST will only include women ages 45 and over and will screen postmenopausal women every two years instead of annually. Consequently, TMIST results may be used, inappropriately, to limit access to breast cancer screening starting at the age of 45, and only offer biennial screening for post-menopausal women.

One step further into the blackbox: a pilot study of how to build more confidence around an AI-based decision system of breast nodule assessment in 2D ultrasound

OBJECTIVES

To investigate how a DL model makes decisions in lesion classification with a newly defined region of evidence (ROE) by incorporating "explainable AI" (xAI) techniques.

METHODS

A data set of 785 2D breast ultrasound images acquired from 367 females. The DenseNet-121 was used to classify whether the lesion is benign or malignant. For performance assessment, classification results are evaluated by calculating accuracy, sensitivity, specificity, and receiver operating characteristic for experiments of both coarse and fine regions of interest (ROIs). The area under the curve (AUC) was evaluated, and the true-positive, false-positive, true-negative, and false-negative results with breakdown in high, medium, and low resemblance on test sets were also reported.

RESULTS

The two models with coarse and fine ROIs of ultrasound images as input achieve an AUC of 0.899 and 0.869, respectively. The accuracy, sensitivity, and specificity of the model with coarse ROIs are 88.4%, 87.9%, and 89.2%, and with fine ROIs are 86.1%, 87.9%, and 83.8%, respectively. The DL model captures ROE with high resemblance of physicians' consideration as they assess the image.

CONCLUSIONS

We have demonstrated the effectiveness of using DenseNet to classify breast lesions with limited quantity of 2D grayscale ultrasound image data. We have also proposed a new ROE-based metric system that can help physicians and patients better understand how AI makes decisions in reading images, which can potentially be integrated as a part of evidence in early screening or triaging of patients undergoing breast ultrasound examinations.

KEY POINTS

• The two models with coarse and fine ROIs of ultrasound images as input achieve an AUC of 0.899 and 0.869, respectively. The accuracy, sensitivity, and specificity of the model with coarse ROIs are 88.4%, 87.9%, and 89.2%, and with fine ROIs are 86.1%, 87.9%, and 83.8%, respectively. • The first model with coarse ROIs is slightly better than the second model with fine ROIs according to these evaluation metrics. • The results from coarse ROI and fine ROI are consistent and the peripheral tissue is also an impact factor in breast lesion classification.

Analysis of Predictors of Breast Cancer Screening among Japanese Women using Nationally Representative Survey Data, 2001-2013

Objective:

Predictors of participation in breast cancer screening in recent years or the trend of participation rate by predictors over the years has not been investigated in Japan. In this study, we investigated predictors for participation in breast cancer screening and analyzed the trend of participation rate depending on the predictors using nationally representative survey data in Japan.

Methods:

The data of “Comprehensive Survey of Living Conditions” in Japan from 2001 to 2013 were used. Participation in breast cancer screening was used as an outcome. Next, as explanatory variables, we used age group, marital status, living arrangements, educational level, household income, employment status, smoking status, regular outpatient visit status, and self-rated health status. Then, the participation rate for breast cancer screening was calculated for each of the factors over the years. In addition, multivariate logistic regression analysis was conducted to analyze the association between each factor and the participation rate using data from 2010 and 2013.

Results:

We found that non-married women, women with lower educational level, women with low household income, self-employed or unemployed women, smokers, and women with low self-rated health status were significantly less likely to participate in breast cancer screening. Conversely, the participation rate increased for all predictor groups from 2001 to 2013, and the increase in the participation rate for never-married women was particularly evident compared with the other marital statuses. However, significant differences in the participation rate for breast cancer screening existed depending on marital status, household income, employment status, and smoking status throughout the analyzed years.

Conclusion:

Our findings suggest that further recommendations for breast cancer screening are particularly needed among women of low socioeconomic status and those who are self-employed or unemployed to increase the participation rate in Japan.

Breast cancer screening program in Lithuania: trends in breast cancer mortality before and during the introduction of the mammography screening programme

Abstract. Background.

Breast cancer is the most frequent oncological disease as well as the leading cause of cancer death among women worldwide. Decline in mortality in economically strong countries is observed. This decline is mostly related to early diagnosis (an improvement in breast cancer awareness and the mammography screening program (MSP)) and a more effective treatment. In the end of 2005, MSP started in Lithuania. The main aim of this article is to evaluate the breast cancer mortality during 22 years in Lithuania, as well as changes before the start of the MSP and during its implementation, in order to assess the influence of the MSP on mortality.

Materials and methods.

Analysis is based on data from the population-based Lithuanian Cancer Registry. Analysis of changes in mortality includes the period from 1998 to 2019. Age standardized mortality rates are calculated for assessment of changes. Joinpoint regression analysis is used.

Results.

Applying the segmental regression model, it was found that during the study period mortality was statistically significantly decreasing by -1.1% each year. Mortality among women under the age of 50 decreased both before and during the implementation of MSP. Mortality in the target population also was already decreasing until the implementation of the program, but a significant reduction in mortality was observed in this group since 2006.

Conclusions.

Overall breast cancer mortality is decreasing in Lithuania. After the implementation of MSP the largest reduction in mortality was observed in the target population, however, it is not as pronounced as it could be with the well-organized MSP.

Breast-cancer mortality in screened versus unscreened women: Long-term results from a population-based study in Queensland, Australia

OBJECTIVE

In the context of a mature mammographic screening programme, the aim of this population-based study was to estimate rates of breast-cancer mortality among participants versus non-participants in Queensland, Australia.

METHODS

The Queensland Electoral Roll was used to identify women aged 50-65  in the year 2000 (n = 269,198). Women with a prior history of invasive or in situ breast cancer were excluded (n = 6,848). The study population was then linked to mammography records from BreastScreen Queensland together with the Wesley Breast Screening Clinic (the largest provider of private screening in Queensland) to establish a screened cohort (n = 187,558) and an unscreened cohort (n = 74,792). Cohort members were matched and linked to cancer notifications and deaths through the state-based Queensland Oncology Repository. Differences in breast-cancer mortality between the two cohorts were measured using Cox proportional hazards regression.

RESULTS

After 16 years of follow-up, women in the screened cohort showed a 39% reduction in breast-cancer mortality compared to the unscreened cohort (HR = 0.61, 95%CI = 0.55-0.68). Cumulative mortality over the same period was 0.47% and 0.77% in the screened and unscreened cohorts, respectively.

CONCLUSIONS

This study found a significant reduction in breast-cancer mortality for women who participated in mammographic screening compared to unscreened women. Our findings of a breast-cancer mortality benefit for women who have mammographic screening are in line with other observational studies.

Frequency and diagnostic outcome of bilateral recall at screening mammography

Our study was performed to determine the frequency of recall for bilateral breast lesions at screening mammography and compare its outcome with respect to unilateral recall. We included 329 132 screening mammograms (34 889 initial screens and 294 243 subsequent screens) from a Dutch screening mammography program between January 2013 and January 2018. During a 2‐year follow‐up, we collected radiological data, pathology reports and surgical reports of all recalled women. At bilateral recall, the lesion with the highest Breast Imaging Reporting and Data System score was used as the index lesion when comparing screening mammography characteristics at bilateral vs unilateral recall. A total of 9806 women were recalled at screening (recall rate, 3.0%). Bilateral recall comprised 2.8% (271/9806) of all recalls. Biopsy was more frequently performed after bilateral recall than unilateral recall (54.6% [148/271] vs 44.1% [4201/9535], P < .001), yielding a lower positive predictive value (PPV) of biopsy after bilateral recall (42.6% vs 51.7%, P = .029). The PPV of recall was comparable for both groups (23.2% [63/271] vs 22.8% [2173/9535], P = .85). Invasive cancers after bilateral recall were larger than those diagnosed after unilateral recall (P = .02), but histological subtype, histologic grading, receptor status and proportions of lymph node positive cancers were comparable. Bilateral recall infrequently occurs at screening mammography. Biopsy is more frequently performed following bilateral recall, but the PPV of recall is similar for unilateral and bilateral recall. Invasive cancers of both groups show comparable pathological features except of a larger tumor size after bilateral recall.

What's new?

Data on bilateral breast cancer in a screened population is sparse, and information on bilateral recall is lacking. Based on more than 329,000 screening mammograms, our study shows that bilateral recall occurs infrequently at screening mammography, and that the majority of these recalls are false positives. Invasive cancer has comparable pathological features in bilateral and unilateral breast cancer patients, except larger tumour size after bilateral recall. Altogether, the results highlight the need for screening radiologists to pay vigorous attention to the contralateral breast after detecting a screening mammographic abnormality in order to facilitate a timely diagnosis of bilateral breast cancer.

Psychosocial well-being at time of diagnosis of breast cancer affects the decision whether or not to undergo breast reconstruction

OBJECTIVES

Numerous studies have shown that breast reconstruction after mastectomy improves QoL in breast cancer survivors. However, still about half of the patients does not opt for reconstruction. In order to accommodate suitable counseling, we should elucidate the factors that play a role in the decision-making process. This study aimed to evaluate the influence of QoL, among women diagnosed with breast cancer before the start of any treatment, on their decision whether or not to undergo breast reconstruction.

MATERIALS AND METHODS

BREAST-Q surveys were provided to breast cancer patients at the specialized breast care outpatient clinic after their first consultation with a surgical oncologist, between June 2017 and March 2019. The Q-scores of the subdomains physical well-being, psychosocial well-being, sexual well-being, and satisfaction with breasts of patients that underwent mastectomy were statistically analyzed.

RESULTS

Sixty-seven patients, undergoing mastectomy, completed the questionnaire. Fifty-four percent received reconstructive surgery. Mean age of patients seeking breast reconstruction was significantly lower than patients who did not opt for a reconstruction (53.5 vs. 63.7). Mean follow-up after mastectomy was 18.1 months. Except for satisfaction with breasts, mean Q-scores were higher in the group of patients who did not choose for reconstructive surgery. Psychosocial well-being was significantly higher in the non-reconstruction group (p = 0.012).

CONCLUSIONS

Psychosocial well-being at time of diagnosis of breast cancer was significantly higher in patients refraining from breast reconstructive surgery after mastectomy. Psychosocial characteristics might be essential for the decision-making process as well. Further prospective research should evaluate this.

Time to Adjuvant Radiotherapy in Breast Cancer Affects Survival: Implications for the American College of Surgeons Commission on Cancer Quality Metrics

BACKGROUND

To optimize breast cancer care, the American College of Surgeons Commission on Cancer developed quality measures regarding receipt and timing of adjuvant radiotherapy (RT). Nationwide compliance with these measures and its impact on overall survival (OS) are evaluated herein.

PATIENTS AND METHODS

Patients (n = 285,291) diagnosed with invasive breast cancer from 2004 to 2012 were identified from the National Cancer Database. Compliance with RT administration within 365 days from diagnosis was determined for patients with stage III disease with ≥ 4 positive lymph nodes post mastectomy and stage I-III disease post breast-conserving surgery (BCS). Univariate and multivariate logistic regression and Cox proportional hazard models were used to assess factors associated with compliance and OS, respectively.

RESULTS

In the mastectomy cohort, 66.9% received timely RT, showing improved OS versus no RT patients (HR 0.70, 95% CI 0.67-0.73). Delayed RT patients (≥ 365 days) achieved equivalent OS to those receiving timely RT (HR 1.07, 95% CI 0.93-1.23) and superior OS to no RT patients (HR 0.74, 95% CI 0.65-0.85). In the BCS cohort, 89.4% received timely RT, showing improved OS versus no RT patients (HR 0.47, 95% CI 0.45-0.49). Delayed RT was associated with improved OS versus no RT (HR 0.64, 95% CI 0.56-0.74) and decreased OS versus timely RT (HR 1.37, 95% CI 1.19-1.58). Factors associated with noncompliance included insurance type and distance to hospital.

CONCLUSIONS

Quality measure compliance with adjuvant RT improves OS, regardless of timing after mastectomy. However, timeliness does impact OS after BCS. Focus on modifiable factors to improve compliance such as access to care may lead to improved compliance and OS.

Evidence for reducing cancer-specific mortality due to screening for breast cancer in Europe: A systematic review

BACKGROUND

The aim of this study was to quantify the impact of organised mammography screening on breast cancer mortality across European regions. Therefore, a systematic review was performed including different types of studies from all European regions and stringently used clearly defined quality appraisal to summarise the best evidence.

METHODS

Six databases were searched including Embase, Medline and Web of Science from inception to March 2018. To identify all eligible studies which assessed the effect of organised screening on breast cancer mortality, two reviewers independently applied predefined inclusion and exclusion criteria. Original studies in English with a minimum follow-up of five years that were randomised controlled trials (RCTs) or observational studies were included. The Cochrane risk of bias instrument and the Newcastle-Ottawa Scale were used to assess the risk of bias.

RESULTS

Of the 5015 references initially retrieved, 60 were included in the final analysis. Those comprised 36 cohort studies, 17 case-control studies and 7 RCTs. None were from Eastern Europe. The quality of the included studies varied: Nineteen of these studies were of very good or good quality. Of those, the reduction in breast cancer mortality in attenders versus non-attenders ranged between 33% and 43% (Northern Europe), 43%-45% (Southern Europe) and 12%-58% (Western Europe). The estimates ranged between 4% and 31% in invited versus non-invited.

CONCLUSION

This systematic review provides evidence that organised screening reduces breast cancer mortality in all European regions where screening was implemented and monitored, while quantification is still lacking for Eastern Europe. The wide range of estimates indicates large differences in the evaluation designs between studies, rather than in the effectiveness of screening.

A Review on Curability of Cancers: More Efforts for Novel Therapeutic Options Are Needed

Cancer remains a major cause of death globally. Given its relapsing and fatal features, curing cancer seems to be something hardly possible for the majority of patients. In view of the development in cancer therapies, this article summarizes currently available cancer therapeutics and cure potential by cancer type and stage at diagnosis, based on literature and database reviews. Currently common cancer therapeutics include surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy. However, treatment with curative intent by these methods are mainly eligible for patients with localized disease or treatment-sensitive cancers and therefore their contributions to cancer curability are relatively limited. The prognosis for cancer patients varies among different cancer types with a five-year relative survival rate (RSR) of more than 80% in thyroid cancer, melanoma, breast cancer, and Hodgkin's lymphoma. The most dismal prognosis is observed in patients with small-cell lung cancer, pancreatic cancer, hepatocellular carcinoma, oesophagal cancer, acute myeloid leukemia, non-small cell lung cancer, and gastric cancer with a five-year RSR ranging between 7% and 28%. The current review is intended to provide a general view about how much we have achieved in curing cancer as regards to different therapies and cancer types. Finally, we propose a small molecule dual-targeting broad-spectrum anticancer strategy called OncoCiDia, in combination with emerging highly sensitive liquid biopsy, with theoretical curative potential for the management of solid malignancies, especially at the micro-cancer stage.

Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in implementing and financing prevention strategies. On the contrary, the morbidity-based scheme to distribute financial resources from the Central Reallocation Pool among the different sickness funds may counteract efforts of effective prevention from an economic perspective. We assessed financial impacts of prevention from a sickness funds perspective in a retrospective controlled study. Claims data of 6,247,275 persons were analyzed and outcomes between two propensity-matched groups (n = 852,048) of prevention users and non-users were compared in a 4-year follow-up. Using a difference-in-differences approach, we analyzed healthcare expenditures, the development of morbidity, financial transfers from the Central Reallocation Pool, and contribution margins. The group of prevention users develops less morbidity (incidences and disease aggravations) compared to the control group. Healthcare expenditures increase in both groups within 4 years, whereas the increase is lower for prevention users compared to non-users (€568.04 vs. €640.60, p < 0.0001). Taking morbidity-based financial transfers into account, the decrease in contribution margins is stronger for prevention users (- €188.44 vs. - €138.73, p < 0.0001). This study demonstrates an economic disincentive from a sickness funds' perspective. In the semi-competitive SHI market, sickness funds will be discouraged from effective prevention strategies if investments are not worth it financially. Their efforts and knowledge are, however, crucial for joint action to foster prevention over cure in the health system.

Cost- Effectiveness of Mammography Screening Program in a Resource-Limited Post-Soviet Country of Kazakhstan

OBJECTIVES

To conduct cost effectiveness and benefit-cost analyses of the organized mammography-screening program in the Republic of Kazakhstan comparing women who developed breast cancer in screened and unscreened scenario.

METHODS

389,352 screened women were included in the study. Among these, 895 women were further diagnosed with breast cancer. Outcomes measures include life years saved, quality-adjusted life years, incremental cost-effectiveness ratio, and value of statistical life year. Sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared to no screening scenario, an organized mammography yielded an additional 1,253 life years and 790 quality-adjusted life years in 2016. The incremental cost-effectiveness ratio was equal to 3,157 USD per one QALY saved, which is two times less than the GDP per capita in Kazakhstan in 2016. Sensitivity analysis showed that the mammography remains cost-effective in the majority of the scenarios.

CONCLUSION

Mammography screening in Kazakhstan was found to be highly cost-effective, associated with treatment cost savings, and can be an efficient use of limited resources in Kazakhstan.

Effect of screening mammography on breast cancer mortality: Quasi-experimental evidence from rollout of the Dutch population-based program with 17-year follow-up of a cohort

There is uncertainty about the magnitude of the effect of screening mammography on breast cancer mortality. The relevance and validity of evidence from dated randomized controlled trials has been questioned, whereas observational studies often lack a valid comparison group. There is no estimate of the effect of one screening invitation only. We exploited the geographic rollout of the Dutch screening mammography program across municipalities to estimate the effects of one additional biennial screening invitation on breast cancer and all‐cause mortality. Population administrative data provided vital status and cause of death of a cohort of women aged 49–63 in 1995 over 17 years. Linear probability models were used to estimate the mortality effects. We estimated 154 fewer breast cancer deaths (95% confidence interval: 40–267; p = 0.01) over 17 years in a population of 100,000 women aged 49–63 who received one additional biennial screening invitation, which corresponds to an 9.6% risk reduction for a woman of age 56. The estimated effect on all‐cause mortality was negative but not close to statistical significance. Our study shows that one single invitation for breast cancer screening is effective in reducing breast cancer mortality, which is important for health policy. The effect is smaller than previous estimates of the effect of invitation for multiple screens, which further emphasizes the importance of achieving regular participation.

What's new?

To date, there is still uncertainty about the magnitude of the effect of screening mammography on breast cancer mortality. Here, the authors exploited the geographic rollout of the Dutch screening mammography program and high‐quality national population, cancer, and death registries to avoid limitations of observational research by comparing breast cancer mortality across groups of women of the same age who joined the mammography program at different dates. The analysis provides a unique estimate of the effect of one additional invitation for screening mammography on breast cancer mortality (around 10%) and delivers evidence in favour of the effectiveness of such screening.

Antecedents: A Half-Century of Imaging the Breast

The field of Breast Imaging evolved because a fairly small number of dedicated individuals realized the lifesaving potential of detecting breast cancer earlier. They persevered despite persistent efforts to curtail screening. From the first attempts to produce X-ray images of the breast to magnetic resonance and digital breast tomosynthesis, investigators have worked continuously to develop better ways to detect breast cancer at a time when cure is possible, while working continuously to preserve access for women to screening. Consequently, the death rate from breast cancer has declined by more than 40%. Therapy has improved, but therapy saves lives when breast cancers are treated early.

Tumour characteristics of bilateral screen-detected cancers and bilateral interval cancers in women participating at biennial screening mammography

BACKGROUND

Unilateral interval breast cancers show less favourable prognostic features than unilateral screen-detected cancers, but data on tumour characteristics of bilateral interval cancers in a systematically screened population are sparse. Therefore, we compared tumour characteristics of bilateral interval cancers with those of bilateral screen-detected cancers.

METHODS

We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all recalled women and of all women who presented with interval breast cancer. In women with synchronous bilateral breast cancer, the tumour with the highest tumour stage was defined as the index cancer. For comparison of data between both groups Fisher exact test and Chi-square test were used.

RESULTS

Synchronous bilateral cancer was diagnosed in 2.2% of screen-detected cancers (64/2947) and in 3.2% of interval cancers (24/753) (P = 0.1). Index tumours of bilateral screen-detected cancers and interval cancers showed similar characteristics, except for a larger proportion of T-stage 2 or worse (T2+) cancers among interval cancers (16/24 (66.7%) versus 23/58 (39.7%) (P = 0.03). Index cancers, compared to contralateral cancers, were less frequently stage T1 in both bilateral screen-detected cancers and bilateral interval cancers (35/64 (60.3%) versus 40/64 (88.9%) (P = 0.001) and 8/24 (33.3%) versus 18/24 (85.7%) (P < 0.001), respectively). In bilateral screen-detected cancers, contralateral cancers were more often stage 1a-c (P < 0.001) compared to index cancers. In bilateral index cancers, index cancers were more often of the lobular subtype (P < 0.001).

CONCLUSION

Index cancers of bilateral screen-detected cancers and bilateral interval cancers show significant differences in tumour size, whereas nodal status, receptor status and final surgical treatment are comparable. In bilateral screen-detected cancer, index cancers had a significantly higher tumour stage. In bilateral screen-detected cancer, index cancers were more often the ductal invasive subtype compared to contralateral cancers.

Frequency and characteristics of additionally detected ipsilateral breast lesions following recall at screening mammography

PURPOSE

To determine the frequency and outcome of additionally detected ipsilateral breast abnormalities following recall at screening mammography.

METHODS AND MATERIALS

We included a consecutive series of 130,338 screening mammograms obtained between January 1, 2014 and January 1, 2016. During 2-year follow-up, clinical data were collected of all recalls. Women with a bilateral recall (115) and women recalled for multiple lesions in one breast (165) were excluded from the analyses. Screening outcome parameters were determined for recalled women with or without evaluation of additional ipsilateral breast abnormalities following recall.

RESULTS

A total of 3995 women were recalled (recall rate, 3.1%). In 258 (6.4%) of these women, another lesion was detected in the ipsilateral breast than the one for which she had been recalled. Biopsy was more frequently performed of additionally detected ipsilateral lesions than of recalled lesions (55.8% (144/258)) versus 39.7% (1375/3457), (p < 0.001)). The proportion of malignancy in recalled lesions and additionally detected lesions was comparable (21.5% (743/3457) versus 19.0% (49/258), p = 0.34). Of all 144 biopsies of additionally detected ipsilateral lesions, 9 revealed a synchronous tumour in addition to a malignant recalled lesion, and 33 biopsies revealed multicentric or multifocal tumours. In 5 women, the recalled lesion turned out to be benign, whereas the additional lesion in a different quadrant was malignant at biopsy. A total of 97 biopsies showed benign findings.

CONCLUSION

A substantial proportion of women are analyzed for additional ipsilateral breast lesions following recall. These lesions are more frequently biopsied than recalled lesions, but have a comparable probability of being malignant. The majority of additionally detected cancerous lesions are part of multifocal or multicentric malignancies.

Breast cancer mortality and screening mammography in New Zealand: Incidence-based and aggregate analyses

OBJECTIVE

To investigate trends in breast cancer mortality in New Zealand women, to corroborate or negate a causal association with service screening mammography.

METHOD

Cumulated mortality rates from breast cancer deaths individually linked to incident cases diagnosed before and after screening commencement were compared, in women aged 50-64 (from 2001) and aged 45-49 and 65-69 (from 2006). Trends and differences in aggregate invasive breast cancer mortality (1975-2013) were assessed in relation to introduction of mammography screening targeting women aged 50-64 and 45-69. Joinpoint analysis was also undertaken.

RESULTS

The reduction in incidence-based cumulated breast cancer mortality before and after the introduction of screening was -15% (p = 0.006) for women aged 45-69, and 17% (p = 0.005) for those aged 50-64. Aggregate mortality declined by -34% (2005-13 compared with 1992-98) in the age group 50-64, and by -28% among women aged 45-49 and -25% among women aged 65-74. For women aged 50-64 the 2-joinpoint model shows a 1990 turning point, from prior rising mortality to a mean -1.8% decline per annum, coinciding with improvements in primary treatment of breast cancer; and a steepening of the decline (-3.0% p.a.) from the late 1990s, coinciding with the introduction of service mammography screening.

CONCLUSION

Breast cancer mortality declines occurring since the advent of screening mammography in New Zealand are consistent with other incidence-based and aggregate studies of screening mammography in populations, individual-based cohort studies, and randomized controlled trials.

Frequency and characteristics of contralateral breast abnormalities following recall at screening mammography

PURPOSE

To determine the frequency and characteristics of contralateral, non-recalled breast abnormalities following recall at screening mammography.

METHODS

We included a series of 130,338 screening mammograms performed between 1 January 2014 and 1 January 2016. During the 1-year follow-up, clinical data were collected for all recalls. Screening outcome was determined for recalled women with or without evaluation of contralateral breast abnormalities.

RESULTS

Of 3,995 recalls (recall rate 3.1%), 129 women (3.2%) underwent assessment of a contralateral, non-recalled breast abnormality. Most lesions were detected at clinical mammography and/or breast tomosynthesis (101 women, 78.3%). The biopsy rate was similar for recalled lesions and contralateral, non-recalled lesions, but the positive predictive value of biopsy was higher for recalled lesions (p = 0.01). A comparable proportion of the recalled lesions and contralateral, non-recalled lesions were malignant (p = 0.1). The proportion of ductal carcinoma in situ was similar for both groups, as well as invasive cancer characteristics and type of surgical treatment.

CONCLUSIONS

About 3% of recalled women underwent evaluation of contralateral, non-recalled breast lesions. Evaluation of the contralateral breast after recall is important as we found that 15.5% of contralateral, non-recalled lesions were malignant. Contralateral cancers and screen-detected cancers show similar characteristics, stage and surgical treatment.

KEY POINTS

• 3% of recalled women underwent evaluation of contralateral, non-recalled lesions • One out of seven contralateral, non-recalled lesions was malignant • A contralateral cancer was diagnosed in 0.5% of recalls • Screen-detected cancers and non-recalled, contralateral cancers showed similar histological characteristics • Tumour stage and surgical treatment were similar for both groups.

Is the incidence of advanced-stage breast cancer affected by whether women attend a steady-state screening program?

In this cross-sectional population-based study, we assessed the incidence of advanced breast cancer based on screening attendance. Women from the Netherlands Cancer Registry were included if aged ≥49 years and diagnosed with breast cancer between 2006 and 2011, and data were linked with the screening program. Cancers were defined as screen-related (diagnosed <24 months after screening) or nonscreened (all other breast cancers). Two cut-offs were used to define advanced breast cancer: TNM-stage (III-IV vs 0-I-II) and T-stage alone (≥15 mm vs <15 mm or DCIS). The incidence rates were adjusted for age and logistic regression was used to compare groups. Of the 72,612 included women diagnosed with breast cancer, 44,246 (61%) had screen-related breast cancer. By TNM stage, advanced cancer was almost three times as likely to be at an advanced TNM stage in the nonscreened group compared with the screen-related group (38 and 94 per 100,000, respectively; OR: 2.86, 95%CI: 2.72-3.00). By T-stage, the incidence of advanced cancer was higher overall, and in nonscreened women was significantly higher than in screened women (210 and 169 per 100,000; OR: 1.85, 95%CI: 1.78-1.93). Data on actual screening attendance showed that the incidence of advanced breast cancer was significantly higher in nonscreened women than in screened women, supporting the expectation that screening would cause a stage shift to early detection. Despite critical evaluations of breast cancer screening programs, our data show that breast cancer screening is a valuable tool that can reduce the disease burden in women.

Breast Imaging Outcomes following Abnormal Thermography

RATIONALE AND OBJECTIVES

The study aimed to determine the outcome of patients presenting for evaluation of abnormal breast thermography.

MATERIALS AND METHODS

Following Institutional Review Board approval, retrospective search identified 38 patients who presented for conventional breast imaging following a thermography-detected abnormality. Study criteria included women who had mammogram and/or breast ultrasound performed for evaluation of a thermography-detected abnormality between January 1, 2000, and December 31, 2015. Patients whose mammograms and ultrasounds were initiated at an outside institution or who did not have imaging at our institution were excluded. Records were reviewed for clinical history, thermography results, mammogram and/or ultrasound findings, and pathology. Mammograms and ultrasounds were prospectively interpreted by one of 14 Mammography Quality Standards Act-certified breast imaging radiologists with 3-30 years of experience. Patient outcomes were determined by biopsy or at least 1 year of follow-up. Patient ages ranged from 23 to 70 years (mean = 50 years).

RESULTS

Ninety-five percent (36 of 38) of patients did not have breast cancer. The two patients diagnosed with breast cancer had suspicious clinical symptoms including palpable mass and erythema. No asymptomatic woman had breast cancer. Negative predictive value was 100%. Of 38 patients, 79% (30 of 38) had Breast Imaging Reporting and Data System (BI-RADS) 1 or 2 assessments; 5% (2 of 38) had BI-RADS 3; and 16% (6 of 38) had BI-RADS 4 (n = 5) or BI-RADS 5 (n = 1) assessments. Two of six patients with biopsy recommendations were diagnosed with breast cancer (Positive predictive value 2 = 33.3%). All findings recommended for biopsy were ipsilateral to the reported thermography abnormality.

CONCLUSIONS

No cancer was diagnosed among asymptomatic women. The 5% of patients diagnosed with cancer had co-existing suspicious clinical findings. Mammogram and/or ultrasound were useful in accurately characterizing patients with abnormal thermography.

Preliminary Results of a New Auxiliary Mechatronic Near-Field Radar System to 3D Mammography for Early Detection of Breast Cancer

Accurate and early detection of breast cancer is of high importance, as it is directly associated with the patients’ overall well-being during treatment and their chances of survival. Uncertainties in current breast imaging methods can potentially cause two main problems: (1) missing newly formed or small tumors; and (2) false alarms, which could be a source of stress for patients. A recent study at the Massachusetts General Hospital (MGH) indicates that using Digital Breast Tomosynthesis (DBT) can reduce the number of false alarms, when compared to conventional mammography. Despite the image quality enhancement DBT provides, the accurate detection of cancerous masses is still limited by low radiological contrast (about 1%) between the fibro-glandular tissue and affected tissue at X-ray frequencies. In a lower frequency region, at microwave frequencies, the contrast is comparatively higher (about 10%) between the aforementioned tissues; yet, microwave imaging suffers from low spatial resolution. This work reviews conventional X-ray breast imaging and describes the preliminary results of a novel near-field radar imaging mechatronic system (NRIMS) that can be fused with the DBT, in a co-registered fashion, to combine the advantages of both modalities. The NRIMS consists of two antipodal Vivaldi antennas, an XY positioner, and an ethanol container, all of which are particularly designed based on the DBT physical specifications. In this paper, the independent performance of the NRIMS is assessed by (1) imaging a bearing ball immersed in sunflower oil and (2) computing the heat Specific Absorption Rate (SAR) due to the electromagnetic power transmitted into the breast. The preliminary results demonstrate that the system is capable of generating images of the ball. Furthermore, the SAR results show that the system complies with the standards set for human trials. As a result, a configuration based on this design might be suitable for use in realistic clinical applications.

Shifting breast cancer surveillance from current hospital setting to a community based setting: a cost-effectiveness study

BACKGROUND

This study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP).

METHODS

Using a decision tree, strategies were compared on effectiveness and costs from a healthcare perspective over a 5-year time horizon. Women aged 50-75 without distant metastases that underwent breast conserving surgery in 2003-2006 were selected from the Netherlands Cancer Registry (n = 14,093). Key input parameters were mammography sensitivity and specificity, risk of loco regional recurrence (LRR), and direct healthcare costs. Primary outcome measure was the proportion true test results (TTR), expressed as the positive and negative predictive value (PPV, NPV). The incremental cost-effectiveness ratio (ICER) is defined as incremental costs per TTR forgone.

RESULTS

For the NBCSP-strategy, 13,534 TTR (8 positive; 13,526 negative), and 12,923 TTR (387 positive; 12,536 negative) were found for low and high risks respectively. For the hospital-based strategy, 26,663 TTR (13 positive; 26,650 negative) and 24,883 TTR (440 positive; 24,443 negative) were found for low and high risks respectively. For low risks, the PPV and NPV for the NBCSP-based strategy were 3.31% and 99.88%, and 2.74% and 99.95% for the hospital strategy respectively. For high risks, the PPV and NPV for the NBCSP-based strategy were 64.10% and 98.87%, and 50.98% and 99.71% for the hospital-based strategy respectively. Total expected costs of the NBCSP-based strategy were lower than for the hospital-based strategy (low risk: €1,271,666 NBCSP vs €2,698,302 hospital; high risk: €6,939,813 NBCSP vs €7,450,150 hospital), rendering ICERs that indicate cost savings of €109 (95%CI €95-€127) (low risk) and €43 (95%CI €39-€56) (high risk) per TTR forgone.

CONCLUSION

Despite expected cost-savings of over 50% in the NBCSP-based strategy, it is nearly 50% lower accurate than the hospital-based strategy, compromising the goal of early detection of LRR to an extent that is unlikely to be acceptable.

Incidence and tumour characteristics of bilateral and unilateral interval breast cancers at screening mammography

BACKGROUND

Detected by screening mammography, bilateral breast cancer has a different pathological profile compared to unilateral breast cancer. We investigated the incidence of bilateral interval breast cancers and compared their characteristics with those of unilateral interval breast cancers.

METHODS

We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all referred women and of all women who presented with interval breast cancer. The tumour with the highest tumour stage (index cancer) was used for comparison with unilateral interval cancers.

RESULTS

A total of 753 interval cancers were detected, of which 24 (3.2%) were bilateral. Among the invasive interval cancers, bilateral cancers more frequently showed a lobular histology than unilateral cancers (37.5% (9/24) vs. 16.1% (111/691), P = .01). There is a trend towards a larger proportion of bilateral than unilateral interval cancers graded 1 (45.8% (11/24) vs. 27.8% (192/691), P = .08). There were no other statistically significant differences in tumour characteristics. Also, the proportion of interval cancers showing significant mammographic abnormalities at the latest screen was comparable for unilateral and bilateral interval cancers (23.0% vs. 25.0%, P = .9).

DISCUSSION

Bilateral interval cancers comprise a small proportion of all interval cancers. Except of a higher proportion of invasive lobular cancers and a more favourable histological grade of invasive cancers, tumour characteristics are comparable for bilateral and unilateral interval breast cancers.

Breast cancer screening: Where have we been and where are we going? A personal perspective based on history, data and experience

It is important to understand the history of breast cancer screening to better understand the continuing effort to reduce access to screening. Since the randomized, controlled trials have shown a statistically significant mortality reduction for women ages 40-74, the appropriate threshold for initiating screening is age 40 with no data to support the use of the age of 50 as a threshold for screening. All women are at risk for developing breast cancer and all women should have access to screening.

Mammography screening: A major issue in medicine

Breast cancer mortality is declining in most high-income countries. The role of mammography screening in these declines is much debated. Screening impacts cancer mortality through decreasing the incidence of number of advanced cancers with poor prognosis, while therapies and patient management impact cancer mortality through decreasing the fatality of cancers. The effectiveness of cancer screening is the ability of a screening method to curb the incidence of advanced cancers in populations. Methods for evaluating cancer screening effectiveness are based on the monitoring of age-adjusted incidence rates of advanced cancers that should decrease after the introduction of screening. Likewise, cancer-specific mortality rates should decline more rapidly in areas with screening than in areas without or with lower levels of screening but where patient management is similar. These two criteria have provided evidence that screening for colorectal and cervical cancer contributes to decreasing the mortality associated with these two cancers. In contrast, screening for neuroblastoma in children was discontinued in the early 2000s because these two criteria were not met. In addition, overdiagnosis - i.e. the detection of non-progressing occult neuroblastoma that would not have been life-threatening during the subject's lifetime - is a major undesirable consequence of screening. Accumulating epidemiological data show that in populations where mammography screening has been widespread for a long time, there has been no or only a modest decline in the incidence of advanced cancers, including that of de novo metastatic (stage IV) cancers at diagnosis. Moreover, breast cancer mortality reductions are similar in areas with early introduction and high penetration of screening and in areas with late introduction and low penetration of screening. Overdiagnosis is commonplace, representing 20% or more of all breast cancers among women invited to screening and 30-50% of screen-detected cancers. Overdiagnosis leads to overtreatment and inflicts considerable physical, psychological and economic harm on many women. Overdiagnosis has also exerted considerable disruptive effects on the interpretation of clinical outcomes expressed in percentages (instead of rates) or as overall survival (instead of mortality rates or stage-specific survival). Rates of radical mastectomies have not decreased following the introduction of screening and keep rising in some countries (e.g. the United States of America (USA)). Hence, the epidemiological picture of mammography screening closely resembles that of screening for neuroblastoma. Reappraisals of Swedish mammography trials demonstrate that the design and statistical analysis of these trials were different from those of all trials on screening for cancers other than breast cancer. We found compelling indications that these trials overestimated reductions in breast cancer mortality associated with screening, in part because of the statistical analyses themselves, in part because of improved therapies and underreporting of breast cancer as the underlying cause of death in screening groups. In this regard, Swedish trials should publish the stage-specific breast cancer mortality rates for the screening and control groups separately. Results of the Greater New York Health Insurance Plan trial are biased because of the underreporting of breast cancer cases and deaths that occurred in women who did not participate in screening. After 17 years of follow-up, the United Kingdom (UK) Age Trial showed no benefit from mammography screening starting at age 39-41. Until around 2005, most proponents of breast screening backed the monitoring of changes in advanced cancer incidence and comparative studies on breast cancer mortality for the evaluation of breast screening effectiveness. However, in an attempt to mitigate the contradictions between results of mammography trials and population data, breast-screening proponents have elected to change the criteria for the evaluation of cancer screening effectiveness, giving precedence to incidence-based mortality (IBM) and case-control studies. But practically all IBM studies on mammography screening have a strong ecological component in their design. The two IBM studies done in Norway that meet all methodological requirements do not document significant reductions in breast cancer mortality associated with mammography screening. Because of their propensity to exaggerate the health benefits of screening, case-control studies may demonstrate that mammography screening could reduce the risk of death from diseases other than breast cancer. Numerous statistical model approaches have been conducted for estimating the contributions of screening and of patient management to reductions in breast cancer mortality. Unverified assumptions are needed for running these models. For instance, many models assume that if screening had not occurred, the majority of screen-detected asymptomatic cancers would have progressed to symptomatic advanced cancers. This assumption is not grounded in evidence because a large proportion of screen-detected breast cancers represent overdiagnosis and hence non-progressing tumours. The accumulation of population data in well-screened populations diminishes the relevance of model approaches. The comparison of the performance of different screening modalities - e.g. mammography, digital mammography, ultrasonography, magnetic resonance imaging (MRI), three-dimensional tomosynthesis (TDT) - concentrates on detection rates, which is the ability of a technique to detect more cancers than other techniques. However, a greater detection rate tells little about the capacity to prevent interval and advanced cancers and could just reflect additional overdiagnosis. Studies based on the incidence of advanced cancers and on the evaluation of overdiagnosis should be conducted before marketing new breast-imaging technologies. Women at high risk of breast cancer (i.e. 30% lifetime risk and more), such as women with BRCA1/2 mutations, require a close breast surveillance. MRI is the preferred imaging method until more radical risk-reduction options are eventually adopted. For women with an intermediate risk of breast cancer (i.e. 10-29% lifetime risk), including women with extremely dense breast at mammography, there is no evidence that more frequent mammography screening or screening with other modalities actually reduces the risk of breast cancer death. A plethora of epidemiological data shows that, since 1985, progress in the management of breast cancer patients has led to marked reductions in stage-specific breast cancer mortality, even for patients with disseminated disease (i.e. stage IV cancer) at diagnosis. In contrast, the epidemiological data point to a marginal contribution of mammography screening in the decline in breast cancer mortality. Moreover, the more effective the treatments, the less favourable are the harm-benefit balance of screening mammography. New, effective methods for breast screening are needed, as well as research on risk-based screening strategies.

Potential Use of American College of Radiology BI-RADS Mammography Atlas for Reporting and Assessing Lesions Detected on Dedicated Breast CT Imaging: Preliminary Study

RATIONALE AND OBJECTIVES

Dedicated breast computed tomography (DBCT) is an emerging and promising modality for breast lesions. The objective of this study was to evaluate the potential use of applying the BI-RADS Mammography Atlas 5th Edition for reporting and assessing breast lesions on DBCT. Currently, no atlas exists for DBCT.

MATERIALS AND METHODS

Four radiologists trained in breast imaging were recruited in this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study. The enrolled radiologists, who were blinded to mammographic and histopathologic findings, individually reviewed 30 randomized DBCT cases that contained marked lesions. Thirty-four lesions were included in this study: 24 (70.6%) masses, 7 (20.6%) calcifications, and 3 (8.8%) architectural distortions. Eight (23.5%) lesions were malignant and 26 (76.5%) were benign. The reader was asked to specify according to the BI-RADS Mammography Atlas for each marked DBCT lesion: primary findings, features, breast density, and final assessment. We calculated readers' diagnostic performances for differentiating between benign and malignant lesions and interobserver variability for reporting and assessing lesions using a generalized estimating equation and the Fleiss kappa (κ) statistic.

RESULTS

The estimated overall sensitivity of the readers was 0.969, and the specificity was 0.529. There were no significant differences in the sensitivity and the specificity between lesion types. For reporting the presence of a primary finding, the overall substantial agreement (κ = 0.70) was seen. In assigning the breast density and the final assessment, the overall agreement was moderate (κ = 0.53) and fair (κ = 0.30).

CONCLUSION

The use of the BI-RADS Mammography Atlas 5th Edition for DBCT showed high performance and good agreement among readers.

Harms of Restrictive Risk-Based Mammographic Breast Cancer Screening

OBJECTIVE

The objective of this study was to determine if restrictive risk-based mammographic screening could miss breast cancers that population-based screening could detect.

MATERIALS AND METHODS

Through a retrospective search of records at a single institution, we identified 552 screen-detected breast cancers in 533 patients. All in situ and invasive breast cancers detected at screening between January 1, 2011, and December 31, 2014, were included. Medical records were reviewed for history, pathology, cancer size, nodal status, breast density, and mammographic findings. Mammograms were interpreted by one of 14 breast imaging radiologists with 3-30 years of experience, all of whom were certified according to the Mammography Quality Standards Act. Patient ages ranged from 36 to 88 years (mean, 61 years). The breast cancer risks evaluated were family history of breast cancer and dense breast tissue. Positive family history was defined as a first-degree relative with breast cancer. Dense breast parenchyma was either heterogeneously or extremely dense.

RESULTS

Group 1 consisted of the 76.7% (409/533) of patients who had no personal history of breast cancer. Of these patients, 75.6% (309/409) had no family history of breast cancer, and 56% (229/409) had nondense breasts. Group 2 consisted of the 16.7% (89/533) of patients who were 40-49 years old. Of these patients, 79.8% (71/89) had no family history of breast cancer, and 30.3% (27/89) had nondense breasts. Ductal carcinoma in situ made up 34.6% (191/552) of the cancers; 65.4% (361/552) were invasive. The median size of the invasive cancers was 11 mm. Of the screen-detected breast cancers, 63.8% (352/552) were minimal cancers.

CONCLUSION

Many screen-detected breast cancers occurred in women without dense tissue or a family history of breast cancer. Exclusive use of restrictive risk-based screening could result in delayed cancer detection for many women.

The effect of population-based mammography screening in Dutch municipalities on breast cancer mortality: 20 years of follow-up

Long-term follow-up data on the effects of screening are scarce, and debate exists on the relative contribution of screening versus treatment to breast cancer mortality reduction. Our aim was therefore to assess the long-term effect of screening by age and time of implementation. We obtained data on 69,630 breast cancer deaths between 1980 and 2010 by municipality (N = 431) and age of death (40-79) in the Netherlands. Breast cancer mortality trends were analyzed by defining the municipality-specific calendar year of introduction of screening as Year 0. Additionally, log-linear Poisson regression was used to estimate the turning point in the trend after Year 0, per municipality, and the annual percentage change (APC) before and after this point. Twenty years after introduction of screening breast cancer mortality was reduced by 30% in women aged 55-74 and by 34% in women aged 75-79, compared to Year 0. A similar and significant decrease was present in municipalities that started early (1987-1992) and late (1995-1997) with screening, despite the difference in availability of effective adjuvant treatment. In the age groups 55-74 and 75-79, the turning point in the trend in breast cancer mortality was estimated in Years 2 and 6 after the introduction of screening, respectively, after which mortality decreased significantly by 1.9% and 2.6% annually. These findings show that the implementation of mammography screening in Dutch municipalities is associated with a significant decline in breast cancer mortality in women aged 55-79, irrespective of time of implementation.

Mammography Positioning Standards in the Digital Era: Is the Status Quo Acceptable?

OBJECTIVE

The objective of our study was to evaluate positioning of full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT) compared with film-screen (FS) mammography positioning standards.

MATERIALS AND METHODS

A retrospective study was conducted of consecutive patients who underwent screening FFDM in 2010-2012 and DBT in 2012-2013 at an academic institution. Examinations were performed by five experienced technologists who underwent updated standardized positioning training. Positioning criteria were assessed by consensus reads among three breast radiologists and compared with FS mammography data from a 1993 study by Bassett and colleagues.

RESULTS

One hundred seventy patients (n = 340 examinations) were analyzed, showing significant differences between FFDM and DBT examinations (p < 0.05) for medial or inferior skin folds (FFDM vs DBT: craniocaudal [CC] view, 16% [n = 56] vs 23% [n = 77]; mediolateral oblique [MLO] view, 35% [n = 118] vs 45% [n = 154]), inclusion of lateral glandular tissue on CC view (FFDM vs DBT, 73% [n = 247] vs 81% [n = 274]), and concave pectoralis muscle shape (FFDM vs DBT, 36% [n = 121] vs 28% [n = 95]). In comparison with Bassett et al. data, all positioning criteria for both FFDM and DBT examinations were significantly different (p < 0.05). The largest differences were found in visualization of the pectoralis muscle on CC views and the inframammary fold on MLO views, inclusion of posterior or lateral glandular tissue, and inclusion of skin folds, with DBT and FFDM more frequently exhibiting all criteria than originally reported Bassett et al.

FINDINGS

CONCLUSION

DBT and FFDM mammograms more frequently include posterior or lateral tissue, the inframammary fold on MLO views, the pectoralis muscle on CC views, and skin folds than FS mammograms. Inclusion of more breast tissue with newer technologies suggests traditional positioning standards, in conjunction with updated standardized positioning training, are still applicable at the expense of including more skin folds.

The Long-Term Effectiveness and Cost Effectiveness of Organized versus Opportunistic Screening for Breast Cancer in Austria

BACKGROUND

In 2014, Austrian health authorities implemented an organized breast cancer screening program. Until then, there has been a long-standing tradition of opportunistic screening.

OBJECTIVES

To evaluate the cost-effectiveness of organized screening compared with opportunistic screening, as well as to identify factors influencing the clinical and economic outcomes.

METHODS

We developed and validated an individual-level state-transition model and assessed the health outcomes and costs of organized and opportunistic screening for 40-year-old asymptomatic women. The base-case analysis compared a scenario involving organized biennial screening with a scenario reflecting opportunistic screening practice for an average-risk woman aged 45 to 69 years. We applied an annual discount rate of 3% and estimated the incremental cost-effectiveness ratio in terms of the cost (2012 euros) per life-year gained (LYG) from a health care perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared with opportunistic screening, an organized program yielded on average additional 0.0118 undiscounted life-years (i.e., 4.3 days) and cost savings of €41 per woman. In the base-case analysis, the incremental cost-effectiveness ratio of organized screening was approximately €20,000 per LYG compared with no screening. Assuming a willingness-to-pay threshold of €50,000 per LYG, there was a 70% probability that organized screening would be considered cost-effective. The attendance rate, but not the test accuracy of mammography, was an influential factor for the cost-effectiveness.

CONCLUSIONS

The decision to adopt organized screening is likely an efficient use of limited health care resources in Austria.

The Effect of Electronic Health Record Use and Patient-Centered Communication on Cancer Screening Behavior: An Analysis of the Health Information National Trends Survey

The present study used the 2013 Health Information National Trends Survey (N = 3185) to examine the effects of patient-centered communication (PCC) and the use of electronic health records (EHRs) on the likelihood of patients receiving a recommended screening for cancer (i.e., mammogram, PSA test). Self-determination theory, a framework of self-initiated extrinsic behaviors, was applied to test mediation models of PCC and EHR use, respectively, through patient activation. The results demonstrated that PCC and EHR use predicted cancer screening (mediated through patient activation), but only for women recommended for biannual mammograms. The aforementioned relationship was not found for men who are recommended for prostate cancer screening. PCC and EHRs do appear to facilitate a patient's ability to take care of their own health, but only under certain circumstances. It was additionally found that men were more likely to report higher degrees of physician PCC when their physicians maintained an EHR, whereas women reported no difference. Future research should examine more nuanced personality factors that affect the perception of PCC in the presence of EHRs and the relationship between men's activation and likelihood of receiving a cancer screen.

Cost-Effectiveness of Breast Cancer Screening in Turkey, a Developing Country: Results from Bahçeşehir Mammography Screening Project

OBJECTIVE

We used the results from the first three screening rounds of Bahcesehir Mammography Screening Project (BMSP), a 10-year (2009-2019) and the first organized population-based screening program implemented in a county of Istanbul, Turkey, to assess the potential cost-effectiveness of a population-based mammography screening program in Turkey.

MATERIALS AND METHODS

Two screening strategies were compared: BMSP (includes three biennial screens for women between 40-69) and Turkish National Breast Cancer Registry Program (TNBCRP) which includes no organized population-based screening. Costs were estimated using direct data from the BMSP project and the reimbursement rates of Turkish Social Security Administration. The life-years saved by BMSP were estimated using the stage distribution observed with BMSP and TNBCRP.

RESULTS

A total of 67 women (out of 7234 screened women) were diagnosed with breast cancer in BMSP. The stage distribution for AJCC stages O, I, II, III, IV was 19.4%, 50.8%, 20.9%, 7.5%, 1.5% and 4.9%, 26.6%, 44.9%, 20.8%, 2.8% with BMSP and TNBCRP, respectively. The BMSP program is expected to save 279.46 life years over TNBCRP with an additional cost of $677.171, which implies an incremental cost-effectiveness ratio (ICER) of $2.423 per saved life year. Since the ICER is smaller than the Gross Demostic Product (GDP) per capita in Turkey ($10.515 in 2014), BMSP program is highly cost-effective and remains cost-effective in the sensitivity analysis.

CONCLUSION

Mammography screening may change the stage distribution of breast cancer in Turkey. Furthermore, an organized population-based screening program may be cost-effective in Turkey and in other developing countries. More research is needed to better estimate life-years saved with screening and further validate the findings of our study.