Mammography service screening and breast cancer mortality in New Zealand: a National Cohort Study 1999-2011

Breast Cancer Screening Interval: Effect on Rate of Late-Stage Disease at Diagnosis and Overall Survival

PURPOSE

Controversy continues regarding the effect of screening mammography on breast cancer outcomes. We evaluated late-stage cancer rate and overall survival (OS) for different screening intervals using a real-world institutional research data mart.

METHODS

Patients having both a cancer registry record of new breast cancer diagnosis and prediagnosis screening history between 2004 and 2019 were identified from our institutional research breast data mart. Time interval between the two screening mammograms immediately preceding diagnosis and the time to cancer diagnosis were determined. Screening interval was deemed annual if ≤15 months, biennial if >15 and ≤27 months, intermittent if >27 months, and baseline if only one prediagnosis screen was known. The primary end point was late-stage cancer (TNM stage IIB or worse), and the secondary end point was OS. The association of screening interval and late-stage cancer was analyzed using multivariable logistic regression adjusting for prediagnosis characteristics. Proportional hazards regression was used for survival analysis. Potential lead time was analyzed using survival from a uniform fixed time point.

RESULTS

In total, 8,145 patients with breast cancer had prediagnosis screening mammography in the timeframe. The percentage of late-stage cancers diagnosed increased significantly with screening interval with 9%, 14%, and 19% late stages for annual, biennial, and intermittent groups (P < .001), respectively. The trend persisted regardless of age, race, and menopausal status. Biennial and intermittent groups had substantially worse OS than the annual screened group, with relative hazards of 1.42 (95% CI, 1.11 to 1.82) and 2.69 (95% CI, 2.11 to 3.43), respectively, and 1.39 (95% CI, 1.08 to 1.78) and 2.01 (95% CI, 1.58 to 2.55) after adjustment for potential lead time.

CONCLUSION

Annual mammographic screening was associated with lower risk of late-stage cancer and better OS across clinical and demographic subgroups. Our study suggests benefit of annual screening for women 40 years and older.

Targeted Screening for Cancer: Learnings and Applicability to Melanoma: A Scoping Review

This scoping review aims to systematically gather evidence from personalized cancer-screening studies across various cancers, summarize key components and outcomes, and provide implications for a future personalized melanoma-screening strategy. Peer-reviewed articles and clinical trial databases were searched for, with restrictions on language and publication date. Sixteen distinct studies were identified and included in this review. The studies' results were synthesized according to key components, including risk assessment, risk thresholds, screening pathways, and primary outcomes of interest. Studies most frequently reported about breast cancers (n = 7), followed by colorectal (n = 5), prostate (n = 2), lung (n = 1), and ovarian cancers (n = 1). The identified screening programs were evaluated predominately in Europe (n = 6) and North America (n = 4). The studies employed multiple different risk assessment tools, screening schedules, and outcome measurements, with few consistent approaches identified across the studies. The benefit-harm assessment of each proposed personalized screening program indicated that the majority were feasible and effective. The establishment of a personalized screening program is complex, but results of the reviewed studies indicate that it is feasible, can improve participation rates, and screening outcomes. While the review primarily examines screening programs for cancers other than melanoma, the insights can be used to inform the development of a personalized melanoma screening strategy.

Effect of screening mammography on the risk of breast cancer deaths and of all-cause deaths: a systematic review with meta-analysis of cohort studies

OBJECTIVES

Observational cohort studies are used to evaluate the effectiveness of screening mammography in women offered screening. Because screening mammography has no effect on causes of death other than breast cancer (BC), cohort studies should show reductions in the risk of BC death substantially greater than possible reductions in the risk of all-cause death. We assessed the risk of BC deaths and of all-cause (or of nonBC) deaths associated with screening mammography attendance reported in cohort studies.

STUDY DESIGN AND SETTING

Cohort studies published from 2002 to 2022 on women invited to screening mammography were searched in PubMed, Web of Sciences, Scopus, and in review articles. Random effect meta-analyses were performed using relative risks (RRs) of death between women who attended screening compared to women who did not attend screening.

RESULTS

Eighteen cohort studies were identified, nine that reported RRs of BC deaths only, five that reported RRs of all-cause deaths only, and four that reported RRs for both BC deaths and all-cause deaths. The latter four cohort studies reported 12-76 times more all-cause deaths than BC deaths. The random-effect summary of RR for BC mortality in screening attendees vs nonattendees was 0.55 (95% CI: 0.50-0.60) in 13 cohort studies. The summary of RR for all-cause mortality was 0.54 (0.50-0.58) in 10 cohort studies. In the four cohort studies that evaluated both outcomes, the summary of RRs were 0.63 (0.43-0.83) for BC mortality and of 0.54 (0.44-0.64) for all-cause mortality.

CONCLUSION

The similar relative reductions in breast- and all-cause (or nonBC) mortality indicates that screening mammography attendance is an indicator of characteristics associated with a lower risk of dying from any cause, including from BC, which observational studies have falsely interpreted as a screening effect.

The Role of MRI in Assessing Residual Breast Cancer After Neoadjuvant Chemotherapy

INTRODUCTION

Breast cancer is the most common malignancy among women in the world. The role of neoadjuvant chemotherapy (NAC) in the management of breast cancer is increasing. The decision about the management after NAC depends mainly on the tumor response to NAC.

OBJECTIVES

The role of the current study is to evaluate the role of the MRI scan in assessing the residual disease after NAC, which would help in decision making regarding the best treatment plan for the patient.

PATIENTS AND METHODS

We did this retrospective review for all patients who were diagnosed with breast cancer in our center and had NAC over four years. All patients in our study had a post-NAC magnetic resonance imaging (MRI) scan to assess the residual tumor size. A 2×2 table was used to calculate the diagnostic accuracy, and SPSS software version 25 was used to get the correlation coefficients between the post-NAC MRI measurements and pathological size.

RESULTS

28 female patients were included in our study. The average age was 45.25 ± 10 years. We utilized the tumor size on histology as the standard for comparison. We calculated MRI sensitivity, specificity, PPV, and NPV rates of 90.9%, 100%, 100%, and 94.4%, respectively. The correlation coefficient was strong (r = 0.859, P = 0.01).

CONCLUSION

Magnetic resonance imaging is a good test to assess the residual tumor disease after NAC in breast cancer patients. However, cases of under- and overestimation are still seen, which require more caution when making a decision regarding the management of such cases.

Breast Cancer Risk Assessment and Screening Practices Reported Via an Online Survey

BACKGROUND

Breast cancer screening guidelines differ between organizations, and significant variations in practice patterns exist. Previous evidence suggests that provider-level factors are the greatest contributors to risk assessment and screening practice variability. This study aimed to characterize provider factors associated with breast cancer risk assessment and screening practice patterns, and to assess perceived barriers to providing risk assessment.

METHODS

An online survey was distributed to providers at a single academic institution and to providers publicly via social media (January to August 2022). Respondents in the United States who care for adult women at risk for the development of breast cancer were included.

RESULTS

Most of the respondents in the 143 completed surveys were white/Caucasian (79%) females (90%) age 50 years or younger (79%), and whereas 97% discuss breast cancer screening with their patients, only 90% order screening mammograms. Risk factor assessment was common (93%), typically performed at the first visit (51%). Additional training in genetics or risk assessment was uncommon (17%), although the majority were interested but did not have the time or resources (55%). Although most (64%) did not perceive barriers to providing risk assessment or appropriate screening, the most common barriers were time (77%) and education (55%). Barriers were more common among family practice or obstetrics and gynecology (OB/GYN) providers and those who worked in an academic setting (all p < 0.05).

CONCLUSIONS

Breast cancer risk assessment and screening practices are highly variable. Although time is the major barrier to providing risk assessment, providers also need education. Primary care organizations could partner with breast cancer-focused societies for additional resources.

Multicenter, Multivendor Validation of an FDA-approved Algorithm for Mammography Triage

OBJECTIVE

Artificial intelligence (AI)-based triage algorithms may improve cancer detection and expedite radiologist workflow. To this end, the performance of a commercial AI-based triage algorithm on screening mammograms was evaluated across breast densities and lesion types.

METHODS

This retrospective, IRB-exempt, multicenter, multivendor study examined 1255 screening 4-view mammograms (400 positive and 855 negative studies). Images were anonymized by providing institutions and analyzed by a commercially available AI algorithm (cmTriage, CureMetrix, La Jolla, CA) that performed retrospective triage at the study level by flagging exams as "suspicious" or not. Sensitivities and specificities with confidence intervals were derived from area under the curve (AUC) calculations.

RESULTS

The algorithm demonstrated an AUC of 0.95 (95% CI: 0.94-0.96) for case identification. Area under the curve held across densities (0.95) and lesion types (masses: 0.94 [95% CI: 0.92-0.96] or microcalcifications: 0.97 [95% CI: 0.96-0.99]). The algorithm has a default sensitivity of 93% (95% CI: 95.6%-90.5%) with specificity of 76.3% (95% CI: 79.2%-73.4%). To evaluate real-world performance, a sensitivity of 86.9% (95% CI: 83.6%-90.2%) was tested, as observed for practicing radiologists by the Breast Cancer Surveillance Consortium (BCSC) study. The resulting specificity was 88.5% (95% CI: 86.4%-90.7%), similar to the BCSC specificity of 88.9%, indicating performance comparable to real-world results.

CONCLUSION

When tested for lesion detection, an AI-based triage software can perform at the level of practicing radiologists. Drawing attention to suspicious exams may improve reader specificity and help streamline radiologist workflow, enabling faster turnaround times and improving care.

The Benefits of Early Detection: Evidence From Modern International Mammography Service Screening Programs

Research from randomized controlled trials initiated up to 60 years ago consistently confirms that regular screening with mammography significantly reduces breast cancer mortality. Despite this success, there is ongoing debate regarding the efficacy of screening, which is confounded by technologic advances and concerns about cost, overdiagnosis, overtreatment, and equitable care of diverse patient populations. More recent screening research, designed to quell the debates, derives data from variable study designs, each with unique strengths and weaknesses. This article reviews observational population-based screening research that has followed the early initial long-term randomized controlled trials that are no longer practical or ethical to perform. The advantages and disadvantages of observational data and study design are outlined, including the three subtypes of population-based observational studies: cohort/case-control, trend, and incidence-based mortality/staging. The most recent research, typically performed in countries that administer screening mammography to women through centralized health service programs and directly track patient-specific outcomes and detection data, is summarized. These data are essential to understand and inform construction of effective new databases that facilitate continuous assessment of optimal screening techniques in the current era of rapidly developing medical technology, combined with a focus on health care that is both personal and equitable.

Advances in breast cancer screening modalities and status of global screening programs

Breast cancer (BC) is the most prevalent malignancy worldwide, and a continued upward trend has been predicted in the coming decades. Screening in selected targeted populations, which is effective in reducing cancer-related mortality, has been widely implemented in many countries. This review summarizes the advances in BC screening techniques, organized or opportunistic BC screening programs across different countries, and screening modalities recommended by different academic authorities. Mammography is the most widely used and effective technique for BC screening. Other complementary techniques include ultrasound, clinical breast examination, and magnetic resonance imaging. Novel screening tests, including digital breast tomosynthesis and liquid biopsies, are still under development. Globally, the implementation status of BC screening programs is uneven, which is reflected by differences in screening modes, techniques, and population coverage. The recommended optimal screening strategies varied according to the authoritative guidelines. The effectiveness of current screening programs is influenced by several factors, including low detection rate, high false-positive rate, and unsatisfactory coverage and uptake rates. Exploration of accurate BC risk prediction models and the development of risk-stratified screening strategies are highly warranted in future research.

Nationwide mammographic screening and breast cancer mortality in Taiwan: an interrupted time-series analysis

BACKGROUND

In Taiwan, breast cancer is the third leading cause of cancer death in women. A nationwide screening program with biennial mammography for women aged 40-69 in Taiwan was implemented since July 2004, but the impact on breast cancer mortality has not been investigated.

METHODS

The interrupted time-series analysis was used to estimate the impact of mammographic screening on temporal trends of breast cancer mortality and to calculate the level of temporal changes due to the mammographic screening.

RESULTS

The annual average percentage changes of the age-standardized breast cancer mortality rates for all women aged 40-69 were 1.06% from 1991 to 2004 (before mammographic screening) and 0.33-0.34% from 2005 to 2019 (after mammographic screening). For all women aged 40-69, the results of interrupted time-series analysis showed that the increasing trends of breast cancer mortality were all attenuated after the implementation of mammographic screening. An estimation of 2114 women prevented from death of breast cancer may be attributable to screening. For women aged 40-44, 55-59, 60-64 and 65-69, the percentage changes in mortality rates were - 12.1% (- 5.1 to - 19.6%), - 20.8% (- 16.5 to - 25.2%), - 12.8% (- 8.5 to - 17.3%) and - 13.0% (- 7.9 to - 18.3%), respectively, after screening. For women aged 45-49 and 50-54, the reduction of deaths and mortality rates of breast cancer were a little.

CONCLUSIONS

This study revealed that the nationwide screening program with biennial mammography may be associated with the attenuation of breast cancer mortality trends in women aged 40-69 in Taiwan.

Comparison of the sensitivity of mammography, ultrasound, magnetic resonance imaging and combinations of these imaging modalities for the detection of small (≤2 cm) breast cancer

The aim of this study was to compare the sensitivity of mammography (MG), ultrasound (US), magnetic resonance imaging (MRI), and combinations of these imaging modalities for the detection of small (≤2 cm) breast cancer and to evaluate the benefit of preoperative breast MRI after performing conventional imaging techniques for small breast cancer.This was an observational retrospective review of 475 patients with pathologically confirmed breast cancer. We reviewed the medical records; assessed the preoperative reports of MG, US, and MRI; and categorized them as benign features (BI-RADS 1-3) or malignant features (BI-RADS 4 or 5). The criterion standard for detection was the pathologic assessment of the surgical specimen. The sensitivities of the different techniques were compared using the McNemar test.Among the 475 women, the sensitivity of MG was significantly greater in patients with low breast density than in those with high breast density (84.5% vs 65.8%, P < .001). US had higher sensitivity than MG (P < .001), and the combination of MG + US showed better sensitivity than MG or US alone (P < .001). Further addition of MRI to the combination of MG and US statistically contributed to the sensitivity yield (from 93.3% to 98.2%; P < .001) but did not significantly increase the mastectomy rate (from 48.2% to 49.3%; P = .177).MG has limited diagnostic sensitivity in patients with small breast cancer, especially in those with dense breast tissue. US is better than MG at detecting small breast cancer, regardless of breast density. The addition of MRI to MG and US could increase sensitivity without increasing the mastectomy rate. This study suggests performing MRI routinely on the basis of MG and US for small (≤2 cm) breast cancer.

Effect of mammography screening and sociodemographic factors on stage of female breast cancer at diagnosis in New South Wales

Objective The aims of this study were to assess the effects of screening through BreastScreen NSW on the stage of cancer at diagnosis, and differences in cancer stage at diagnosis according to sociodemographic factors. Methods Using linked BreastScreen NSW screening attendance records and NSW Cancer Registry data, the effects of screening participation and sociodemographic characteristics on stage at diagnosis were investigated using Kruskal-Wallis analysis of variance or the Mann-Whitney U-test for the 2002-13 diagnostic period. Multivariate logistic regression was used to investigate predictors of stage at diagnosis. Results The association between BreastScreen NSW participation and earlier stage at diagnosis was strongest when the last screening episode occurred within 24 months of the cancer diagnosis, with an odds ratio of localised versus non-localised cancer of 1.61 (95% confidence interval 1.51-1.72). Women aged ≥70 years, Aboriginal women, residents of major cities and women living in areas of socioeconomic disadvantage were more likely to have distant than non-distant stage at diagnosis. A trend towards more distant stage in more recent diagnostic years was evident after adjusting for screening participation. Conclusions The strongest and most consistent predictor of earlier stage at diagnosis was BreastScreen NSW participation. Continued efforts to increase screening participation are important to achieve earlier stage at diagnosis, particularly for sociodemographic groups with more advanced disease. What is known about the topic? Earlier cancer stage at diagnosis is a prerequisite for mortality reduction from screening. Past research indicated that screening participation in New South Wales (NSW) was strongly associated with early stage at diagnosis and mortality reduction. More contemporary data are needed to monitor screening performance in NSW and assess differences in cancer stage across sociodemographic subgroups. What does this paper add? Using data linkage, this paper indicates associations between screening, sociodemographic factors and stage at diagnosis for the NSW population in 2002-13. Contrary to expectations, major city residents tended to have a lower proportion of early stage breast cancer at diagnosis, which may be indicative of lower screening coverage and barriers to screening. Compared with past research, similar effects of screening and other sociodemographic factors on the stage of breast cancer at diagnosis were observed. This paper compares screening histories across sociodemographic groups, indicating statistically significant differences. What are the implications for practitioners? Increasing screening participation is particularly important for sociodemographic groups who are diagnosed at more advanced stages, including women from lower socioeconomic areas, Aboriginal and Torres Strait Islander women and residents of major cities. In particular, the results reinforce the need to further develop targeted strategies to increase screening participation among NSW women from lower socioeconomic areas and Aboriginal and Torres Strait Islander women. Further investigation into screening coverage and barriers to screening for residents in major cities is needed.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Breast cancer screening adherence rates and barriers of implementation in ethnic, cultural and religious minorities: A systematic review

Breast cancer is the most common cancer affecting women worldwide. Adherence to breast cancer screening guidelines is frequently lower in racial, ethnic and cultural minority populations and is affected by potential inequities or barriers to screening that these minorities face. Therefore, the aim of the present study was to collect information from different minority groups worldwide, assess adherence to breast cancer screening and evaluate barriers or limitations causing non-adherence, which should facilitate the development of effective interventions. A search was conducted through PubMed and Web of Science. Studies were considered as eligible if they met the following criteria: i) Female patients; ii) breast cancer screening program implemented in the country; iii) minority groups; iv) asymptomatic; v) report written in Portuguese or English; vi) study published from 2015 onwards. The Critical Appraisal Skills Programme checklist was used for qualitative studies and the Strengthening The Reporting of Observational Studies in Epidemiology checklist for cross-sectional studies. From the 348 initial articles, 86 were removed due to duplication and 19 were selected, analyzed and summarized, accordingly. Of the 19 studies included, 5.3% were classified as high quality, 52.6% as moderate to high and 42.1% as moderate. A total of 15 studies were cross-sectional and 4 were qualitative, collectively including 250,733 women. The rate of adherence to mammogram in different minorities was evaluated, obtaining a mean value of 49.7% in the last 2 years, and statistically significant barriers were selected and divided into sociodemographic; personal; ethnic, cultural and religious; and external factors. The characteristics of each population play a major role in the population's breast health practices. If the population, adherence rates, barriers and inequities are carefully studied, screening models may be customized and participation to breast cancer screening can be optimized, thereby reducing the high breast cancer-associated mortality.

Beneficial Effect of Consecutive Screening Mammography Examinations on Mortality from Breast Cancer: A Prospective Study

Background Previously, the risk of death from breast cancer was analyzed for women participating versus those not participating in the last screening examination before breast cancer diagnosis. Consecutive attendance patterns may further refine estimates. Purpose To estimate the effect of participation in successive mammographic screening examinations on breast cancer mortality. Materials and Methods Participation data for Swedish women eligible for screening mammography in nine counties from 1992 to 2016 were linked with data from registries and regional cancer centers for breast cancer diagnosis, cause, and date of death (Uppsala University ethics committee registration number: 2017/147). Incidence-based breast cancer mortality was calculated by whether the women had participated in the most recent screening examination prior to diagnosis only (intermittent participants), the penultimate screening examination only (lapsed participants), both examinations (serial participants), or neither examination (serial nonparticipants). Rates were analyzed with Poisson regression. We also analyzed incidence of breast cancers proving fatal within 10 years. Results Data were available for a total average population of 549 091 women (average age, 58.9 years ± 6.7 [standard deviation]). The numbers of participants in the four groups were as follows: serial participants, 392 135; intermittent participants, 41 746; lapsed participants, 30 945; and serial nonparticipants, 84 265. Serial participants had a 49% lower risk of breast cancer mortality (relative risk [RR], 0.51; 95% CI: 0.48, 0.55; P < .001) and a 50% lower risk of death from breast cancer within 10 years of diagnosis (RR, 0.50; 95% CI: 0.46, 0.55; P < .001) than serial nonparticipants. Lapsed and intermittent participants had a smaller reduction. Serial participants had significantly lower risk of both outcomes than lapsed or intermittent participants. Analyses correcting for potential biases made little difference to the results. Conclusion Women participating in the last two breast cancer screening examinations prior to breast cancer diagnosis had the largest reduction in breast cancer death. Missing either one of the last two examinations conferred a significantly higher risk. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Stephen A. Feig in this issue.

Beliefs, fear and awareness of women about breast cancer: Effects on mammography screening practices

AIM

This study sought to investigate the beliefs, fear and awareness about breast cancer and mammography screening practices of women in Iran.

METHODS

This descriptive-correlational study was conducted at Tabriz, East Azerbaijan Province, northwest of Iran from February-July 2017. One hundred and fifty-two women aged 40 years and older, who were referred to 12 health centres for health services were selected via clustering sampling. Associations between variables and mammography screening practices were examined using bivariate and multivariate logistic regression analyses. Participants who had a mammogram within the last 24 months were compared with those who had none. Sociodemographic questionnaire, Champion's Breast Cancer Fear Scale, Champion's Health Belief Model Scale for Mammography Screening, Breast Cancer Awareness Scale and Powe Fatalism Inventory were the tools used for data gathering.

RESULTS

Just 38.2% of women reported having a mammogram within the last 24 months. Self-efficacy (OR = 5.36, B = 1.68, p < .001), susceptibility (OR = 2.83, B = 1.04, p < .001), motivation (OR = 2.11, B = 0.75, p = .024) and lower perceived barriers (OR = 0.25, B = -1.37, p < .001) were associated with being screened. Neither fatalistic belief nor awareness towards breast cancer was significant.

A Validation of Methods for the Evaluation of Observational Studies of Screening Mammography: An Exploratory Analysis Based on Simulating Screening Cohorts

Background

The degree of confidence one should place on non-randomised observational trials studies which estimate the benefit of screening depends on the validity of the analytic method employed. As is the case for all observational trials, screening evaluation studies are subject to bias. The objective of this study was to create a simulated data set and to compare four analytic methods in order to identify the method which was the least biased in terms of estimating the underlying hazard ratio.

Methods

We simulated a cohort of 100,000 women who were accorded US national rates of breast cancer incidence and breast cancer mortality over their lifetime. We assigned at random one-half of them to initiate mammography screening between ages 50 and 60. We used four different analytic approaches to estimate the hazard ratio under a null model (true HR = 1.0) and under a protective model (true HR = 0.80). Two models used the entire data set (with and without including mammography as a time-dependent covariate) and two models invoked matching of screened women with unscreened women (with and without excluding of women who had a mammogram after study initiation). For each of the four analytic methods, we compared the observed hazard ratio with the true hazard ratio. We considered an analytic method to be valid if the observed hazard ratio was close to the true hazard ratio.

Results

Two simple analytic methods generated biased results that led to spurious protective effects observed when none was there. The least biased method was based on matching screened and unscreened women and which emulated a randomized trial design, wherein the unexposed control had no mammogram prior to study entry, but she was not excluded or censored if she had a mammogram after the index date.

Conclusion

There is no single ideal method to analyze observational data to evaluate the effectiveness of screening mammography (ie, which generates an unbiased estimates of the underlying hazard ratio) but designs which emulate randomised trials should be promoted.

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.

Monitoring and evaluation of breast cancer screening programmes: selecting candidate performance indicators

BACKGROUND

In the scope of the European Commission Initiative on Breast Cancer (ECIBC) the Monitoring and Evaluation (M&E) subgroup was tasked to identify breast cancer screening programme (BCSP) performance indicators, including their acceptable and desirable levels, which are associated with breast cancer (BC) mortality. This paper documents the methodology used for the indicator selection.

METHODS

The indicators were identified through a multi-stage process. First, a scoping review was conducted to identify existing performance indicators. Second, building on existing frameworks for making well-informed health care choices, a specific conceptual framework was developed to guide the indicator selection. Third, two group exercises including a rating and ranking survey were conducted for indicator selection using pre-determined criteria, such as: relevance, measurability, accurateness, ethics and understandability. The selected indicators were mapped onto a BC screening pathway developed by the M&E subgroup to illustrate the steps of BC screening common to all EU countries.

RESULTS

A total of 96 indicators were identified from an initial list of 1325 indicators. After removing redundant and irrelevant indicators and adding those missing, 39 candidate indicators underwent the rating and ranking exercise. Based on the results, the M&E subgroup selected 13 indicators: screening coverage, participation rate, recall rate, breast cancer detection rate, invasive breast cancer detection rate, cancers > 20 mm, cancers ≤10 mm, lymph node status, interval cancer rate, episode sensitivity, time interval between screening and first treatment, benign open surgical biopsy rate, and mastectomy rate.

CONCLUSION

This systematic approach led to the identification of 13 BCSP candidate performance indicators to be further evaluated for their association with BC mortality.

Effects of a WhatsApp-Delivered Education Intervention to Enhance Breast Cancer Knowledge in Women: Mixed-Methods Study

Background

Breast cancer is the leading cause of cancer-related death in the female population. Health education interventions based on the use of mobile technologies enable the development of health self-care skills and have emerged as alternative strategies for the control of breast cancer. In previous studies, WhatsApp has stood out as a useful tool in health education strategies; however, it has not yet been applied for breast cancer education.

Objective

This study aimed to analyze the potential of WhatsApp as a health education tool used to improve women's knowledge on the risk reduction of breast cancer. It also aimed to understand how women feel sensitized within the WhatsApp group throughout the intervention and how they incorporate information posted to improve knowledge about early detection and risk reduction methods.

Methods

The study involved a pre-post health educational intervention with 35 women (aged 45-69 years) included in a WhatsApp group to share information (audio, video, text, and images) over 3 weeks on the early detection and risk reduction of breast cancer. Data were collected through questionnaires on topics related to risk reduction, as well as qualitative content analysis of group interactions. Effectiveness and feasibility were analyzed through conversations and the comparison of the scores obtained in the questionnaires before and after the intervention.

Results

A total of 293 messages were exchanged (moderator 120 and users 173). The average scores of the participants were 11.21 and 13.68 points before and after the educational intervention, respectively, with sufficient sample evidence that the difference was significant (P<.001). The intervention enabled women to improve their knowledge on all topics addressed, especially “myths and truths,” “incidence,” “clinical manifestations,” and “protective factors.” Some themes emerged from the interactions in the group, including group dynamics, general doubts, personal narratives, religious messages, daily news, and events.

Conclusions

The use of groups for women in WhatsApp for health education purposes seems to be a viable alternative in strategies on breast cancer control, especially as it provides a space for the exchange of experiences and disinhibition. However, the need for a moderator to answer the questions and the constant distractions by members of the group represent important limitations that should be considered when improving this strategy.

Impact of mammographic screening and advanced cancer definition on the percentage of advanced-stage cancers in a steady-state breast screening programme in the Netherlands

Background

To estimate the percentages of advanced-stage breast cancers (BCs) detected during the course of a steady-state screening programme when using different definitions of advanced BC.

Methods

Data of women aged 49–74 years, diagnosed with BC in 2006–2015, were selected from the Netherlands Cancer Registry and linked to the screening registry. BCs were classified as screen-detected, interval or non-screened. Three definitions of advanced BC were used for comparison: TNM stage (III–IV), NM stage (N+ and/or M+) and T size (invasive tumour ≥15 mm). Analyses were performed assuming a 10% overdiagnosis rate. In sensitivity analyses, this assumption varied from 0 to 30%.

Results

We included 46,734 screen-detected, 17,362 interval and 24,189 non-screened BCs. By TNM stage, 4.9% of screen-detected BCs were advanced, compared with 19.4% and 22.8% of interval and non-screened BCs, respectively (p < 0.001). Applying the other definitions led to higher percentages of advanced BC being detected. Depending on the definition interval, non-screened BCs had a 2–5-times risk of being advanced.

Conclusion

Irrespective of the definition, screen-detected BCs were less frequently in the advanced stage. These findings provide evidence of a stage shift to early detection and support the potential of mammographic screening to reduce treatment-related burdens and the mortality associated with BC.

Worldwide Review and Meta-Analysis of Cohort Studies Measuring the Effect of Mammography Screening Programmes on Incidence-Based Breast Cancer Mortality

In 2012, the Euroscreen project published a review of incidence-based mortality evaluations of breast cancer screening programmes. In this paper, we update this review to October 2019 and expand its scope from Europe to worldwide. We carried out a systematic review of incidence-based mortality studies of breast cancer screening programmes, and a meta-analysis of the estimated effects of both invitation to screening and attendance at screening, with adjustment for self-selection bias, on incidence-based mortality from breast cancer. We found 27 valid studies. The results of the meta-analysis showed a significant 22% reduction in breast cancer mortality with invitation to screening, with a relative risk of 0.78 (95% CI 0.75-0.82), and a significant 33% reduction with actual attendance at screening (RR 0.67, 95% CI 0.61-0.75). Breast cancer screening in the routine healthcare setting continues to confer a substantial reduction in mortality from breast cancer.

Image Quality and Performance Benchmarks in Vehicle and Hospital Mammography

BACKGROUND

Whether the quality and clinical performance of mammograms obtained in vehicles and those obtained in fixed facilities are equal remains unknown. We compared the characteristics of examinees screened in hospital and vehicle settings.

PATIENTS AND METHODS

Data from women who had undergone mammography at Shuang Ho Hospital from January 1, 2013, to December 31, 2016, were obtained from the Women's Breast Screening Database and used for analysis. The records revealed that 43,807 and 11,955 women had undergone mammography in vehicle and hospital settings, respectively. The performance benchmarks, including recall rate, cancer detection rate, and positive predictive value, in the 2 settings were compared. In addition, the image quality was compared by reviewing 110 records from each setting.

RESULTS

The hospital mammograms had greater subtotal mean scores (189.2 ± 5.9) compared with the vehicle mammograms (185.5 ± 7.7; P < .0001) in the mediolateral oblique view. Mobile mammography contributed to a lower odds ratio of classification in the Breast Imaging Reporting and Data System categories of 0, 4, and 5. In general, all performance benchmarks, including the cancer detection rate and positive predictive value of mobile and hospital mammography, were satisfactory. However, the recall rate with the hospital mammography service was slightly greater than the acceptable benchmark.

CONCLUSION

Mobile mammography services should be continued with improvements in image quality. The reduction in the number of patients with a category of 0 in the classification system in both mammography service settings and the enhancement of data linking to previous mammograms warrants additional attention.

Factors associated with readmissions in women participating in screening programs and treated for breast cancer: a retrospective cohort study

Background

We aimed to identify the risk factors associated with early, late and long-term readmissions in women diagnosed with breast cancer participating in screening programs.

Methods

We performed a multicenter cohort study of 1055 women aged 50–69 years participating in Spanish screening programs, diagnosed with breast cancer between 2000 and 2009, and followed up to 2014. Readmission was defined as a hospital admission related to the disease and/or treatment complications, and was classified as early (< 30 days), late (30 days-1 year), or long-term readmission (> 1 year). We used logistic regression to estimate the adjusted odds ratios (aOR), and 95% confidence intervals (95% CI) to explore the factors associated with early, late and long-term readmissions, adjusting by women’s and tumor characteristics, detection mode, treatments received, and surgical and medical complications.

Results

Among the women included, early readmission occurred in 76 (7.2%), late readmission in 87 (8.2%), long-term readmission in 71 (6.7%), and no readmission in 821 (77.8%). Surgical complications were associated with an increased risk of early readmissions (aOR = 3.62; 95%CI: 1.27–10.29), and medical complications with late readmissions (aOR = 8.72; 95%CI: 2.83–26.86) and long-term readmissions (aOR = 4.79; 95%CI: 1.41–16.31).

Conclusion

Our results suggest that the presence of surgical or medical complications increases readmission risk, taking into account the detection mode and treatments received. Identifying early complications related to an increased risk of readmission could be useful to adapt the management of patients and reduce further readmissions.

Trial Registration

ClinicalTrials.govIdentifier: NCT03165006. Registration date: May 22, 2017 (Retrospectively registered).

Outcomes in different ethnic groups of New Zealand patients with screen-detected vs. non-screen-detected breast cancer

Objective

To compare characteristics and survival of New Zealand European, Māori, and Pacific women with screen-detected vs. non-screen-detected breast cancer.

Methods

Women aged 45–69 diagnosed with invasive breast cancer between January 2005 and May 2013 were identified from the Waikato and Auckland Breast Cancer Registries. Patient demographics and tumour characteristics were described by detection mode and ethnicity. Kaplan–Meier method was used to estimate the five-year breast cancer-specific survival of women with stage I–III breast cancer by ethnicity and detection mode.

Results

Women with screen-detected cancers were older, had smaller tumours, fewer stage IV (0.8% vs. 7.6%), fewer high grade (16.8% vs. 39.0%), and fewer lymph node positive diseases (26.3% vs. 51.5%) than women with non-screen-detected cancers. There were more Luminal A (70.0% vs. 54.0%), fewer human epidermal growth factor receptor 2 positive non-Luminal (4.4% vs. 8.8%), and fewer triple negative cases (7.0% vs. 13.8%) in screen-detected than non-screen-detected cancers. If not screen detected, 22.7% of breast cancers in Pacific women were stage IV compared with 2.4% if screen detected. If not screen detected, the five-year breast cancer-specific survival was 91.1% for New Zealand European women, 84.2% for Māori women, and 80.2% for Pacific women (p-value <0.001). For screen-detected breast cancer, survival between different ethnic groups was similar.

Conclusions

Breast cancers detected through screening are diagnosed at an earlier stage and have a greater proportion of subtypes, with better outcome. Variations in survival for Māori and Pacific women are only found in women with non-screen-detected breast cancer.

A new approach for detecting abnormalities in mammograms using a computer-aided windowing system based on Otsu's method

Breast cancer is the most common cancer and the leading cause of cancer deaths in women worldwide. This study aimed to provide an automatic windowing method in mammograms, based on the principles of Otsu's thresholding function, to help radiologists more easily detect abnormalities on mammograms. A total of 322 mammographic images from the Mammographic Image Analysis Society (MIAS) database were used in the present study. The image background was removed based on Otsu's method. After selecting the threshold in the computer-aided windowing (CAW) system, the pixel values were kept larger than the threshold and displayed on a grayscale. A radiologist evaluated images randomly before and after CAW. Using CAW, the radiologist correctly diagnosed all healthy images (207 images). A total of 115 mammograms were evaluated to differentiate malignancy from benign masses. All 63 benign images were accurately diagnosed after using CAW. Moreover, of 52 malignant images, all were accurately recognized as malignant except one, which was recognized as benign. Therefore, specificity and sensitivity were significantly improved to 98% and 99.6%, respectively, and the area under the receiver operating characteristic (ROC) curve was calculated to be 0.99. The study showed that the use of CAW can potentially lead to quicker image assessment and improve the diagnostic accuracy of radiologists in differentiating between benign and malignant masses on mammograms.

Observer Variability in Breast Cancer Diagnosis between Countries with and without Breast Screening

RATIONAL AND OBJECTIVES

Image reporting is a vital component of patient management depending on individual radiologists' performance. Our objective was to explore mammographic diagnostic efficacy in a country where breast cancer screening does not exist.

MATERIALS AND METHODS

Two mammographic test sets were used: a typical screening (TS) and high-difficulty (HD) test set. Nonscreening (NS) radiologists (n = 11) read both test sets, while 52 and 49 screening radiologists read the TS and HD test sets, respectively. The screening radiologists were classified into two groups: a less experienced (LE) group with ≤5 years' experience and a more experienced (ME) group with ≥5 years' experience. A Kruskal-Wallis and Tukey-Kramer post hoc test were used to compare reading performance among reader groups, and the Wilcoxon matched pairs tests was used to compare TS and ND test sets for the NS radiologists.

RESULTS

Across the three reader groups, there were significant differences in case sensitivity (χ² [2] = 9.4, P = .008), specificity (χ² [2] = 10.3, P = .006), location sensitivity (χ² [2] = 19.8, P < .001), receiver operating characteristics, area under the curve (χ² [2] = 19.7, P < .001) and jack-knife free-response receiver operating characteristics (JAFROCs) (χ² [2] = 18.1, P < .001). NS performance for all measured scores was significantly lower than those for the ME readers (P < .006), while only location sensitivity was lower (χ² [2] = 17.5, P = .026) for the NS compared to the LE group. No other significant differences were observed.

CONCLUSION

Large variations in mammographic performance exist between radiologists from screening and nonscreening countries.

The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening

Background

Women and their health care providers need a reliable answer to this important question: If a woman chooses to participate in regular mammography screening, then how much will this choice improve her chances of avoiding a death from breast cancer compared with women who choose not to participate?

Methods

To answer this question, we used comprehensive registries for population, screening history, breast cancer incidence, and disease‐specific death data in a defined population in Dalarna County, Sweden. The annual incidence of breast cancer was calculated along with the annual incidence of breast cancers that were fatal within 10 and within 11 to 20 years of diagnosis among women aged 40 to 69 years who either did or did not participate in mammography screening during a 39‐year period (1977‐2015). For an additional comparison, corresponding data are presented from 19 years of the prescreening period (1958‐1976). All patients received stage‐specific therapy according to the latest national guidelines, irrespective of the mode of detection.

Results

The benefit for women who chose to participate in an organized breast cancer screening program was a 60% lower risk of dying from breast cancer within 10 years after diagnosis (relative risk, 0.40; 95% confidence interval, 0.34‐0.48) and a 47% lower risk of dying from breast cancer within 20 years after diagnosis (relative risk, 0.53; 95% confidence interval, 0.44‐0.63) compared with the corresponding risks for nonparticipants.

Conclusions

Although all patients with breast cancer stand to benefit from advances in breast cancer therapy, the current results demonstrate that women who have participated in mammography screening obtain a significantly greater benefit from the therapy available at the time of diagnosis than do those who have not participated.

After 20 years of follow‐up, women who participate in mammography screening have a 47% lower risk of dying from breast cancer. Although all patients with breast cancer potentially can benefit from advances in breast cancer therapy, women who participate in mammography screening obtain a significantly greater benefit from the therapy available at the time of diagnosis than those who do not participate.

Gendered and racialized social expectations, barriers, and delayed breast cancer diagnosis

BACKGROUND

Black women are more likely to be diagnosed at a later stage of breast cancer in part due to barriers to timely screening mammography, resulting in poorer mortality and survival outcomes. Patient navigation that helps to overcome barriers to the early detection of breast cancer is an effective intervention for reducing breast cancer disparity. However, the ability to recognize and seek help to overcome barriers may be affected by gendered and racialized social expectations of women.

METHODS

Data from a randomized controlled trial, the Patient Navigation in Medically Underserved Areas study, were used. The likelihood of obtaining a follow-up screening mammogram was compared between women who identified ≥1 barriers and those who did not.

RESULTS

Of the 3754 women who received the Patient Navigation in Medically Underserved Areas navigation intervention, approximately 14% identified ≥ 1 barriers, which led to additional navigator contacts. Consequently, those women who reported barriers were more likely to obtain a subsequent screening mammogram. Black women, women living in poverty, and women with a higher level of distrust were less likely to report barriers.

CONCLUSIONS

Minority women living in poverty have always been the source of social support for others. However, gendered and racialized social expectations may affect the ways in which women seek help for their own health needs. A way to improve the effectiveness of navigation would be to recognize how minority women's gender images and expectations could shape how they seek help and support. A report of no barriers does not always translate into no problems. Proactive approaches to identify potential barriers may be beneficial.

Absence of sustained breast cancer incidence inflation in a national mammography screening programme

OBJECTIVE

To investigate the impact of population mammography screening on breast cancer incidence trends in New Zealand.

METHODS

Trends in age-specific rates of invasive breast cancer incidence (1994-2014) were assessed in relation to screening in women aged 50-64 from 1999 and 45-69 following the programme age extension in mid-2004.

RESULTS

Breast cancer incidence increased significantly by 18% in women aged 50-64 compared with 1994-98 (p<0.0001), coinciding with the 1999 introduction of mammography screening, and remained elevated for four years, before declining to pre-screening levels. Increases over 1994-99 incidence occurred in the 45-49 (21%) and 65-69 (19%) age groups following the 2004 age extension (p<0.0001). Following establishment of screening (2006-10), elevated incidence in the screening target age groups was compensated for by lower incidence in the post-screening ⩾70 age groups than in 1994-98. Incidence in women aged ⩾45 was not significantly higher (+5%) after 2006 than in 1994-98. The cumulated risk of breast cancer in women aged 45-84 for 1994-98 was 10.7% compared with 10.8% in 2006-10.

CONCLUSIONS

Increases in breast cancer incidence following introduction of mammography screening in women aged 50-64 did not persist. Incidence inflation also occurred after introduction of screening for age groups 45-49 and 65-69. The cumulated incidence for women aged 45-84 over 2006-10 after screening was well established, compared with 1994-98 prior to screening, shows no increase in diagnosis. Over-diagnosis is not inevitable in population mammography screening programmes.

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.

Short- and Long-Term (10-year) Results of an Organized, Population-Based Breast Cancer Screening Program: Comparative, Observational Study from Hungary

BACKGROUND

A nationwide breast cancer screening program was introduced in Hungary in the year 2002 for women aged 45-65 years to be performed biannually.

METHODS

To investigate and report the short-term and 10-year follow-up results, we analyzed our Breast Unit's prospectively led database of screened (Group A) and age-matched symptomatic (Group B) patients from 2002 to 2007. We compared the clinicopathologic features of tumors and the impact of screening on surgical treatment, as well as the overall (OS), disease-specific (DSS) and disease-free survival (DFS) of different groups.

RESULTS

Data from 208 screen-detected and 101 symptomatic patients between 45 and 65 years of age were examined. Screen-detected women were younger (54 vs. 58.5 years; p = 0.001) had significantly smaller tumors (15.5 vs. 17 mm; p = 0.044), and more breast-conserving surgery (68.8 vs. 59.4%; p = 0.032). Survival statistics were not statistically different at the median follow-up of 123 months; however, there was a trend toward improved DFS in Group A (82.7 vs. 74.3%; p = 0.074).

CONCLUSIONS

Our study showed a significant reduction in rates of mastectomy in the screen-detected group in the short term, which does not translate into better survival rates based on initial long-term data. In order to realize the real advantage of this newly enstated screening program, a longer period of investigation is needed.