Mastectomy rates are decreasing in the era of service screening: a population-based study in Italy (1997-2001)

USPSTF Recommendations and Overdiagnosis

Overdiagnosis is the concept that some cancers detected at screening would never have become clinically apparent during a woman's lifetime in the absence of screening. This could occur if a woman dies of a cause other than breast cancer in the interval between mammographic detection and clinical detection (obligate overdiagnosis) or if a mammographically detected breast cancer fails to progress to clinical presentation. Overdiagnosis cannot be measured directly. Indirect methods of estimating overdiagnosis include use of data from randomized controlled trials (RCTs) designed to evaluate breast cancer mortality, population-based screening studies, or modeling. In each case, estimates of overdiagnosis must consider lead time, breast cancer incidence trends in the absence of screening, and accurate and predictable rates of tumor progression. Failure to do so has led to widely varying estimates of overdiagnosis. The U.S. Preventive Services Task Force (USPSTF) considers overdiagnosis a major harm of mammography screening. Their 2024 report estimated overdiagnosis using summary evaluations of 3 RCTs that did not provide screening to their control groups at the end of the screening period, along with Cancer Intervention and Surveillance Network modeling. However, there are major flaws in their evidence sources and modeling estimates, limiting the USPSTF assessment. The most plausible estimates remain those based on observational studies that suggest overdiagnosis in breast cancer screening is 10% or less and can be attributed primarily to obligate overdiagnosis and nonprogressive ductal carcinoma in situ.

The impact of the COVID-19 pandemic in the clinical assistance to breast cancer patients

PURPOSE

We aimed to disclose the impact of the pandemic on breast cancer patients in a specialized breast cancer center (BCC).

METHODS

A total of 501 breast cancer patients with a first appointment in the BCC from April 1st, 2019 to March 31st, 2021 were divided into four consecutive periods of 6 months. Data from the homologous semesters was compared. Patients with an appointment in the BCC during the study period were eligible for the secondary aim of our study (BCC workload).

RESULTS

After the pandemic declaration (period 3), we found a decrease in the referral by screening programs (p = 0.002) and a reduction in the waiting time between the primary care referral and the first BCC appointment (p < 0.001). There were higher rates of palpable axillary nodes (p = 0.001), an increase in N stage 2 and 3 (p = 0.050), and a trend for primary endocrine therapy as the first treatment (p = 0.021) associated with higher rates of complete axillary node dissection (p = 0.030). In period 4, there were more outward diagnoses (p = 0.003) and a higher rate of surgery as the first treatment (p = 0.013).

CONCLUSION

COVID-19 pandemic implied a more advanced nodal stage, which may be related to the delay in breast cancer screening.

Initial and ten-year treatment patterns among 11,000 breast cancer patients undergoing breast surgery-an analysis of German claims data

BACKGROUND

We aimed to explore the potential of German claims data for describing initial and long-term treatment patterns of breast cancer patients undergoing surgery.

METHODS

Using the German Pharmacoepidemiological Research Database (GePaRD, ~ 20% of the German population) we included patients with invasive breast cancer diagnosed in 2008 undergoing breast surgery and followed them until 2017. We described initial and long-term treatment patterns and deaths. Analyses were stratified by stage (as far as available in claims data), age at diagnosis, and mode of detection (screen-detected vs. interval vs. unscreened cases).

RESULTS

The cohort comprised 10,802 patients. The proportion with neoadjuvant therapy was highest in patients < 50 years (19% vs. ≤ 8% at older ages). The proportion initiating adjuvant chemotherapy within four months after diagnosis decreased with age (< 50 years: 63%, 50-69: 46%, 70-79: 27%, 80 + : 4%). Among women < 69 years, ~ 30% had two breast surgeries in year one (70-79: 21%, 80 + : 14%). Treatment intensity was lower for screen-detected compared to interval or unscreened cases, both in year one (e.g., proportion with mastectomy ~ 50% lower) and within 2-10 years after surgery (proportions with radiotherapy or chemotherapy about one third lower each).

CONCLUSIONS

This study illustrates the potential of routine data to describe breast cancer treatment and provided important insights into differences in initial and long-term treatment by mode of detection and age.

Screening is associated with lower mastectomy rates in eastern Switzerland beyond stage effects

Background

A recent study found an influence of organized mammography screening programmes (MSPs) on geographical and temporal variation of mastectomy rates. We aimed to quantify the effect on the example of one of the cantonal programmes in Switzerland.

Methods

We used incidence data for the years 2010–2017 from the cancer registry of Eastern Switzerland. We included women with invasive-non-metastatic breast cancer (BC) in the screening age group 50–69-year-olds in the canton of St.Gallen. We compared mastectomy rates among cancer patients detected through the organised screening programme (MSP) vs. otherwise detected by stage.

Results

MSP-detected patients in St.Gallen presented with lower stages. 95% of MSP-detected had stages I-II vs 76% of Non-MSP-detected. Within all non-metastatic stage, tumour size and nodal status groups, MSP-detected patients had lower mastectomy rates, overall 10% vs 24% in 50–69-year-old non-participants. Their odds of receiving a mastectomy are about half of the Non-MSP-detected (OR = 0.48, p = 0.002).

Conclusions

Our study showed that MSPs have a positive effect on lowering mastectomy rates. Screening participants are significantly less likely to receive a mastectomy compared to non-participants, which must be attributed to additional factors than just lower stages. Lower mastectomy rates lead to a higher quality of life for many patients.

Do we still need breast cancer screening in the era of targeted therapies and precision medicine?

Breast cancer (BC) is the most common female cancer and the second cause of death among women worldwide. The 5-year relative survival rate recently improved up to 90% due to increased population coverage and women's attendance to organised mammography screening as well as to advances in therapies, especially systemic treatments. Screening attendance is associated with a mortality reduction of at least 30% and a 40% lower risk of advanced disease. The stage at diagnosis remains the strongest predictor of recurrences. Systemic treatments evolved dramatically over the last 20 years: aromatase inhibitors improved the treatment of early-stage luminal BC; targeted monoclonal antibodies changed the natural history of anti-human epidermal growth factor receptor 2-positive (HER2) disease; immunotherapy is currently investigated in patients with triple-negative BC; gene expression profiling is now used with the aim of personalising systemic treatments. In the era of precision medicine, it is a challenging task to define the relative contribution of early diagnosis by screening mammography and systemic treatments in determining BC survival. Estimated contributions before 2000 were 46% for screening and 54% for treatment advances and after 2000, 37% and 63%, respectively. A model showed that the 10-year recurrence rate would be 30% and 25% using respectively chemotherapy or novel treatments in the absence of screening, but would drop to 19% and 15% respectively if associated with mammography screening. Early detection per se has not a curative intent and systemic treatment has limited benefit on advanced stages. Both screening mammography and systemic therapies continue to positively contribute to BC prognosis.

Current controversies in breast cancer screening

Multiple large-scale, randomized controlled trials throughout the world have demonstrated screening mammography significantly reduces a woman's risk of dying from breast cancer. Despite the known mortality reduction, the perceived harms of mammography are weighed against the known value. Multiple national guidelines have moved away from recommending all women have annual screening mammograms beginning at age 40. Instead, many now encourage women at average risk for developing breast cancer to engage in shared decision-making with their providers, carefully weighing the perceived harms against the known benefits of mammography. These factors should be incorporated into the decision about when to begin and how often to screen. This paradigm shift has been particularly controversial as it relates to women in the 40-49-year age group, considering their incidence of breast cancer and therefore derived benefit of screening is lower, yet the breast cancers that do occur tend to be more aggressive and often require intensive therapy. Thus, debates ensue over the appropriate age at which to begin screening for breast cancer, how often screening should occur, and when to stop.

Use of Mastectomy for Overdiagnosed Breast Cancer in the United States: Analysis of the SEER 9 Cancer Registries

Aim

We investigated use of mastectomy as treatment for early breast cancer in the US and applied the resulting information to estimate the minimum and maximum rates at which mastectomy could plausibly be undergone by patients with overdiagnosed breast cancer. Little is currently known about overtreatments undergone by overdiagnosed patients.

Methods

In the US, screening is often recommended at ages ≥40. The study population was women age ≥40 diagnosed with breast cancer in the US SEER 9 cancer registries during 2013 (n=26,017). We evaluated first-course surgical treatments and their associations with case characteristics. Additionally, a model was developed to estimate probability of mastectomy conditional on observed case characteristics. The model was then applied to evaluate possible rates of mastectomy in overdiagnosed patients. To obtain minimum and maximum plausible rates of this overtreatment, we respectively assumed the cases that were least and most likely to be treated by mastectomy had been overdiagnosed.

Results

Of women diagnosed with breast cancer at age ≥40 in 2013, 33.8% received mastectomy. Mastectomy was common for most investigated breast cancer types, including for the early breast cancers among which overdiagnosis is thought to be most widespread: mastectomy was undergone in 26.4% of in situ and 28.0% of AJCC stage-I cases. These rates are substantively higher than in many European nations. The probability-based model indicated that between >0% and <18% of the study population could plausibly have undergone mastectomy for overdiagnosed cancer. This range reduced depending on the overdiagnosis rate, shrinking to >0% and <7% if 10% of breast cancers were overdiagnosed and >3% and <15% if 30% were overdiagnosed.

Conclusions

Screening-associated overtreatment by mastectomy is considerably less common than overdiagnosis itself but should not be assumed to be negligible. Screening can prompt or prevent mastectomy, and the balance of this harm-benefit tradeoff is currently unclear.

Reducing harms from treatment. Sixteen years of surgery of the axilla for screen-detected breast cancers in Italy

OBJECTIVES

Available evidence on axillary surgery has accumulated dramatically in the last two decades in favor of less invasive care. The aim of this paper is to study 16-years trends in the surgical management of the axilla in a large population-based data set of screen-detected breast cancers in Italy and to document at what extent recommendations have been adopted in actual clinical care.

MATERIAL AND METHODS

This is a retrospective cohort study documenting the surgical management of the axilla in primary breast cancer patients over time. We retrieved from the Italian database of screen-detected cancers 41213 cases diagnosed in women aged 50-69 between years 2000 and 2015 in twelve Italian Regions.

RESULTS

In pN0 cases, an increasing trend (p < 0.001) in the number of patients who received sentinel lymph node biopsy (SLNB) as the only axillary staging procedure was observed. In pN + cases SLNB was the only staging procedure in an increasing number of patients (p < 0.001) especially since the publication of the ACOSOG-Z0011 paper. In ductal carcinoma in situ (DCIS) SLNB was more frequent in mastectomies and in high grade and large lesions. However, 45% of low grade, small DCIS over the whole time period had some form of axillary surgery.

CONCLUSION

This large series of screen-detected cases documents a strong time trend in the direction of reducing axillary surgery and hence potential harms from treatment. The continuing practice of SLNB in low risk DCIS is of concern in an era of increasing awareness towards overdiagnosis and overtreatment.

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients

BACKGROUND

Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution.

METHODS

We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction.

RESULTS

A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma.

CONCLUSIONS

Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.

Efficacy of Disease Management Profiles. The Mammographic Screening Program of Lazio

Background

Screening programs are considered disease management profiles. The aim of the present study was to evaluate the efficacy of screening programs compared to regularly offered health care services, using early outcomes and process indicators.

Method

In the study period (1/7/99-30/6/01), six breast cancer screening programs were active in 12 health districts in the Lazio region of Italy. Screening histories of all the incident cases of women surgically treated for a breast neoplasm were reconstructed (not contacted, contacted, non-participants, participants). The subpopulations were then compared for the appropriateness of treatments received.

Results

We identified 3251 women who were treated for malignant neoplasms of the breast and 1562 treated for benign neoplasms. The incidence of malignant neoplasms was higher in the women contacted for screening (incidence rate ratio, 1.45; 95% CI, 1.32–1.60), and the incidence of treatment for non-malignancies was similar in the two populations (incidence rate ratio, 1.00: 95% CI, 0.86–1.16). The percentage of surgery for non-malignancies detected by screening was 16.7%, whereas among the cases diagnosed outside a screening program it was 33.8%. Of malignancies detected outside of screening, 16.6% had a surgical treatment that was too invasive, among the screen-detected malignancies the percentage fell to 11% (prevalence rate ratio, 0.66; 95% CI, 0.48–0.91). Women contacted for screening showed a higher incidence of localized and in situ tumors, whereas the incidence of non-localized and metastatic tumors was basically the same in the two groups.

Conclusions

The first round of screening programs led to more surgical interventions, a similar incidence of mastectomy and of interventions for benign neoplasm, but a lower incidence of unnecessary treatment.

European Code against Cancer, 4th Edition: Cancer screening

In order to update the previous version of the European Code against Cancer and formulate evidence-based recommendations, a systematic search of the literature was performed according to the methodology agreed by the Code Working Groups. Based on the review, the 4th edition of the European Code against Cancer recommends: "Take part in organized cancer screening programmes for: Bowel cancer (men and women); Breast cancer (women); Cervical cancer (women)." Organized screening programs are preferable because they provide better conditions to ensure that the Guidelines for Quality Assurance in Screening are followed in order to achieve the greatest benefit with the least harm. Screening is recommended only for those cancers where a demonstrated life-saving effect substantially outweighs the potential harm of examining very large numbers of people who may otherwise never have, or suffer from, these cancers, and when an adequate quality of the screening is achieved. EU citizens are recommended to participate in cancer screening each time an invitation from the national or regional screening program is received and after having read the information materials provided and carefully considered the potential benefits and harms of screening. Screening programs in the European Union vary with respect to the age groups invited and to the interval between invitations, depending on each country's cancer burden, local resources, and the type of screening test used For colorectal cancer, most programs in the EU invite men and women starting at the age of 50-60 years, and from then on every 2 years if the screening test is the guaiac-based fecal occult blood test or fecal immunochemical test, or every 10 years or more if the screening test is flexible sigmoidoscopy or total colonoscopy. Most programs continue sending invitations to screening up to the age of 70-75 years. For breast cancer, most programs in the EU invite women starting at the age of 50 years, and not before the age of 40 years, and from then on every 2 years until the age of 70-75 years. For cervical cancer, if cytology (Pap) testing is used for screening, most programs in the EU invite women starting at the age of 25-30 years and from then on every 3 or 5 years. If human papillomavirus testing is used for screening, most women are invited starting at the age of 35 years (usually not before age 30 years) and from then on every 5 years or more. Irrespective of the test used, women continue participating in screening until the age of 60 or 65 years, and continue beyond this age unless the most recent test results are normal.

Symptomatic breast cancer diagnosis and multimodal management in women aged 40 to 50 years; consequences of current mammographic screening programs

INTRODUCTION

Consensus exists that screening mammography is appropriate for women aged 50 to 69 years. However, the effectiveness of such screening for women aged 40 to 50 years is still questioned. The aim of our study was to analyze breast cancer management in the 40- to 50-year age group. We also wished to determine the proportion of patients with a significant family history and whether this was associated with more advanced disease.

PATIENTS AND METHODS

All female patients with primary breast cancer diagnosed between 40 and 50 years of age were included over a 4-year period. The database of the National Breast Cancer Research Institute was interrogated, and a chart and radiology review carried out to obtain relevant details of clinical presentation, family history, radiological findings, and treatments undertaken.

RESULTS

Three hundred thirty-four patients were diagnosed in this cohort during the study period. Twenty-two percent of those diagnosed had a family history of breast cancer with 1.8% having a genetically confirmed predisposition to breast cancer. A significant proportion of patients presented with advanced disease, with 50% of patients having nodal involvement and 3% who presented with distant metastases. The overall rate of mastectomy was 47%, with minimal variation between the surgeons who performed the surgeries. More than half of the patients in our analysis underwent axillary clearance (51%).

CONCLUSION

Our results indicate that a large proportion of patients in the 40- to 50-year age group presented with advanced disease and required aggressive surgical and adjuvant treatment. The presence of a family history did not identify a subgroup with more advanced disease at presentation.

Mammography Screening - as of 2013

Introduction: Since 2008 the German Mammography Screening Programme has been available throughout Germany to all women aged between 50 and 69. The programme strictly follows the European Guidelines. There are controversial discussions in the media as well as in the specialised press. Materials and Methods: Overview of the available data with regard to an evaluation of randomised studies and with regard to quality-assured screening programmes in accordance with EU Guidelines (including data from 18 screening countries). Results: Positive effects of screening: reduction in mortality, less invasive treatment. Negative effects: False-positive diagnoses and biopsy recommendations, so-called overdiagnoses, radiation dose. Limits of screening: Interval carcinomas, incomplete reduction in mortality. A mathematical synopsis of the latest publications from the European screening programmes with the diagnosis rates in Germany determined from > 4.6 million screening examinations produces the following: a total of 10 000 mammograms are created for 1000 women (P) taking part in the Mammography Screening Programme (each of whom undergoes 10 mammograms in 20 years). Overall, the risk of triggering breast cancer through a mammogram is very clearly below the annual natural risk of suffering from breast cancer. In the German screening, of these 1000 women, an average of 288 women are called back once in 20 years as a result of changes that are ultimately benign (< 3 % per cycle). Of these, 74 of the 288 women undergo a biopsy due to a benign change (false-positive biopsy recommendations, usually punch or vacuum biopsies). According to EUROSCREEN, 71 carcinomas develop among participants (56 are discovered in the screening, 15 in the interval), and 67 carcinomas among non-participants (N-P) (in some cases, several years later) during this period. The 4 additional diagnoses among the Ps are referred to as overdiagnoses, as they do not contribute to a reduction in mortality (these participants die beforehand from other causes of death). With regard to the carcinomas that concern the screening periods, 11 women out of 1000 die among the Ps; there are 19 deaths among the N-Ps (within the observation period plus follow-up period). Discussion: The false-positive rate is unavoidable, but is far lower with mammography screening than with other methods. Overdiagnoses are to be expected with any early detection. All calculations require assumptions and are therefore highly discrepant. They have very low evidence levels. The radiation dose should not be an argument against screening when applied correctly due to the very low risk and significant benefits. Interval carcinomas indicate the limits of a mammography screening programme. False-negatives only represent a subset of the interval carcinomas and are not to be equated with them. There is a very high evidence level for a significant reduction in mortality through mammography screening. For the first time, an independent expert commission has confirmed the results of the randomised studies and the statement of the WHO from 2002 and their further validity. Participants can expect a reduction in mortality of 30 %. Data from the current European screening programmes confirm a mortality reduction of 43 %, corresponding to 8/19 saved lives among 71 women with breast cancer or 1000 asymptomatic Ps. Many additional Ps benefit from less invasive treatment due to the early detection. Conclusions: As a result of the risk/benefit ratio, mammography screening should absolutely be recommended to asymptomatic women aged between 50-69. High importance is given to the provision of education for women by the treating gynaecologists as regards the opportunities for quality-assured early detection available to them in the healthcare system.

Factors predictive of immediate breast reconstruction following mastectomy for invasive breast cancer in Australia

PURPOSE

To investigate person, cancer and treatment determinants of immediate breast reconstruction (IBR) in Australia.

METHODS

Bi-variable and multi-variable analyses of the Quality Audit database.

RESULTS

Of 12,707 invasive cancers treated by mastectomy circa 1998-2010, 8% had IBR. This proportion increased over time and reduced from 29% in women below 30 years to approximately 1% in those aged 70 years or more. Multiple regression indicated that other IBR predictors included: high socio-economic status; private health insurance; being asymptomatic; a metropolitan rather than inner regional treatment centre; higher surgeon case load; small tumour size; negative nodal status, positive progesterone receptor status; more cancer foci; multiple affected breast quadrants; synchronous bilateral cancer; not having neo-adjuvant chemotherapy, adjuvant radiotherapy or adjuvant hormone therapy; and receiving ovarian ablation.

CONCLUSIONS

Variations in access to specialty services and other possible causes of variations in IBR rates need further investigation.

Decreasing incidence of late-stage breast cancer after the introduction of organized mammography screening in Italy

BACKGROUND

After the introduction of a mammography screening program, the incidence of late-stage breast cancer is expected to decrease. The objective of the current study was to evaluate variations in the total incidence of breast cancer and in the incidence of breast cancers with a pathologic tumor (pT) classification of pT2 through pT4 after the introduction of mammography screening in 6 Italian administrative regions.

METHODS

The study area included 700 municipalities, with a total population of 692,824 women ages 55 to 74 years, that were targeted by organized mammography screening between 1991 and 2005. The year screening started at the municipal level (year 1) was identified. The years of screening were numbered from 1 to 8. The ratio of the observed 2-year, age-standardized (Europe) incidence rate to the expected rate (the incidence rate ratio [IRR]) was calculated. Expected rates were estimated assuming that the incidence of breast cancer was stable and was equivalent to that in the last 3 years before year 1.

RESULTS

The study was based on a total of 14,447 incident breast cancers, including 4036 pT2 through pT4 breast cancers. The total IRR was 1.35 (95% confidence interval, 1.03-1.41) in years 1 and 2, 1.16 (95% confidence interval, 1.10-1.21) in years 3 and 4, 1.14 (95% confidence interval, 1.08-1.20) in years 5 and 6, and 1.14 (95% confidence interval, 1.08-1.21) in years 7 and 8. The IRR for pT2 through pT4 breast cancers was 0.97 (95% confidence interval, 0.90-1.04) in years 1 and 2, 0.81 (95% confidence interval, 0.75-0.88) in years 3 and 4, 0.79 (95% confidence interval, 0.73-0.87) in years 5 and 6, and 0.71 (95% confidence interval, 0.64-0.79) in years 7 and 8.

CONCLUSIONS

A significant and stable decrease in the incidence of late-stage breast cancer was observed from the third year of screening onward, when the IRR varied between 0.81 and 0.71.

Changes in mastectomy rates at a Brazilian public hospital over 20 years (1989 to 2008)

CONTEXT AND OBJECTIVE

Recently, breast-conserving surgery (BCS) has been replacing mastectomy for breast cancer treatment. The aim of this study was to evaluate the changes in mastectomy and BCS rates and the factors relating to these shifts.

DESIGN AND SETTING

A retrospective study in a Brazilian public hospital.

METHODS

Pathological records from female patients who underwent surgery for breast cancer at Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG), between 1989 and 2008 were reviewed. The mastectomy and BCS rates were calculated. The chi-square test was used to assess factors associated with type of surgical treatment and to compare trends in treatment type over the years. Logistic regression was used for multivariate analysis.

RESULTS

From 1989 to 2008, 2050 breast cancer surgical specimens were received in our service, corresponding to 1973 patients; 1324 (64.6%) of them were from mastectomy and 726 (35.4%) from BCS. A shift from mastectomy towards BCS was observed (P < 0.001). In multivariate analysis, earlier year of surgery (P < 0.001), larger tumor size (P < 0.001), having at least one positive axillary lymph node (P < 0.001) and patients' age greater than 68 years (P = 0.007) were predictors of mastectomy.

CONCLUSIONS

There was a shift from mastectomy towards BCS in our institution over the years. This may reflect consolidation of BCS (plus radiotherapy) as an equivalent treatment to mastectomy in terms of survival and a shift to earlier diagnosis for the disease.

Effect of mammography screening on surgical treatment for breast cancer in Norway: comparative analysis of cancer registry data

OBJECTIVE

To determine the effect of mammography screening on surgical treatment for breast cancer.

DESIGN

Comparative analysis of data from Norwegian cancer registry.

SETTING

Mammography screening, Norway (screening of women aged 50-69 was introduced sequentially from 1996 to 2004).

PARTICIPANTS

35,408 women aged 40-79 with invasive breast cancer or ductal carcinoma in situ treated surgically from 1993 to 2008.

MAIN OUTCOME MEASURES

Rates of breast surgery (mastectomy plus breast conserving treatment) and rates of mastectomy for three age groups of women: 40-49, 50-69, and 70-79. Changes in rates from pre-screening period (1993-5) to introduction of screening phase (1996-2004) and then to screening period (2005-8) are presented as hazard ratios in invited and non-invited women.

RESULTS

The annual rate for breast surgery from the pre-screening period (1993-5) to screening period (2005-8) in Norway increased by 70% (hazard ratio 1.70, 95% confidence interval 1.62 to 1.78), from 180 to 305 per 100,000 women in the invited age group (50-69 years). In the younger, non-invited age group (40-49 years), however, the increase was only 8% (1.08, 1.00 to 1.16), from 133 to 144 per 100,000 women per year, whereas in the older, non-invited age group (70-79 years) the rate decreased by 8% (0.92, 0.86 to 1.00), from 227 to 214 per 100,000 women per year. The rates for mastectomy decreased similarly from the pre-screening period to screening period in invited and non-invited women. From the pre-screening period to the introduction phase of screening (1996-2004), however, the annual mastectomy rate in women aged 50-69 invited to screening increased by 9% (1.09, 1.03 to 1.14), from 156 to 167 per 100,000 women, and in the younger non-invited women declined by 17% (0.83, 0.78 to 0.90), from 109 to 91 per 100,000 women. In consequence, the mastectomy rate was 31% (1.31, 1.20 to 1.43) higher in the invited than in the non-invited younger age group.

CONCLUSIONS

Mammography screening in Norway was associated with a noticeable increase in rates for breast cancer surgery in women aged 50-69 (the age group invited to screening) and also an increase in mastectomy rates. Although over-diagnosis is likely to have caused the initial increase in mastectomy rates and the overall increase in surgery rates in the age group screened, the more recent decline in mastectomy rates has affected all age groups and is likely to have resulted from changes in surgical policy.

Measuring the influence of colleagues on a consultant team's use of breast conserving surgery

OBJECTIVES

The aim of this study was to examine potential reasons why the use of breast conserving surgery (BCS) for breast cancer varies substantially between hospital teams in England, and in particular to examine whether colleague influence has a role in influencing BCS rates locally.

METHODS

Routinely collected Hospital Episode Statistics (HES) data relating to 420 surgical teams in England who performed more than ten breast cancer operations during the financial year 2006/07 were used to identify predictors of team BCS use. Team BCS rates (as a proportion of all types of breast excision surgery) were subject to a regression analysis that incorporated, as independent variables, a range of patient, organizational, and local demographic factors, as well as the BCS rate of colleagues working alongside them in the same hospitals(s).

RESULTS

After adjusting for the effects of other variables, BCS use by colleagues working in the same hospital(s) was a significant predictor of a team's own BCS rate (standardized b = 0.224; p < .001), denoting a typical 3 percent increase in a team's BCS rate for every 10 percent increase in the BCS rate of colleagues.

CONCLUSIONS

The practice of colleagues seems to have a measurable influence upon a surgical team's BCS usage. Guidance from HTA organizations can set national standards about the use of new techniques and innovations, but dissemination can be either slowed down or accelerated by the influence of local colleagues. A strategy of disseminating guidance through professional networks or "local champions" could be a powerful avenue for change.

Disentangling the roles of mammographic screening and HRT in recent breast cancer incidence trends in italy by analyses based on calendar time and time since screening activation

The aim of the study was to evaluate the roles of screening activation and hormone replacement therapy discontinuation on the recent declining breast cancer incidence trends in Italy. We analyzed 41,358 invasive female breast cancers incident during 1991-2004 in six Italian population-based cancer registries. Overall and age-specific incidence trends were evaluated using Joinpoint analysis. In addition to calendar years, data were analyzed on a years-since-screening-activation basis. Annual percentage change of standardized rates was computed. There were statistically significant increasing trends for women 40-44 and 45-49 years that did not change after screening activation. On the contrary, for women 50-69 years old and for those 70+ years, the increasing trends flattened around 2 years after screening activation. The prevalence of hormone replacement therapy use in Italy is and was rather low. In conclusion, the recent tendency toward stabilization observed in Italy for female breast cancer incidence rates in women aged 50 years or more follows the introduction of mammographic screening.

Incidence of breast cancer in Italy: mastectomies and quadrantectomies performed between 2000 and 2005

OBJECTIVES

We aimed to determine the incidence of women's breast cancer in Italy without using statistical approximations.

METHODS

We analyzed the national hospitalizations database at the Ministry of Health to calculate the number of major surgeries in Italian women (mastectomies and quadrantectomies) due to breast cancer between 2000 and 2005, overall and by age groups (<44, 45-64, 65-74 and >or= 75 years old).

RESULTS

Over the six years examined, an overall number of 100,745 mastectomies and 168,147 quadrantectomies were performed. A total of 41,608 major surgeries due to breast cancer were performed in the year 2000 and this number rose to 47,200 in 2005, with a 13.4% increase over six years.

CONCLUSION

by analyzing the hospitalizations database concerning major breast surgery, incidence of breast cancer in Italy was found to be 26.5% higher than the official estimations which have been computed using statistical models (namely 47,200 vs. 37,300 cases in year 2005).

The other side of technology: risk of overdiagnosis of breast cancer with mammography screening

Estimates of overdiagnosis of breast cancer with mammography screening differ between studies. The estimate of overdiagnosis obtained using the cumulative incidence approach with data from randomized clinical trials ranges from 10 to 14%. In observational studies, where statistical adjustment for lead-time was utilized, the estimate was lower than 5% in two Italian studies, while it was quite higher in a Swedish study. Most of the differences are explained by different methodology, study design and measures. In this review we discuss the concept and the definition of the measure of overdiagnosis, and present different study methods to estimate overdiagnosis of breast cancer with mammography screening.

Appropriateness of early breast cancer management in relation to patient and hospital characteristics: a population based study in Northern Italy

Administrative data may provide valuable information for monitoring the quality of care at population level and offer an efficient way of gathering data on individual patterns of care, and also to shed light on inequalities in access to appropriate medical care. The aim of the study was to investigate the role of patient and hospital characteristics in the initial treatment of early breast cancer using administrative data. Incident breast cancer patients were identified from hospital discharge records and linked to the radiotherapy outpatient database during 2000-2004 in the Piedmont region of Northwestern Italy. Women treated with breast-conserving surgery followed by radiotherapy (BCS + RT) were compared to those treated with BCS without radiotherapy (BCS w/o RT) or mastectomy using multinomial logistic regression models. Out of 16,022 incident cases, 46.2% received BCS + RT, 20.3% received BCS w/o RT, and 33.5% received a mastectomy. Compared to BCS + RT, the factors associated with BCS w/o RT were: increased age (OR = 1.54; 95% CI = 1.29-1.85, for ages 70-79 vs. <50), being unmarried (1.24; 1.13-1.36), presence of co-morbidities (1.32; 1.10-1.58), being treated at hospitals with low surgical volume (1.31; 1.07-1.60 for hospitals with less than 50 vs. > or =150 interventions/year), and living far from radiotherapy facilities (1.75; 1.39-2.20 for those at a distance of >45 min). These same factors were also associated with mastectomy. During the 5-year period observed, there was a trend of reduced probability of receiving a mastectomy (0.70; 0.56-0.88 for 2004 vs. 2000). The presence or absence of nodal involvement was positively associated with mastectomy (2.28; 1.83-2.85) and negatively associated with BCS w/o RT (0.65; 0.56-0.76). After adjustment for potential confounders, education level did not show any association with the type of treatment. Social and geographical factors, in addition to hospital specialization, should be considered to reduce inappropriateness of care for breast cancer.

Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction

The aim of this study was the evaluation of the impact of service screening programmes on breast cancer mortality in five regions of Italy. We conducted a matched case-control study with four controls for each case. Cases were defined as breast cancer deaths occurred not later than 31 December 2002. Controls were sampled from the local municipality list and matched by date of birth. Screening histories were assessed by the local, computerised, screening database and subjects were classified as either invited or not-yet-invited and as either screened or unscreened. There were a total of 1750 breast cancer deaths within the 50 to 74-year-old breast cancer cases and a total of 7000 controls. The logistic conditional estimate of the cumulative odds ratios comparing invited with not-yet-invited women was 0.75 (95% CI: 0.62-0.92). Restricting the analyses to invited women, the odds ratio of screened to never-respondent women corrected for self-selection bias was 0.55 (95% CI: 0.36-0.85). The introduction of breast cancer screening programmes in Italy is associated with a reduction in breast cancer mortality attributable to the additional impact of service screening over and above the background access to mammography.

Evaluation of service mammography screening impact in Italy. The contribution of hazard analysis

12,987 invasive breast cancer cases were diagnosed in women aged 50-69 upto the year 2001 in nine Italian areas where a screening programme was active. Cases were followed up in 2005 for a total of 1921 breast cancer failures. The 10-year survival rates were 85.3% for the invited group against 75.6% for the non-invited. A time dependent analysis was performed using 5-year intervals. Crude hazard ratios for the invited group in comparison to the not invited group were 0.52 and 0.64 respectively in the (0-5) year and [5-10] year time windows. Hazard ratio adjusted for tumour characteristics was 0.96 in the [5-10] year time window, suggesting minimal or any length bias. Consistent with the results of randomised trials, these analyses of service screening data document a mortality reduction of 36% at 5-10 years after diagnosis.

Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery

BACKGROUND

Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume.

METHODS

Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression.

RESULTS

Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload.

CONCLUSION

The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.