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

Assessment of proprioception, muscle strength and endurance during dynamic isokinetic test in patients with breast cancer-related lymphedema

BACKGROUND

Breast cancer-related lymphedema is a common complication after breast cancer treatment.This study examined isokinetic proprioception, muscular strength, and endurance by comparing extremity with lymphedema and the extremity without lymphedema in women with breast cancer-related lymphedema.

METHODS

A total of 15 individuals aged between 35 and 70 years participated in this study. Cybex Humac NORM Isokinetic dynamometer (CSMi, Stoughton, MA) were used to assess upper extremity passive proprioception, active proprioception, kinesthesia, muscle strength, and muscle endurance. The upper extremity lymphedema was measured with the water displacement arm volumetry test using a volumeter.

FINDINGS

All isokinetic measurements demonstrated a statistically significant difference between the extremity with lymphedema and the extremity without lymphedema, suggesting lower scores in the extremity with lymphedema (p < .05). There was a positive correlation between passive internal rotation in the extremity with lymphedema and the time after mastectomy (r= 0.628, p = .012) and a moderate positive relationship was found between the time after lymphedema and passive internal rotation (r = 0.577; p = .024), and active external rotation position sense (r = 0.540; p = .038) in the extremity with lymphedema. Also, a unidirectional positive moderate (r = 0.594; p = .020) relationship was found between the lymphedema stage and passive external rotation in the extremity with lymphedema.

INTERPRETATION

The difference in proprioception, muscle strength, and endurance between the extremity with lymphedema and the extremity without lymphedema in women with breast cancer-related lymphedema will provide valuable information in terms of prioritizing these parameters in treatment.

The effect of the Flemish breast cancer screening program on breast cancer-specific mortality: A case-referent study

BACKGROUND

Breast cancer screening programs were introduced in many countries worldwide following randomized controlled trials in the 1980s showing a reduction in breast cancer-specific mortality. However, their effectiveness remains debated and estimates vary. A breast cancer screening program was introduced in 2001 in Flanders, Belgium where high levels of opportunistic screening practices are observed. The effectiveness of this program was estimated by measuring its effect on breast cancer-specific mortality.

METHODS

We performed a case-referent study to investigate the effect of participation in the Flemish population-based mammography screening program (PMSP) on breast cancer-specific mortality from 2005 to 2017. A multiple logistic regression model assessed the association between breast cancer-specific death and screening program participation status in the four years prior to (pseudo)diagnosis (yes/no), with adjustment for potential confounders (individual socio-economic position and calendar year of diagnosis) and stratified for age. In addition, we performed different sensitivity analyses.

RESULTS

We identified 1571 cases and randomly selected 6284 referents. After adjustment, women who participated in PMSP had a 51 % lower risk of breast cancer-specific mortality compared to those who did not (adjusted odds ratio [aOR] =0.49, 95 % CI: 0.44-0.55). Sensitivity analyses did not markedly change the estimated associations. Correction for self-selection bias reduced the effect size, but the estimate remained significant.

CONCLUSION

Our results indicate that in a context of high opportunistic screening rates, participation in breast cancer screening program substantially reduces breast cancer-specific mortality. For policy, these results should be balanced against the potential harms of screening, including overdiagnosis and overtreatment.

Effectiveness of the cervical cancer prevention programme: a case-control mortality audit in Lithuania

The cervical cancer burden in Lithuania has remained high, and there are no previous effectiveness studies of cervical cancer prevention programme in the country. We investigated the effect of a prevention programme on the risk of mortality from cervical cancer in Lithuania by conducting a mortality audit study. The register-based case-control study included 715 cervical cancer deaths that occurred during 2010-2015 in Lithuania and their 2145 matched controls. Screening histories for cases and controls were obtained from the National Health Insurance Fund database. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression and corrected for self-selection bias. Index screening was associated with a 56% reduction in the cervical cancer death risk, OR: 0.44; 95% CI 0.26-0.74. The ORs for stage I and stage II+ cancers were 0.80; 95% CI 0.32-2.00 and 0.36; 95% CI 0.21-0.62, respectively. The preventive effect was statistically significant for women aged ≥40 years, while nonsignificant for younger. In women who died of cervical cancer, 71% were not invited and 88% were not screened within the recommended 36 months prior to index date. Among cases with index invitation, 32% had index screening compared to 70% in controls. In conclusion, participation in screening has been effective in reducing cervical cancer mortality in Lithuania. The study shows poor screening attendance, emphasizing the importance of greater efforts at the national level to improve the effectiveness of the screening.

The potential of breast cancer screening in Europe

Currently, all European countries offer some form of breast cancer screening. Nevertheless, disparities exist in the status of implementation, attendance and the extent of opportunistic screening. As a result, breast cancer screening has not yet reached its full potential. We examined how many breast cancer deaths could be prevented if all European countries would biennially screen all women aged 50 to 69 for breast cancer. We calculated the number of breast cancer deaths already prevented due to screening as well as the number of breast cancer deaths which could be additionally prevented if the total examination coverage (organised plus opportunistic) would reach 100%. The calculations are based on total examination coverage in women aged 50 to 69, the annual number of breast cancer deaths for women aged 50 to 74 and the maximal possible mortality reduction from breast cancer, assuming similar effectiveness of organised and opportunistic screening. The total examination coverage ranged from 49% (East), 62% (West), 64% (North) to 69% (South). Yearly 21 680 breast cancer deaths have already been prevented due to mammography screening. If all countries would reach 100% examination coverage, 12 434 additional breast cancer deaths could be prevented annually, with the biggest potential in Eastern Europe. With maximum coverage, 23% of their breast cancer deaths could be additionally prevented, while in Western Europe it could be 21%, in Southern Europe 15% and in Northern Europe 9%. Our study illustrates that by further optimising screening coverage, the number of breast cancer deaths in Europe can be lowered substantially.

Effects of smartphone application education combined with hands-on practice in breast self-examination on junior nursing students in South Korea

BACKGROUND

Breast self-examination is a convenient and effective way to detect breast abnormalities. Based on Dale's Cone of Experience theory, we hypothesized that the combination of a smartphone application with hands-on practice would have a greater impact than using a smartphone application alone. The purpose of this study was to compare the effects of different educational methods on (a) knowledge, (b) attitudes, (c) skills, and (d) students' satisfaction with the learning methods.

METHODS

We conducted a pre- and post-test quasi-experimental design and developed a smartphone application using a video clip. One experimental group received smartphone-based education, another group received smartphone-based education combined with hands-on practice, and the control group received a one-time classroom lecture. We administered a pre-test, provided intervention, and conducted a post-test.

RESULTS

Among the three groups, the knowledge and attitude of the experimental groups were significantly higher than that of the control group. In addition, the group using the combination of the smartphone application and hands-on practice showed the highest score changes in skills and satisfaction with the learning methods.

CONCLUSIONS

Smartphone application use combined with hands-on practice could be an effective education method for breast self-examination.

Breast Cancer Survivorship, Quality of Life, and Late Toxicities

Breast cancer is the most frequent cancer in women: in 2018, almost two million cases have been diagnosed all over the world and it represents the principal cause of death from a neoplastic disease in women. In the past years, breast cancer prognosis has significantly improved over time: currently 5-year survival rates are in the range of 90%, and 10-year survival is about 80%. This improvement has been mostly observed in western countries, due to high coverage and compliance with screening programs, leading to early diagnosis, i.e., when the disease is at a subclinical level, and to an improvement in tumor molecular characterization and innovative systemic treatments. Yet the identification of different biological breast cancer subtypes prompted the development of innovative targeted agents and improved treatment personalization. On the other hand, longer survival rates and increasing proportions of cured patients require dedicated strategies to manage long-term sequelae of breast cancer treatments, with particular attention to quality of life. This review analyzes the most important issues, potentially occurring with cancer treatments, concerning long-term sequelae and quality of life, to define a global approach to breast cancer survivorship.

Negative controls to detect uncontrolled confounding in observational studies of mammographic screening comparing participants and non-participants

BACKGROUND

When comparing mammography-screening participants and non-participants, estimates of reduction in breast-cancer mortality may be biased by poor baseline comparability. We used negative controls to detect uncontrolled confounding.

METHODS

We designed a closed cohort of Danish women invited to a mammography-screening programme at age 50-52 years in Copenhagen or Funen from 1991 through 2001. We included women with a normal screening result in their first-invitation round. Based on their second-invitation round, women were divided into participants and non-participants and followed until death, emigration or 31 December 2014, whichever came first. We estimated hazard ratios (HRs) of death from breast cancer, causes other than breast cancer and external causes. We added dental-care participation as an exposure to test for an independent association with breast-cancer mortality. We adjusted for civil status, parity, age at first birth, educational attainment, income and hormone use.

RESULTS

Screening participants had a lower hazard of breast-cancer death [HR 0.47, 95% confidence interval (CI) 0.32, 0.69] compared with non-participants. Participants also had a lower hazard of death from other causes (HR 0.43, 95% CI 0.39, 0.46) and external causes (HR 0.35, 95% CI 0.23, 0.54). Reductions persisted after covariate adjustment. Dental-care participants had a lower hazard of breast-cancer death (HR 0.75, 95% CI 0.56, 1.01), irrespective of screening participation.

CONCLUSIONS

Negative-control associations indicated residual uncontrolled confounding when comparing breast-cancer mortality among screening participants and non-participants.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development of breast cancer mortality considering the implementation of mammography screening programs - a comparison of western European countries

Background

Triggered by the successive implementation of organized mammography screening programs (MSPs) throughout western European countries over the last decades, there is an ongoing debate questioning their effectiveness. Since it is difficult to assess the effect of MSPs on a population level, we rather aim to assess the impact of the implementation itself on breast cancer mortality rates utilizing an ecological study design.

Methods

We analyzed age group-specific (50–59, 60–69 and 70–79 years) female breast cancer mortality rates in 14 western European countries between 1980 and 2017 using Joinpoint regression, interrupted time series (ITS) regression and multivariable Poisson regression.

Results

The Joinpoint analysis demonstrated decreasing trends resulting in annual percentage changes ranging from − 1.5% to − 5.4% (50–59), − 0.2% to − 8.1% (60–69) and 0% to − 7.1% (70–79) depending on the country within 3 years after MSP implementation. The ITS analysis results in highly significant interaction terms (calendar year * binary MSP indicator) for all age groups. The multivariable regression using “calendar year”, “year of MSP implementation” and “years with MSP” as independent variables yielded a significant yearly decrease for “years with MSP” ranging from 0.9 to 1.2%.

Conclusions

The results of this study suggest a positive association between the implementation of MSPs and the (accelerated) reduction of breast cancer mortality rates. Measuring and quantifying the isolated effect of MSPs on a population level will require additional studies using individual data.

Associations between cervical, breast and colorectal cancer screening uptake, chronic diseases and health-related behaviours: Data from the Italian PASSI nationwide surveillance

Screening programmes have been proposed as a privileged setting for health promotion interventions. We aim to assess the associations between behavioural risk factors, chronic conditions and diseases and cervical, breast and colorectal cancer screening uptake. Secondly, we aim to assess whether these associations are due to underlying differences in socioeconomic characteristics. In Italy, a random sample was interviewed by the PASSI surveillance (106,000 interviews) in 2014-2016. Screening uptake adjusted for age and gender alone and for age, gender and socioeconomic characteristics (educational attainment and self-reported economic difficulties) were estimated using multivariate Poisson regression models. Screening uptake was 79%, 73% and 45% for cervical (age 25-64), breast (women aged 50-69) and colorectal cancer (both sexes age 50-69), respectively. People with low consumption of vegetables and fruits and those with insufficient physical activity had lower uptake than people with healthy behaviours (20-22% and 8-15% lower, respectively), as did those obese and diabetic compared to healthier people (7-10% and 5-8% lower, respectively). Those with high-risk drinking behaviour, self-reported driving after drinking alcohol, and former smokers had higher screening uptake (3-7%, 3-6%, and 7-14% higher, respectively). Differences in uptake decreased after adjusting for socioeconomic characteristics, but trends were unvaried. In conclusion, screening uptake is negatively associated with unfavourable behaviours and health conditions that are also risk factors for breast and colorectal cancer incidence. Socioeconomic characteristics do not fully explain these differences. Health promotion interventions targeting diet and physical activity nested in screening programmes might miss part of the at-risk population.

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.

Effect of population breast screening on breast cancer mortality to 2005 in England and Wales: A nested case-control study within a cohort of one million women

Objectives

To evaluate the effectiveness of the NHS breast screening programme (NHSBSP) on breast cancer mortality in England and Wales and to compare findings with a cohort analysis of the same underlying population.

Methods

A nested case-control study within a cohort of 959,738 women in England and Wales aged 49–64 who were eligible for routine NHSBSP screening during 1991–2005. Cases who died from breast cancer in 1991–2005 were matched to controls without breast cancer at the case diagnosis date and alive when the case died. Risk of breast cancer mortality associated with intention to screen (ITS) (7047 cases/28,188 controls) and screening attendance (4707 cases/9413 controls) was examined. Bias was minimised in accordance with currently advocated best practice. Odds ratios (ORs) were calculated using conditional logistic regression. Results were compared with findings from an incidence-based breast cancer mortality cohort analysis.

Results

ITS was associated with a 21% breast cancer mortality reduction (OR = 0.79, 95% confidence interval [CI]: 0.71–0.88, P < 0.001). Attendance ≤5 years before diagnosis was associated with a 47% reduction in breast cancer mortality after self-selection correction (OR = 0.53, 95% CI: 0.46–0.62, P < 0.001). Breast cancer mortality reduction associated with ITS was 21% in both the case-control and cohort analyses, but the impact of attendance was marginally greater in the case-control analysis (36% vs. 32%).

Conclusions

Case-control studies designed and analysed according to current best practice guidelines offer an effective means of evaluating population breast screening.

Advanced breast cancer rates in the epoch of service screening: The 400,000 women cohort study from Italy

BACKGROUND

The objective of this study was to evaluate if mammography screening attendance is associated with a reduction in late-stage breast cancer incidence.

METHODS

The cohort included over 400,000 Italian women who were first invited to participate in regional screening programmes during the 1990s and were followed for breast cancer incidence for 13 years. We obtained individual data on their exposure to screening and correlated this with total and stage-specific breast cancer incidence. Socio-economic status and pre-screening incidence data were used to assess the presence of self-selection bias.

RESULTS

Overall, screening attendance was associated with a 10% excess risk of in situ and invasive breast cancer (IRR = 1.10; 95% confidence interval (CI): 1.06-1.14), which dropped to 5% for invasive cancers only (IRR = 1.05; 95% CI: 1.01-1.09). There were significant reductions among attenders for specific cancer stages; we observed a 39% reduction for T2 or larger (IRR = 0.61; 95% CI: 0.57-0.66), 19% for node positives (IRR = 0.81; 95% CI: 0.76-0.86) and 28% for stage II and higher (IRR = 0.72; 95% CI: 0.68-0.76). Our data suggest that the presence of self-selection bias is limited and, overall, invited women experienced a 17% reduction of advanced cancers compared with pre-screening rates.

CONCLUSIONS

Comparing attenders' and non-attenders' stage-specific breast cancer incidence, we have estimated that screening attendance is associated with a reduction of nearly 30% for stages II+.

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

Background:

This breast cancer mortality evaluation of service screening mammography in New Zealand, the first since commencement of screening in 1999, applies to the 1999–2011 diagnostic period. Individual-level linked information on mammography screening, breast cancer diagnosis and breast cancer mortality is used to analyse differences in breast cancer mortality according to participation in organised screening mammography, as provided by BreastScreen Aotearoa (BSA).

Methods:

Women were followed from the time they became eligible for screening, from age 50 years (1999–2004) and 45 years (⩾2004). Breast cancer mortality from cancers diagnosed during the screening period from 1999 to 2011 (n=4384) is examined in relation to individual screening participation or non-participation during preceding person-years of follow-up from the time of screening eligibility. To account for changes from never- to ever-screened status, breast cancer mortality is calculated for each year in relation to prior accumulated time of participation and non-participation in screening. Breast cancer mortality is also examined in regularly screened women (screened ⩾3 times and mean screening interval ⩽30 months), and irregularly screened women compared with never-screened women. Statistical analyses are by negative binomial and Poisson regression with adjustment for age and ethnic group (Māori, Pacific women) in a repeated-measures analysis. Relative risks for breast cancer mortality compared with never-screened women, are adjusted also for screening selection bias, to indicate the extent of breast cancer mortality reduction in a population offered and not offered mammography screening. Prognostic indicators at diagnosis of breast cancer are also compared between different screening participation groups, including by grade of tumour, extent of disease (spread), multiple tumour status and maximum tumour size using χ² statistics, t-tests and two-sample median tests.

Results:

For 1999–2011, after adjusting for age and ethnicity, breast cancer mortality in ever-screened women is estimated to be 62% (95% CI: 51–70) lower than in never-screened women. After further adjustment for screening selection bias, the mortality reduction in NZ is estimated to be 29% (95% CI: 20–38) at an average screening coverage of 64% for 2001–2011, and 34% (95% CI: 25–43) for recent screening coverage (2012–13, 71%). For irregularly screened women, the mortality reduction is estimated to be 31% (95% CI: 21–40), and 39% (95% CI: 22–52) in regularly screened women compared with never-screened women, after adjusting for age, ethnicity and screening selection bias (using recent 2012–2013 screening coverage of 71%). Ever-screened women diagnosed with breast cancer have more favourable prognostic indicators than never-screened women, with a higher proportion of localised cancer (63 compared with 46%), a higher proportion with a well-differentiated tumour (30 compared with 18%), lower risk of multiple tumours (RR=0.48) and smaller median tumour size (15 mm compared with 20 mm)—all differences are statistically significant (P<0.0001).

Conclusions:

This is the first total population cohort study of an established nation-wide screening mammography programme using individual-level information on screening participation and mortality outcomes from breast cancer. The findings are in accord with other mammography screening service evaluations and with randomised trials of mammography screening.

Effect of population breast screening on breast cancer mortality up to 2005 in England and Wales: an individual-level cohort study

BACKGROUND

Population breast screening has been implemented in the UK for over 25 years, but the size of benefit attributable to such programmes remains controversial. We have conducted the first individual-based cohort evaluation of population breast screening in the UK, to estimate the impact of the NHS breast screening programme (NHSBSP) on breast cancer mortality.

METHODS

We followed 988 090 women aged 49-64 years in 1991 resident in England and Wales, who because of the staggered implementation of the NHSBSP, included both invited subjects and an uninvited control group. Individual-level breast screening histories were linked to individual-level mortality and breast cancer incidence data from national registers. Risk of death from breast cancer was investigated by incidence-based mortality analyses in relation to intention to screen and first round attendance. Overdiagnosis of breast cancer following a single screening round was also investigated.

RESULTS

Invitation to NHSBSP screening was associated with a reduction in breast cancer mortality in 1991-2005 of 21% (RR=0.79, 95% CI: 0.73-0.84, P<0·001) after adjustment for age, socioeconomic status and lead-time. Breast cancer deaths among first invitation attenders were 46% lower than among non-attenders (RR=0.54, 95% CI: 0.51-0·57, P<0.001) and 32% lower following adjustment for age, socioeconomic status and self-selection bias (RR=0.68, 95% CI: 0.63-0·73, P<0.001). There was little evidence of overdiagnosis associated with invitation to first screen.

CONCLUSIONS

The results indicate a substantial, statistically significant reduction in breast cancer mortality between 1991 and 2005 associated with NHSBSP activity. This is important in public health terms.

Breast cancer screening effect across breast density strata: A case-control study

Breast cancer screening is known to reduce breast cancer mortality. A high breast density may affect this reduction. We assessed the effect of screening on breast cancer mortality in women with dense and fatty breasts separately. Analyses were performed within the Nijmegen (Dutch) screening programme (1975-2008), which invites women (aged 50-74 years) biennially. Performance measures were determined. Furthermore, a case-control study was performed for women having dense and women having fatty breasts. Breast density was assessed visually with a dichotomized Wolfe scale. Breast density data were available for cases. The prevalence of dense breasts among controls was estimated with age-specific rates from the general population. Sensitivity analyses were performed on these estimates. Screening performance was better in the fatty than in the dense group (sensitivity 75.7% vs 57.8%). The mortality reduction appeared to be smaller for women with dense breasts, with an odds ratio (OR) of 0.87 (95% CI 0.52-1.45) in the dense and 0.59 (95% CI 0.44-0.79) in the fatty group. We can conclude that high density results in lower screening performance and appears to be associated with a smaller mortality reduction. Breast density is thus a likely candidate for risk-stratified screening. More research is needed on the association between density and screening harms.

Factors associated with breast screening radiologists' annual mammogram reading volume in Italy

PURPOSE

Screening mammogram reading volume (SMRV) and total (screening and clinical) mammogram reading volume (TMRV) per year are strongly associated with the radiologist's diagnostic performance in breast cancer screening. The current article reports the prevalence and correlates of a SMRV and a TMRV ≥5000 among Italian breast screening radiologists.

MATERIALS AND METHODS

A questionnaire survey was carried out in 2013-2014 by the Italian Group for Mammography Screening (GISMa). The questionnaire included items of information for radiologist's experience-related characteristics and for facility-level factors supposedly associated with SMRV and TMRV. Multivariate analysis was performed using backward stepwise multiple logistic regression models.

RESULTS

Data for 235 radiologists from 51 local screening programmes were received. Of the 222 radiologists who were eligible, 133 (59.9 %) reported a SMRV ≥5000 and 163 (73.4 %) a TMRV ≥5000. Multivariate factors positively associated with both characteristics included: the number of years of experience reading mammograms; the percentage of total working time dedicated to breast imaging and breast care; the participation in diagnostic assessment; and the availability of digital tomosynthesis at facility. Full-time dedication to breast imaging and breast care was associated with the highest odds ratio for a SMRV and a TMRV ≥5000, i.e. 11.80 and 46.74, respectively, versus a percentage of time ≤50 %. An early (<2000) year of implementation of the screening programme and the availability of vacuum-assisted biopsy at facility were associated with a SMRV and, respectively, a TMRV ≥5000.

CONCLUSIONS

Increasing the proportion of radiologists with full-time dedication to breast imaging and breast care qualified as the most effective approach to improve SMRV and TMRV.

Impact of organised mammography screening on breast cancer mortality in a case-control and cohort study

BACKGROUND

The usefulness of case-control studies has been questioned. Our aim was to evaluate the long-term effect of screening on breast cancer mortality within the population-based mammography programme in Finland using a case-control design, and to compare the analyses with the earlier cohort study.

METHODS

The cases were women invited to screening, diagnosed and died from breast cancer in 1992-2011 while being 50-84 years at death. We chose 10 controls for each case with non-restrictive eligibility criteria. Our data included 1907 cases and 18 978 matched controls. We analysed associations between the screening participation and the risk of breast cancer death using the conditional Cox proportional hazards model. The effect estimates were corrected for self-selection bias.

RESULTS

An overall effect of screening was 0.67 (95% confidence interval (CI): 0.49-0.90), and that remained unchanged over time. Analyses with matching criteria comparable to the cohort study yielded an effect (0.70, 95% CI: 0.49-1.00) in 1992-2003 similar to that of the previous cohort analysis (0.72, 95% CI: 0.56-0.88).

CONCLUSIONS

Organised mammography screening decreases mortality from breast cancer by 33% among the participants. If made comparable, a case-cohort study can yield effect estimates similar to a cohort study.

Impact of Screening on Breast Cancer Mortality: The UK Program 20 Years On

BACKGROUND

With changes in diagnosis, treatment, and management of breast cancer since the mammography screening trials, there is a need to evaluate contemporary breast screening programs. A case-control study was set up to assess the current impact of attendance in the English Breast Screening Program on breast cancer mortality.

METHODS

Cancer registry cases who died from primary breast cancer ages 47 to 89 years in London in 2008 to 2009 (869 women) were matched to 1 or 2 general population controls (1,642 women) with no diagnosis of breast cancer at the time of the case's diagnosis, who were alive at the case's death. Cases and controls were matched for date of birth and screening area, and had been invited to breast screening at least once prior to the case's diagnosis. ORs were estimated using conditional logistic regression. Self-selection bias was addressed using contemporaneous attendance at the cervical screening program. Sensitivity analyses were undertaken to assess the likely effect of lead time bias.

RESULTS

Attendance at breast screening resulted in a breast cancer mortality reduction of 39% [OR, 0.61; 95% confidence interval (CI), 0.44-0.85] after self-selection correction. Attendance in the last 3 years prior to diagnosis resulted in a 60% mortality reduction (OR, 0.40; 95% CI, 0.31-0.51). Lead time bias effects were negligible.

CONCLUSION

Our results suggest that community breast screening programs provide their expected benefit in terms of reducing the risk of breast cancer death among women participating.

IMPACT

Mammography is an important tool for reducing breast cancer mortality and its impact could be increased by encouraging regular attendance.

Case-control Studies on the Effectiveness of Breast Cancer Screening: Insights from the UK Age Trial

BACKGROUND

Ongoing breast cancer screening programs can only be evaluated using observational study designs. Most studies have observed a reduction in breast cancer mortality, but design differences appear to have resulted in different estimates. Direct comparison of case-control and trial analyses gives more insight into this variation. Here, we performed case-control analyses within the randomized UK Age Trial.

METHODS

The Age Trial assessed the effect of screening on breast cancer mortality in women ages 40-49 years. In our approach, case subjects were defined as breast cancer deaths between trial entry (1991-1997) and 2004. Women were ages 39-41 years at entry. For every case subject, five control subjects were selected. All case subjects were included in analyses of screening invitation (356 case subjects, 1,780 controls), whereas analyses of attendance were restricted to women invited to screening (105 case subjects, 525 age-matched controls). Odds ratios (OR) were estimated with conditional logistic regression. We used and compared two methods to correct for self-selection bias.

RESULTS

Screening invitation resulted in a breast cancer mortality reduction of 17% (95% confidence interval [CI]: -36%, +6%), similar to trial results. Different exposure definitions and self-selection adjustments influenced the observed breast cancer mortality reduction. Depending on the method, "ever screened" appeared to be associated with a small reduction (OR: 0.86, 95% CI: 0.40, 1.89) or no reduction (OR: 1.02, 95% CI: 0.48, 2.14) using the two methods of correction. Recent attendance resulted in an adjusted mortality reduction of 36% (95% CI: -69%, +31%) or 45% (95% CI: -71%, +5%).

CONCLUSIONS

Observational studies, and particularly case-control studies, are an important monitoring tool for breast cancer screening programs. The focus should be on diminishing bias in observational studies and gaining a better understanding of the influence of study design on estimates of mortality reduction.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.

Breast cancer mortality in relation to receipt of screening mammography: a case-control study in Saskatchewan, Canada

PURPOSE

The efficacy of screening mammography in reducing breast cancer mortality continues to be controversial. In addition, few data exist on the efficacy of screening mammography in women 70 years of age or older. An organized screening mammogram program has existed in Saskatchewan since the mid-1990s. It offers mammography every 2 years to women ≥50 years of age.

METHODS

We conducted a population-based case-control study to evaluate the efficacy of screening mammography, as practiced in Saskatchewan, Canada. Cases (n = 501) were women who died of breast cancer during 1995-2008 and were at least 52 years of age at the time of their diagnosis. Controls (n = 5,009) were matched to cases on birth year and duration of healthcare coverage prior to the cases' breast cancer diagnosis date. In cases and controls, receipt of screening mammography during the several years up to and including the date of the case's diagnosis of breast cancer was ascertained from the records of the screening program.

RESULTS

Receipt of a screening mammogram in the preceding 2 years was more common among controls (53 %) than cases (37 %), OR 0.51 (95 % CI 0.42-0.62). A decreased risk was observed among women in all age groups, including those 70-79 years (OR 0.40; 95 % CI 0.27-0.60).

CONCLUSION

Our findings suggest that receipt of screening mammography among women in Saskatchewan has been associated with a decreased risk of death from breast cancer.

Breast cancer in European Union: an update of screening programmes as of March 2014 (review)

Breast cancer, a major cause of female morbidity and mortality, is a global health problem; 2008 data show an incidence of ~450,000 new cases and 140,000 deaths (mean incidence rate 70.7 and mortality rate 16.7, world age-standardized rate per 100,000 women) in European Union Member States. Incidence rates in Western Europe are among the highest in the world. We review the situation of BC screening programmes in European Union. Up to date information on active BC screening programmes was obtained by reviewing the literature and searching national health ministries and cancer service websites. Although BC screening programmes are in place in nearly all European Union countries there are still considerable differences in target population coverage and age and in the techniques deployed. Screening is a mainstay of early BC detection whose main weakness is the rate of participation of the target population. National policies and healthcare planning should aim at maximizing participation in controlled organized screening programmes by identifying and lowering any barriers to adhesion, also with a view to reducing healthcare costs.

Screening mammography benefit controversies: sorting the evidence

Numerous clinical studies have confirmed that screening women age 40 years and older reduces breast cancer mortality by 30% to 50%. Several factors including faster breast cancer growth rates and lower breast cancer incidence among younger women, as well as shorter life expectancy and more comorbid conditions among older women, should also be considered in screening guidelines. Annual screening beginning at age 40 years and continuing with no upper age limit, as long as a woman has a life expectancy of at least 5 years and no significant comorbid conditions, is currently recommended.

Breast cancer screening halves the risk of breast cancer death: a case-referent study

Large-scale epidemiologic studies have consistently demonstrated the effectiveness of mammographic screening programs, however the benefits are still subject to debate. We estimated the effect of the Dutch screening program on breast cancer mortality. In a large multi-region case-referent study, we identified all breast cancer deaths in 2004 and 2005 in women aged 50-75 who had been invited for screening (cases). Cases were individually matched to referents from the population invited to screening. Conditional logistic regression was used to estimate the odds ratio (OR) of breast cancer death according to individual screening history. The OR was adjusted for self-selection bias using regional correction factors for the difference in baseline risk for breast cancer death between screened and unscreened women. A total of 1233 cases and 2090 referents were included in this study. We found a 58% reduction in breast cancer mortality in screened versus unscreened women (adjusted OR = 0.42, 95% CI 0.33-0.53). Screening, i.e. early detection and treatment, has resulted in a substantial reduction in breast cancer mortality, indicating that the Dutch breast cancer screening program is highly effective.

Type of breast cancer diagnosis, screening, and survival

INTRODUCTION

Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence of breast cancers detected through screening, before and after introduction of an organized screening, and we evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected breast cancer or those with palpable breast cancers.

MATERIALS AND METHODS

We collected data about all women who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and recurrences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant.

RESULTS

Among the 2070 cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A), 843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extrascreening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively, 99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference between the first 2 groups and the third (P < .05) and a trend between groups A and B (P = .081).

CONCLUSION

The diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the diagnosis, but a longer follow-up is necessary to confirm this data.

Breast cancer mortality in participants of the Norwegian Breast Cancer Screening Program

BACKGROUND

The Norwegian Breast Cancer Screening Program started in 1996. To the authors' knowledge, this is the first report using individual-based data on invitation and participation to analyze breast cancer mortality among screened and nonscreened women in the program.

METHODS

Information on dates of invitation, attendance, breast cancer diagnosis, emigration, death, and cause of death was linked by using unique 11-digit personal identification numbers assigned all inhabitants of Norway at birth or immigration. In total, 699,628 women ages 50 to 69 years without prior a diagnosis of breast cancer were invited to the program from 1996 to 2009 and were followed for breast cancer through 2009 and death through 2010. Incidence-based breast cancer mortality rate ratios (MRRs) were compared between the screened and nonscreened cohorts using a Poisson regression model. The MRRs were adjusted for calendar period, attained age, years since inclusion in the cohorts, and self-selection bias.

RESULTS

The crude breast cancer mortality rate was 20.7 per 100,000 women-years for the screened cohort compared with 39.7 per 100,000 women-years for the nonscreened cohort, resulting in an MRR of 0.52 (95% confidence interval, 0.47-0.59). The mortality reduction associated with attendance in the program was 43% (MRR, 0.57; 95% confidence interval, 0.51-0.64) after adjusting for calendar period, attained age, years after inclusion in the cohort, and self-selection bias.

CONCLUSIONS

After 15 years of follow-up, a 43% reduction in mortality was observed among women who attended the national mammographic screening program in Norway.

Estimates of cancer burden in Tuscany

Aims and background

The Tuscan cancer registry has been operating since 1985, providing cancer incidence and survival data in Tuscany; it covers about 33% of the regional population. The purpose of this paper is to provide incidence, prevalence and mortality estimates for the major cancers in the whole Tuscany region for the period 1970—2015.

Methods

The estimated figures were obtained by applying the MIAMOD method. Starting from mortality and survival data, incidence and prevalence were derived using a statistical back-calculation approach. Survival was modeled on the basis of published data from the Italian cancer registries.

Results

According to the estimates, the most frequent cancer sites were colon-rectum in both genders, prostate in men and breast in women, with 4,188, 3,082 and 3,092 new diagnoses, respectively, in 2012. The incidence rates were steadily increasing for lung cancer in women and melanoma in both sexes, while they were decreasing for uterine cervix cancer in women, lung cancer in men and stomach cancer in both sexes. For colorectal cancer a small reduction in incidence was estimated for both sexes in recent years. The incidence rates for prostate cancer, after a steep increase and subsequent stabilization, were estimated to increase slightly in the last years. The breast cancer incidence was estimated to stabilize in the last 10 years. The mortality trends were decreasing for all considered cancers except female lung cancer. Prevalence increased for most of the studied cancers except stomach cancer in both sexes, lung cancer in men and cervix cancer in women. The highest prevalence was estimated for breast cancer, with over 42,000 cases in 2012.

Conclusion

This paper provides an updated description of the cancer burden in Tuscany until 2015. These trends will have a significant impact on the regional health services and it is therefore important to enhance both primary prevention, for reducing the cancer incidence, and oncological surveillance, for evaluating the care and assistance of cancer patients.

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.

The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies

OBJECTIVES

To assess the impact of population-based mammographic screening on breast cancer mortality in Europe, considering different methodologies and limitations of the data.

METHODS

We conducted a systematic literature review of European trend studies (n = 17), incidence-based mortality (IBM) studies (n = 20) and case-control (CC) studies (n = 8). Estimates of the reduction in breast cancer mortality for women invited versus not invited and/or for women screened versus not screened were obtained. The results of IBM studies and CC studies were each pooled using a random effects meta-analysis.

RESULTS

Twelve of the 17 trend studies quantified the impact of population-based screening on breast cancer mortality. The estimated breast cancer mortality reductions ranged from 1% to 9% per year in studies reporting an annual percentage change, and from 28% to 36% in those comparing post- and prescreening periods. In the IBM studies, the pooled mortality reduction was 25% (relative risk [RR] 0.75, 95% confidence interval [CI] 0.69-0.81) among invited women and 38% (RR 0.62, 95% CI 0.56-0.69) among those actually screened. The corresponding pooled estimates from the CC studies were 31% (odds ratio [OR] 0.69, 95% CI 0.57-0.83), and 48% (OR 0.52, 95% CI 0.42-0.65) adjusted for self-selection.

CONCLUSIONS

Valid observational designs are those where sufficient longitudinal individual data are available, directly linking a woman's screening history to her cause of death. From such studies, the best 'European' estimate of breast cancer mortality reduction is 25-31% for women invited for screening, and 38-48% for women actually screened. Much of the current controversy on breast cancer screening is due to the use of inappropriate methodological approaches that are unable to capture the true effect of mammographic screening.

Mammographic screening and breast cancer mortality: a case-control study and meta-analysis

BACKGROUND

Observational studies are necessary to assess the impact of population screening on breast cancer mortality. While some ecological studies have notably found little or no association, case-control studies consistently show strong inverse associations, but they are sometimes ignored, perhaps due to theoretical biases arising from the study design. We conducted a case-control study of breast cancer deaths in Western Australia to evaluate the effect of participation in the BreastScreen Australia program, paying particular attention to potential sources of bias, and undertook an updated meta-analysis of case-control studies.

METHODS

Our study included 427 cases (women who died from breast cancer), each matched to up to 10 controls. We estimated the association between screening participation and breast cancer mortality, quantifying the effect of potential sources of bias on our findings, including selection bias, information bias, and confounding. We also conducted a meta-analysis of published case-control studies.

RESULTS

The OR for participation in the Western Australian BreastScreen program in relation to death from breast cancer was 0.48 [95% confidence interval (CI), 0.38-0.59; P < 0.001]. We were unable to identify biases that could negate this finding: sensitivity analyses generated ORs from 0.45 to 0.52. Our meta-analysis yielded an OR of 0.51 (95% CI, 0.46-0.55).

CONCLUSIONS

Our findings suggest an average 49% reduction in breast cancer mortality for women who are screened. In practice, theoretical biases have little effect on estimates from case-control studies.

IMPACT

Case-control studies, such as ours, provide robust and consistent evidence that screening benefits women who choose to be screened.

Breast cancer screening: are we seeing the benefit?

A decline in breast cancer mortality has been observed in western European Countries since the middle of the 1990s. Different methodological approaches, including case-control studies, incidence-based mortality studies, and trend studies, have been used to assess the effectiveness of mammography screening programmes in reducing breast cancer mortality. However, not all methods succeed in distinguishing the relative contributions of service screening and taking correctly into consideration the potential source of bias that might affect the estimate. Recently, a review of six case-control studies confirmed a breast cancer mortality reduction ranging from 38% to 70% among screened women. This figure is in accordance with the estimate obtained from incidence-based mortality studies if screening compliance is taken into account. We will describe the methodological constraints of mortality trend studies in predicting the impact of screening on mortality and the necessary caution that must be applied when interpreting the results of such studies. In conclusion, when appropriate methodological approaches are used, it is evident that mammographic screening programmes have contributed substantially to the observed decline in breast cancer mortality.

Biological characterization and selection criteria of adjuvant chemotherapy for early breast cancer: experience from the Italian observational NEMESI study

Background

International treatment guidelines recommend administration of adjuvant chemotherapy in early breast cancer based on clinical, prognostic and predictive parameters.

Methods

An observational study (NEMESI) was conducted in 63 Italian oncology centres in patients with early breast cancer. Age, performance status, concomitant disease, menopausal status, histology, tumor dimension (pT), axillary lymph node status (pN), grading (G), estrogen and progesterone receptor (ER and PgR), proliferative index (ki67 or MIB-1), human epidermal growth factor receptor 2 (HER2) and type of adjuvant treatment were recorded. The primary objective of the study was to define parameters influencing the decision to prescribe adjuvant chemotherapy and the type of chemotherapy.

Results

Data for 1894 patients were available. 69.0% postmenopausal, 67.0% pT1, 22.3% pTmic/pT1a/pT1b, 61.0% pN0, 48.7% luminal A, 18.1% luminal B, 16.1% HER2 positive, 8.7% triple negative, 8.4% unknown. 57.8% received adjuvant chemotherapy: 38.1% of luminal A, 67.3% luminal B, 88.2% HER2-positive, 97.6% triple negative. Regimens administered: 9.1% CMF-like, 48.8% anthracyclines, 38.4% anthracyclines plus taxanes, 3.7% taxanes alone. Increasing pT/pN and, marginally, HER2-positive were associated with the prescription of anthracyclines plus taxanes. Suboptimal schedules (CMF-like or AC/EC or FEC-75) were prescribed in 37.3% receiving chemotherapy, even in HER2-positive and triple negative disease (36.5% and 34.0%, respectively).

Conclusions

This study showed an overprescription of adjuvant chemotherapy for early breast cancer, particularly referred to luminal A. pT, pN and, marginally, HER2 were the principal determinants for the choice of chemotherapy type. Suboptimal chemotherapy regimens were adopted in at least one third of HER2-positve and triple negative.

Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study

BACKGROUND

Breast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.

METHODS

A cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.

RESULTS

Education and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.

CONCLUSIONS

Inequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

Minor influence of self-selection bias on the effectiveness of breast cancer screening in case-control studies in the Netherlands

Background

Self-selection bias is considered to be a problem when evaluating the effectiveness of breast cancer service screening in case-control studies.

Objective

Using the incidence-based mortality method (IBM), a correction factor for the potential influence of self-selection can be derived from a group of non-screened women and a group of not-invited women.

Methods

Breast cancer patients, diagnosed in 1990–1995 and between the ages of 50 to 70, were selected from the Netherlands Cancer Registry and five screening regions in the Netherlands. Person-years were calculated for non-screened and not-invited women by using population data available on the number of women invited, the number of women screened and the total population. Incidence-based breast cancer mortality rates according to screening status were calculated for the five screening regions.

Results

Between 1990–1995, 15,541 patients were diagnosed with breast cancer. An analysis of ten-year follow-up after diagnosis resulted in 3903 breast cancer deaths, of which 2631 were not-invited and 345 were non-screened. Poisson regression analysis showed heterogeneity between the regions with a range of IBM ratios from 0.64 (95% CI: 0.46–0.90) to 1.08 (95% CI: 0.82–1.43).

Conclusions

Heterogeneity between the regions stresses the importance of a country- and/or region-specific estimate of self-selection. Adjusting for self-selection bias in the regional case-control studies would not change the breast cancer mortality reduction in three regions and would result in an even larger effect in two regions. Looking at the range of IBM ratios the overall influence of self-selection in the Netherlands is minor.

Mammography: EUSOBI recommendations for women's information

This paper summarises the basic information to be offered to women who undergo mammography. After a delineation of the general aim of early diagnosis of breast cancer, the main difference between screening mammography and diagnostic mammography is explained. The best time for scheduling mammography in fertile women is defined. The need to bring images and reports from the previous mammogram (and from other recent breast imaging examinations) is highlighted. The technique and procedure of mammography are briefly described with particular attention to discomfort and pain experienced by a fraction of women who undergo the test. Information is given on the recall during a screening program and on the request for further work-up after a diagnostic mammography. The logic of the diagnostic mammography report and of classification systems such as BI-RADS and R1-R5 is illustrated, and brief but clear information is given about the diagnostic performance of the test, with particular reference to interval cancers. Moreover, the breast cancer risk due to radiation exposure from mammography is compared to the reduction in mortality obtained with the test, and the concept of overdiagnosis is presented. Finally, five frequently asked questions are answered.

Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk italian 1 study): final results

OBJECTIVES

: To prospectively compare clinical breast examination, mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (MRI) in a multicenter surveillance of high-risk women.

MATERIALS AND METHODS

: We enrolled asymptomatic women aged ≥ 25: BRCA mutation carriers; first-degree relatives of BRCA mutation carriers, and women with strong family history of breast/ovarian cancer, including those with previous personal breast cancer.

RESULTS

: A total of 18 centers enrolled 501 women and performed 1592 rounds (3.2 rounds/woman). Forty-nine screen-detected and 3 interval cancers were diagnosed: 44 invasive, 8 ductal carcinoma in situ; only 4 pT2 stage; 32 G3 grade. Of 39 patients explored for nodal status, 28 (72%) were negative. Incidence per year-woman resulted 3.3% overall, 2.1% <50, and 5.4% ≥ 50 years (P < 0.001), 4.3% in women with previous personal breast cancer and 2.5% in those without (P = 0.045). MRI was more sensitive (91%) than clinical breast examination (18%), mammography (50%), ultrasonography (52%), or mammography plus ultrasonography (63%) (P < 0.001). Specificity ranged 96% to 99%, positive predictive value 53% to 71%, positive likelihood ratio 24 to 52 (P not significant). MRI showed significantly better negative predictive value (99.6) and negative likelihood ratio (0.09) than those of the other modalities. At receiver operating characteristic analysis, the area under the curve of MRI (0.97) was significantly higher than that of mammography (0.83) or ultrasonography (0.82) and not significantly increased when MRI was combined with mammography and/or ultrasonography. Of 52 cancers, 16 (31%) were diagnosed only by MRI, 8 of 21 (38%) in women <50, and 8 of 31 (26%) in women ≥ 50 years of age.

CONCLUSION

: MRI largely outperformed mammography, ultrasonography, and their combination for screening high-risk women below and over 50.

Residual confounding after adjustment for age: a minor issue in breast cancer screening effectiveness

Residual confounding, after adjustment for age, is the major criticism of observational studies on breast cancer screening effectiveness. We developed realistic scenarios for the prevalence and strength of risk factors on screened and not screened groups, and explored the impact of residual confounding bias. Our results demonstrate that residual confounding bias is a minor issue in screening programme evaluations.