Predicted long-term mortality reduction associated with the second round of breast screening in East Anglia

Early evaluation of an organised mammography screening program in Greece 2004-2009

OBJECTIVE

The aim of the current study was to present early performance indicators of a breast cancer screening program in Greece.

METHODS

Between March 2004 and July 2009, 9621 women aged between 40 and 69 years were recruited into programme on a voluntary basis. The participating women were residents of two adjacent administrative regions of Greece. Several performance indicators were calculated for the first and subsequent screen, separately.

RESULTS

A total of 9621 mammograms were 1st screens and 4462 were subsequent screens. The attendance rate was almost 1.5%. The technical repeat rate was 1.7%. On the 1st screen, the recall rate was 11.4%, while the recall rate of the subsequent screens was 5.5%. The vast majority of detected cancers were invasive and only the 1/7 of cancers was identified as DCIS. As concerns tumour size of invasive cancers, the 1.9% and 16.7% was unknown, in the first and subsequent screen, respectively. Moreover, 38.5% and 44.4% of cancers detected in the 1st and subsequent screen, respectively, were less than 15 mm in diameter. Almost 1/5 of diagnosed cancers were interval cancers.

CONCLUSIONS

This breast cancer screening programme is the first one in Greece and the attendance rate is extremely low. Taking into account that an organised screening programme may benefit women with a reduction in breast cancer mortality, there is an urgent need to develop a national-based screening programme, to increase participation and to improve the information system used to monitor programme performance.

Evaluating Population-Based Screening Mammography Programs Internationally

This report describes the purpose and activities of the International Breast Cancer Screening Network (IBSN), a voluntary consortium of countries that focuses on collaborative research to identify and promote efficient, effective approaches to breast cancer control world-wide through population-based screening mammography. Sponsored by the U.S. National Cancer Institute, the IBSN was established in 1988 with eleven participating countries. By 2005, membership had grown to 27 countries. Recent IBSN efforts have involved gathering information on program organization and quality assurance activities, evaluating measures and methodologies for assessing screening mammography performance and outcomes, and examining the information that programs are providing to women as a means of facilitating informed decision-making about the benefits and risks of screening mammography. The ongoing IBSN effort demonstrates that-despite marked differences in health care systems-international collaborative work can contribute new knowledge to the monitoring and evaluation of organized, population-based screening mammography programs, and identify potential areas for improvement in screening performance in practice.

The effect of data quality at the time of introduction of population-based screening on the estimate of programme impact using surrogate outcome measures

OBJECTIVE

The aim of this study was to examine the availability and quality of surrogate outcome measure data to enable the evaluation of the breast screening programme. As the observed effect on mortality of a screening programme occurs many years after the introduction of screening, surrogate outcome measures offer an attractive alternative, allowing estimates of the effect to be calculated earlier.

METHODS

The exercise was undertaken by the Oxford Cancer Intelligence Unit and the Cancer Screening Evaluation Unit in collaboration with cancer registries in England, Scotland and Wales.

RESULTS

The conclusion of the exercise was that, in general, the available data quality was insufficient to allow a precise estimate of the overall mortality reduction from breast screening to be made using surrogate measures.

CONCLUSIONS

When a screening programme is started, it is vital that forward planning is undertaken to ensure that the necessary information is ready to be collected before the start of the programme. The use of surrogate measures is dependent on high-quality data in the uninvited group of women (pre-screening or from a staggered start over areas), and improving data quality over time after the start of the programme is of very limited value for a surrogate measures approach. The collection of appropriate high-quality information before the programme starts is, therefore, critical to measuring the success of the programme. Cancer registries and staff within the screening programme need to be ready to collect the appropriate data before the introduction of a screening programme. The exercise undertaken therefore has important implications where new screening programmes are being considered.

Evaluating organized breast cancer screening implementation: the prevention of late-stage disease?

The objective of our study was to evaluate organized breast cancer screening implementation by measuring the association between screening program enrollment and late-stage disease. Our setting was a health plan using mailed mammography reminders to women ages > or = 40. We conducted yearly cross-sectional summaries of mammography experience and late-stage (regional or distant Surveillance Epidemiology and End Results Reporting (SEER) stage) breast cancer occurrence for all of the health-plan women ages > or = 40 (1986-1998). We estimated the odds of late-stage breast cancer among health-plan and surrounding community women because it was too early to compare changes in mortality. We also estimated the odds of late-stage disease (1995-1998) associated with program enrollment and mammography screening among health-plan women. We found that mammography-within-two-years increased within the health plan from 25.9% to 51.2% among women ages 40-49 and from 32.9% to 74.7% among women ages> or = 50. Health-plan late-stage rates were lower than those in the surrounding community [ages 40-49: odds ratio (OR), 0.87; 95% confidence interval (CI), 0.77-0.99; ages 50-79: OR, 0.86; 95% CI, 0.80-0.92] and declined parallel to the community. Among health-plan cancer cases, women ages > or = 43 who were enrolled in the screening program and who had at least one program mammogram were less likely to have late-stage disease compared with the women not enrolled in the program (OR, 0.31; 95% CI, 0.16-0.61) but the odds of late-stage was also reduced among program-enrolled women not receiving program mammograms (OR, 0.45; 95% CI, 0.21-0.95). We concluded that enrollment in organized screening is associated with increased likelihood of mammography and reduced odds of late-stage breast cancer. Addressing the concerns of un-enrolled women and those without mammograms offers an opportunity for further late-stage disease reduction.

Improvements in survival for women with breast cancer in Scotland between 1987 and 1993: impact of earlier diagnosis and changes in treatment

We investigated changes in survival, and their causes, in women with early breast cancer diagnosed in Scotland. The Scottish Cancer Registry identified 1617 and 2077 such women, without metastases at diagnosis who underwent surgery as part of their primary treatment, diagnosed in 1987 and 1993, respectively. There was a statistically significant 11% improvement in 8-year survival between 1987 and 1993. Survival improved across almost all clinical/pathological, treatment and health care delivery/deprivation categories; improvement was not limited to those women diagnosed through the screening programme. In a multivariate model, improved survival appeared to be explained largely by screening and clinical/pathological prognostic factors. Deprivation also had an adverse effect on survival; however, the geographical variation in survival observed for women diagnosed in 1987 was not apparent by 1993. We did not demonstrate a significant independent effect of surgical caseload on survival. We conclude that survival has increased partly as a consequence of screening and earlier diagnosis, but also due to improvements in the organisation and delivery of care.

Breast cancer incidence and mortality trends in 16 European countries

Trends in the incidence of and mortality from breast cancer result from a variety of influences including screening programmes, such as those introduced in several European countries in the late 1980s. Incidence and mortality rates for 16 European countries are analysed. Incidence increased in all countries. The estimated annual percent change (EAPC) varied from 0.8 to 2.8% in prescreening years in 6 'screened' countries and from 1.2 to 3.0% in 10 'non-screened' countries. Screening related temporary increases were visible. Earlier mortality trends were maintained in the most recent decade in Estonia (EAPC +1.8%) and Sweden (-1.2%). In other countries, previously increasing trends changed. Trends flattened in Finland, Denmark, France, Italy and Norway (EAPC 0.0 to -0.3%), while they declined in England and Wales (-3.1%), Scotland (-2.0%), and The Netherlands (-1.0%), all of which have national screening programmes, and in Slovakia (-1.1%), Spain (-0.7%), and Switzerland (-1.1%). In some countries with screening programmes, declines in mortality started before screening was introduced, and declines also occurred in non-screened age groups and in some countries without national screening programmes. This suggests that the major determinants of the observed trends vary among the countries and may include earlier detection through screening in countries where this has been introduced, but also improvements in therapy, in countries with or without screening.

Evaluation of the UK breast screening programmes

National breast screening programmes were set up in the UK in the early 1990s. Although they are quality-assured and publish process measures of performance, there is a lack of data linking the screening process to breast cancer mortality. A new analysis of trends in England and Wales suggests that the effect of screening has been to reduce mortality by 8% over 10 years in those eligible for screening in 1990.

Impact of false-positive mammography on subsequent screening attendance and risk of cancer

BACKGROUND

One area of concern within the largely successful UK National Health Service breast screening programme is the relatively high proportion of women showing mammographic abnormalities who undergo further diagnostic tests that prove negative. Previous studies suggest that, in addition to increasing anxiety, such false-positive mammography is associated with increased risk of subsequent interval cancer. In the present article, we quantify this increased risk, investigate whether it extends to cancers detected at rescreening, and determine whether cancers differ between women who have, and have not, experienced false-positive mammography.

METHODS

This was a retrospective cohort study of 140,387 women aged 49-63 years routinely invited for first screening by the East Anglian National Health Service breast screening programme. Proportions reattending, and subsequent risk and pathological attributes of cancer were compared between women who underwent further (negative) assessment following false-positive mammography and women mammographically normal at first screen.

RESULTS

At first screen, 108,617 (91.9%) of the screened women were mammographically normal, 4278 (3.6%) were assessed and then judged normal, and 514 (0.4%) underwent benign biopsy. Compared with nonassessed normal women, reattendance was lower among assessed women: 83.1% (95% confidence interval [CI], 82.0-84.1) versus 85.7% (95% CI, 85.5-85.9) (odds ratio [OR], 0.82; 95% CI, 0.76-0.89). Assessed women were at greater risk of interval cancer (rate per 1000 women screened, 9.6 [95% CI, 6.8-12.4] versus 3.0 [95% CI, 2.7-3.4]; OR, 3.19 [95% CI, 2.34-4.35]), and also of cancer detected at second screen (rate per 1000, 8.4 [95% CI, 5.8-10.9] versus 3.9 [95% CI, 3.5-4.3]; OR, 2.15 [95% CI, 1.55-2.98]). More cancers in assessed women measured >or = 20 mm (OR, 1.59; 95% CI, 0.99-2.55).

CONCLUSIONS

Women undergoing false-positive mammography at first screen were less likely to reattend for subsequent screens than were nonassessed women, yet they were more likely to develop interval cancers or cancers at second screen, and their cancers were larger. Factors predisposing for false-positive mammography require investigation. Women should be encouraged to continue with screening.

The evolution of screening

Botany is usually considered to be the gentlest of sciences with botanists being regarded as people who study relatively safe specimens, compared with, for example, anthropologists or microbiologists. However, botanists have their moments, particularly when collecting new species. The great botanists of the eighteenth and nineteenth centuries risked their lives in collecting and bringing back species, which we now take for granted, and Robert Brown was one of these adventurers, a young Scot who accompanied Sir Joseph Banks to New Holland. It was not, however, for his adventurous lifestyle that Brown is remembered but for his startling observation of the movements of pollen grains on a microscope slide. He noted that the pollen grains were in perpetual agitated motion, without purpose or direction but full of energy. This motion, called Brownian motion, arises from the movement of molecules, and Brownian motion is the term that has been applied to much of healthcare, including many screening programmes, which have in the past been marked more by the amount of energy and activity than by a clear sense of direction or positive achievement.