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Talala K, Walter S, Taari K, Tammela TLJ, Kujala P, Auvinen A. Screening history and risk of death from prostate cancer: a nested case-control study within the screening arm of the Finnish Randomized Study of Screening for Prostate Cancer (FinRSPC). Cancer Causes Control 2024; 35:695-703. [PMID: 38063980 PMCID: PMC10960891 DOI: 10.1007/s10552-023-01828-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/02/2023] [Indexed: 03/24/2024]
Abstract
PURPOSE We assessed the risk of death from prostate cancer (PCa) in relation to men's screening histories, i.e., screening attendance among men who were offered screening. METHODS Men in the Finnish Randomized Study of Screening for Prostate Cancer (FinRSPC) screening arm were invited to up to three screening rounds with the serum prostate-specific antigen (PSA) test at 4-year intervals during 1996-2007. Case subjects (n = 330) were men who died from PCa. Each case was matched to five controls (n = 1544) among the men who were free of PCa. Screening history was defined as (1) never/ever attended screening prior to the case diagnosis; (2) attended at the first screening round; and (3) recency of screening, calculated as the time from last screening attendance to the date of case diagnosis. The association between screening history and the risk of death from PCa was estimated by odds ratios (OR) with 95% confidence intervals (CI) using conditional logistic regression. RESULTS Having ever attended screening versus never attended was associated with a reduced risk of PCa death (OR 0.60, 95% CI 0.45-0.81) and a similar association was found for those attended (versus not attended) the first screening round (OR 0.67, 95% CI 0.51-0.87). The effect by time since last screen for the risk of PCa death was significantly lower 2-7 years since last screen. CONCLUSION Among men invited to screening, subjects who attended any PSA screening during the previous 19 years had a 40% reduction in PCa mortality compared to non-screened men.
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Affiliation(s)
- Kirsi Talala
- Finnish Cancer Registry, Unioninkatu 22, 00130, Helsinki, Finland.
| | - Stephen Walter
- Faculty of Health Sciences, McMaster University, Hamilton, ON, L8S 3L8, Canada
| | - Kimmo Taari
- Department of Urology, Helsinki University Hospital and University of Helsinki, 00029, Helsinki, Finland
| | - Teuvo L J Tammela
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland
- Department of Surgery, Tampere University Hospital, 33521, Tampere, Finland
| | - Paula Kujala
- Department of Pathology, Fimlab Laboratories, 33101, Tampere, Finland
| | - Anssi Auvinen
- Faculty of Social Sciences/Health Sciences, Tampere University, 33014, Tampere, Finland
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De Troeyer K, Silversmit G, Rosskamp M, Truyen I, Van Herck K, Goossens MM, Martens P, Kellen E, Hendrickx E, Rummens E, De Smet F, Broeders M, Verdoodt F, De Schutter H. The effect of the Flemish breast cancer screening program on breast cancer-specific mortality: A case-referent study. Cancer Epidemiol 2023; 82:102320. [PMID: 36608495 DOI: 10.1016/j.canep.2022.102320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Katrien De Troeyer
- Belgian Cancer Registry, 1210 Brussels, Belgium; Family Medicine and Population Health, Department of Epidemiology and Social Medicine, University of Antwerp, 2000 Antwerp, Belgium
| | | | | | - Inge Truyen
- Belgian Cancer Registry, 1210 Brussels, Belgium
| | | | - Mathijs Michiel Goossens
- Centre for Cancer Detection, 8000 Bruges, Belgium; Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | | | - Eliane Kellen
- Centre for Cancer Detection, 8000 Bruges, Belgium; University Hospital Leuven, Campus Sint Rafael, 3000 Leuven, Belgium
| | - Erik Hendrickx
- Agency for Care and Health, Flemish Government, 1030 Brussels, Belgium
| | - Elise Rummens
- Christian Health Insurance Fund, 1031 Brussels, Belgium
| | - Frank De Smet
- Christian Health Insurance Fund, 1031 Brussels, Belgium; Department of Public Health and Primary Care, Environment and Health, KU Leuven, 3000 Leuven, Belgium
| | - Mireille Broeders
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Eby PR, Ghate S, Hooley R. The Benefits of Early Detection: Evidence From Modern International Mammography Service Screening Programs. JOURNAL OF BREAST IMAGING 2022; 4:346-356. [PMID: 38416986 DOI: 10.1093/jbi/wbac041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Indexed: 03/01/2024]
Abstract
Research from randomized controlled trials initiated up to 60 years ago consistently confirms that regular screening with mammography significantly reduces breast cancer mortality. Despite this success, there is ongoing debate regarding the efficacy of screening, which is confounded by technologic advances and concerns about cost, overdiagnosis, overtreatment, and equitable care of diverse patient populations. More recent screening research, designed to quell the debates, derives data from variable study designs, each with unique strengths and weaknesses. This article reviews observational population-based screening research that has followed the early initial long-term randomized controlled trials that are no longer practical or ethical to perform. The advantages and disadvantages of observational data and study design are outlined, including the three subtypes of population-based observational studies: cohort/case-control, trend, and incidence-based mortality/staging. The most recent research, typically performed in countries that administer screening mammography to women through centralized health service programs and directly track patient-specific outcomes and detection data, is summarized. These data are essential to understand and inform construction of effective new databases that facilitate continuous assessment of optimal screening techniques in the current era of rapidly developing medical technology, combined with a focus on health care that is both personal and equitable.
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Affiliation(s)
- Peter R Eby
- Virginia Mason Medical Center, Department of Radiology, Seattle, WA, USA
| | - Sujata Ghate
- Duke University School of Medicine, Department of Radiology, Durham, NC, USA
| | - Regina Hooley
- Yale New Haven Hospital, Department of Radiology and Biomedical Imaging, New Haven, CT, USA
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Case-control Studies on the Effectiveness of Breast Cancer Screening: Insights from the UK Age Trial. Epidemiology 2016; 26:590-6. [PMID: 25767987 DOI: 10.1097/ede.0000000000000285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Massat NJ, Sasieni PD, Parmar D, Duffy SW. An ongoing case-control study to evaluate the NHS Bowel Cancer Screening Programme. BMC Cancer 2014; 14:945. [PMID: 25495609 PMCID: PMC4320602 DOI: 10.1186/1471-2407-14-945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 12/04/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cause of cancer death in both males and females in England. A national bowel cancer screening programme was rolled out in England between 2006 and 2010. In the post-randomised controlled trials epoch, assessment of the impact of the programme using observational studies is needed. This study protocol was set up at the request of the UK Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis to evaluate the effect of the current bowel cancer screening programme on incidence of advanced primary colorectal cancer. METHODS/DESIGN All incident cases of primary colorectal cancer in England will be included. Cases will be matched to controls with respect to sex, age, area of registration and year of first invitation to screening. Each evaluation round will cover a 2-year period, starting from January 2012, and ongoing thereafter. In the first instance, a pilot will be carried out in a single region. Variables related to colorectal tumour pathology will be obtained to enable selection and matching of cases and controls, and to allow analyses stratification by anatomical subsite within the bowel. Cases at Duke's stage B or worse will be considered as "advanced stage". The influence of sex will also be investigated. The incidence ratio observed in randomised controlled trials between controls (not invited) and non-attender invitees will be used to correct for self-selection bias overall. Screening participation at other national screening programmes (cervical, breast) will also be collected to derive a more contemporaneous adjustment factor for self-selection bias and assess consistency in self-selection correction in female patients.Full ethical approval was obtained from the Health Research Authority. DISCUSSION The case-control design is potentially prone to a number of biases. The size of the planned study, the design specifications and the development of analytical strategies to cope with bias should enable us to obtain accurate estimates of reduction in incidence of advanced stage disease. The results of analyses by sex and anatomical subsite may highlight the potential need for sex-specific recommendations in the programme.
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Affiliation(s)
- Nathalie J Massat
- />Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Peter D Sasieni
- />Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Dharmishta Parmar
- />Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Stephen W Duffy
- />Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
- />Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts’ and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Massat NJ, Sasieni PD, Parmar D, Duffy SW. An ongoing case-control study to evaluate the NHS breast screening programme. BMC Cancer 2013; 13:596. [PMID: 24330588 PMCID: PMC3866937 DOI: 10.1186/1471-2407-13-596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/04/2013] [Indexed: 11/22/2022] Open
Abstract
Background In England, a national breast screening programme (NHSBSP) has been in place since 1988, and assessment of its impact on breast cancer incidence and mortality is essential to ensure that the programme is indeed doing more good than harm. This article describes large observation studies designed to estimate the effects of the current programme in terms of the benefits on breast cancer incidence and mortality and detrimental effect in terms of overdiagnosis. The case-control design of the cervical screening programme evaluation was highly effective in informing policy on screening intervals and age ranges. We propose innovative selection of cases and controls and gathering of additional variables to address new outcomes of interest and develop new methodologies to control for potential sources of bias. Methods/Design Traditional case-control evaluation of breast screening uses women who have died from breast cancer as cases, and women known to be alive at the time of case death as controls. Breast screening histories prior to the cases’ date of first diagnosis are compared. If breast screening is preventing mortality from breast cancer, cases will be characterised by a lesser screening history than controls. All deaths and incident cases of primary breast cancer in England within each 2-year study period will be included in this ongoing evaluation. Cases will be age- and area-matched to controls and variables related to cancer treatment and breast tumour pathology will be obtained to investigate the interplay between screening and treatment, and the effect of screening on incidence of advanced stage disease. Screening attendance at other national screening programmes will also be collected to derive superior adjustment for self-selection bias. The study is registered and has received full ethics approval.
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Affiliation(s)
| | | | | | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine - Room 009, Queen Mary University of London, London EC1M 6BQ, UK.
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Paap E, Verbeek A, Puliti D, Paci E, Broeders M. Breast cancer screening case–control study design: impact on breast cancer mortality. Ann Oncol 2011; 22:863-869. [DOI: 10.1093/annonc/mdq447] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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