Four Principles to Consider Before Advising Women on Screening Mammography

Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors

OBJECTIVE

To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo.

METHODS

Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators.

RESULTS

Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR - relative risk: 0.97; 95%CI - credible interval: 0.93-1.00); women being the head of the household (RR 0.97; 95%CI 0.94-0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00-1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87-0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18-1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01-1.18).

CONCLUSION

The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors

ABSTRACT Objective: To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo. Methods: Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators. Results: Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR – relative risk: 0.97; 95%CI – credible interval: 0.93–1.00); women being the head of the household (RR 0.97; 95%CI 0.94–0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00–1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87–0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18–1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01–1.18). Conclusion: The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

Pink October and mammograms: when health communication misses the target

Breast cancer is the most frequently diagnosed type of cancer and is the leading cause of death from cancer in the female population. Screening mammograms and early treatment are the most frequently used means to attempt to reduce this mortality and are promoted during Pink October, an annual awareness-raising campaign. However, recent studies have correlated the increase in screening with higher morbidity and mortality, due to overdiagnosis and overtreatment. The current study assessed searches related to breast cancer and mammogram in Google Trends from 2004 to 2019 in terms of trend, seasonality, and distribution in Brazilian states. The study also evaluatedH the correlation between the number of searches in Google Trends and the number of screening mammograms. The two series showed a seasonal pattern with peaks in October, and there was an excess in tests performed outside the recommended age bracket. Pink October transmitted and popularized health information and induced behaviors related to this information, which are three desirable aspects in health communication and education. However, the campaign also generated an excess in screening mammograms and did not encourage autonomy and free and informed consent. Pink October revealed both the potential of mass communication in health and the need for messages to be aligned with the best available scientific evidence.

Cost-effectiveness evaluation of mammography screening program in Taiwan: Adjusting different distributions of age and calendar year for real world data

BACKGROUND/PURPOSE

We estimated loss-of-life expectancy (LE) and lifetime medical expenditures (LME) stratified by stages to evaluate the cost-effectiveness of breast cancer (BC) screening in Taiwan.

METHODS

We interlinked four national databases- Cancer Registry, Mortality Registry, National Health Insurance Claim, and Mammography Screening. A cohort of 123,221 BC was identified during 2002-2015 and followed until December 31, 2017. We estimated LE and loss-of-LE by rolling extrapolation algorithm using age-, sex-, and calendar-year-matched referents simulated from vital statistics. LME was estimated by multiplying monthly cost with survival probability and adjusted for annual discount rate. We calculated incremental cost-effectiveness ratio (ICER) by comparing the loss-of-LE of those detected by screening versus non-screening after accounting for administration fees and radiation-related excess BC.

RESULTS

The LEs of stages I, II, III, and IV were 31.4, 27.2, 20.0, and 5.2 years, respectively, while the loss-of-LEs were 1.2, 4.9, 11.7, and 25.0 years with corresponding LMEs of US$ 73,791, 79,496, 89,962, and 66,981, respectively. The difference in LE between stages I and IV was 26.2 years while that of loss-of-LE was 23.8 years, which implies that a potential lead time bias may exist if diagnosis at younger ages for earlier stages were not adjusted for. The ICER of mammography seemed cost-saving after the coverage exceeded half a million.

CONCLUSION

Mammography could detect BC early and be cost-saving after adjustment for different distributions of age and calendar year of diagnosis. Future studies exploring healthcare expenditure and impaired quality of life for false-positive cases are warranted.

Screening for reducing morbidity and mortality in malignant melanoma

BACKGROUND

Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged.

OBJECTIVES

To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population.

SEARCH METHODS

We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports.

SELECTION CRITERIA

RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences.

MAIN RESULTS

We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data.

AUTHORS' CONCLUSIONS

Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

Factors associated with false-positive mammography at first screen in an Asian population

Introduction

False-positive recall is an issue in national screening programmes. The aim of this study is to investigate the recall rate at first screen and to identify potential predictors of false-positive recall in a multi-ethnic Asian population-based breast cancer screening programme.

Methods

Women aged 50–64 years attending screening mammography for the first time (n = 25,318) were included in this study. The associations between potential predictors (sociodemographic, lifestyle and reproductive) and false-positive recall were evaluated using multivariable logistic regression models.

Results

The recall rate was 7.6% (n = 1,923), of which with 93.8% were false-positive. Factors independently associated with higher false-positive recall included Indian ethnicity (odds ratio [95% confidence interval]: 1.52 [1.25 to 1.84]), premenopause (1.23 [1.04 to 1.44]), nulliparity (1.85 [1.57 to 2.17]), recent breast symptoms (1.72 [1.31 to 2.23]) and history of breast lump excision (1.87 [1.53 to 2.26]). Factors associated with lower risk of false-positive recall included older age at screen (0.84 [0.73 to 0.97]) and use of oral contraceptives (0.87 [0.78 to 0.97]). After further adjustment of percent mammographic density, associations with older age at screening (0.97 [0.84 to 1.11]) and menopausal status (1.12 [0.95 to 1.32]) were attenuated and no longer significant.

Conclusion

For every breast cancer identified, 15 women without cancer were subjected to further testing. Efforts to educate Asian women on what it means to be recalled will be useful in reducing unnecessary stress and anxiety.

Analysing the ethics of breast cancer overdiagnosis: a pathogenic vulnerability

Breast cancer screening aims to help women by early identification and treatment of cancers that might otherwise be life-threatening. However, breast cancer screening also leads to the detection of some cancers that, if left undetected and untreated, would not have damaged the health of the women concerned. At the time of diagnosis, harmless cancers cannot be identified as non-threatening, therefore women are offered invasive breast cancer treatment. This phenomenon of identifying (and treating) non-harmful cancers is called overdiagnosis. Overdiagnosis is morally problematic as it leads to overall patient harm rather than benefit. Further, breast cancer screening is offered in a context that exaggerates cancer risk and screening benefit, minimises risk of harm and impedes informed choice. These factors combine to create pathogenic vulnerability. That is, breast cancer screening exacerbates rather than reduces women's vulnerability and undermines women's agency. This paper provides an original way of conceptualising agency-supporting responses to the harms of breast cancer overdiagnosis through application of the concept of pathogenic vulnerability.

A suggested framework for conducting esophageal cancer screening in China

Esophageal cancer is one of the most prevalent malignant tumors worldwide. Because of its challenging clinical characteristics, esophageal cancer is a major disease burden on the economy, society, and individuals. There is an urgent need to establish a beneficial policy to reduce the burden and to improve the health-related quality of life of patients. Primary prevention with smoking cessation and reduction of drinking alcohol are highly recommended. Screening, early diagnosis and treatment are suggested. This study intended to establish a modified future screening model from the social perspective that deploys different strategies for different populations. Risk assessment and community-based screening are proposed for high-risk populations. Health education in low-risk areas could help promote primary prevention to mitigate lifestyle factors and to increase public awareness and potentially to increase screening and early detection.

Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis

OBJECTIVE

Identify the factors associated with the age-standardised breast cancer mortality rate in the municipalities of State of São Paulo (SSP), Brazil, in the period from 2006 to 2012.

DESIGN

Ecological study of the breast cancer mortality rate standardised by age, as the dependent variable, having each of the 645 municipalities in the SSP as the unit of analysis.

SETTINGS

The female resident population aged 15 years or older, by age group and municipality, in 2009 (mid-term), obtained from public dataset (Informatics Department of the Unified Health System).

PARTICIPANTS

Women 15 years or older who died of breast cancer in the SSP were selected for the calculation of the breast cancer mortality rate, according to the municipality and age group, from 2006 to 2012.

MAIN OUTCOME MEASURES

Mortality rates for each municipality calculated by the direct standardisation method, using the age structure of the population of SSP in 2009 as the standard.

RESULTS

In the final linear regression model, breast cancer mortality, in the municipal level, was directly associated with rates of nulliparity (p<0.0001), mammography (p<0.0001) and private healthcare (p=0.006).

CONCLUSIONS

The findings that mammography ratio was associated, in the municipal level, with increased mortality add to the evidence of a probable overestimation of benefits and underestimation of risks associated with this form of screening. The same paradoxical trend of increased mortality with screening was found in recent individual-level studies, indicating the need to expand informed choice for patients, primary prevention actions and individualised screening. Additional studies should be conducted to explore if there is a causality link in this association.

Massive Endoscopic Screening for Esophageal and Gastric Cancers in a High-Risk Area of China

OBJECTIVE

This study aims to describe the findings from a massive endoscopic screening program in a high-risk area of China and to evaluate the prognosis of patients diagnosed through endoscopic screening compared with those diagnosed at usual hospital visits because of illness.

METHODS

In 2006, an early detection and treatment program was initiated in Yangzhong county, China. Local residents aged 40-69 years were eligible for free endoscopic screening. Endoscopic examination was performed with Lugol's iodine staining, followed by biopsies. Patients diagnosed with esophageal or gastric cancer were referred for treatment and followed to assess their long-term survival status.

RESULTS

From 2006 through 2012, we screened 12453 participants, including 5334 (42.8%) men and 7119 (57.2%) women. The average age was 52.8 ± 8.0 years. We detected 166 patients with upper digestive tract cancers, including 106 cancers in the esophagus (detection rate: 0.85%) and 60 cancers in the stomach (detection rate: 0.48%). Of these patients, 98.11% with esophageal cancer and 100% with gastric cancer were defined as at the early stage. In the process of follow-up, 17 patients died from cancer-related causes, and the median survival time was greater than 85 months. The overall survival rates for 1, 3 and 5 years were 98.0%, 90.0% and 89.0%, respectively. A significant positive effect was observed for the long-term survival of patients diagnosed through massive endoscopic screening.

CONCLUSIONS

In a high-risk population, massive endoscopic screening can identify early stage carcinoma of esophageal and gastric cancers and improve patients' prognosis through early detection and treatment.