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Irzaldy A, Otten JDM, Kregting LM, van der Molen DRM, Verkooijen HM, van Ravesteyn NT, Heijnsdijk EAM, Doeksen A, van der Pol CC, Evers DJ, Ernst MF, Korfage IJ, de Koning HJ, Broeders MJM. Quality of life of women with a screen-detected versus clinically detected breast cancer in the Netherlands: a prospective cohort study. Qual Life Res 2024:10.1007/s11136-024-03783-0. [PMID: 39287764 DOI: 10.1007/s11136-024-03783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2024] [Indexed: 09/19/2024]
Abstract
PURPOSE Breast cancer (BC) screening enables early detection of BC, which may lead to improved quality of life (QoL). We aim to compare QoL between women with a screen-detected and clinically detected BC in the Netherlands. METHODS We used data from the 'Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaluation' (UMBRELLA) between October 2013 and March 2022. Patients were categorized as screen-detected or clinically detected. We analysed three questionnaires, namely EORTC QLQ C-30, BR23, and HADS (Hospital Anxiety and Depression Scale) completed by BC patients shortly after diagnosis (T1) and one-year after treatment (T2). Independent t-tests were performed to compare QoL average differences between the two groups. Bonferroni-corrected p-value significance threshold of 0.00057 was used. The magnitude of differences was calculated using Cohen's d. The clinical relevance of QLQ-C30 differences was assessed based on interpretation guideline of EORTC-QLQ-C30 results. RESULTS After applying inclusion and exclusion criteria, there were 691 women with screen-detected BC and 480 with clinically detected BC. Generally, screen-detected BC patients reported a better QoL. At T1, their average QLQ-C30 summary score was higher (86.1) than clinically detected BC patients (83.0) (p < 0.0001). Cohen's d for all items ranged between 0.00 and 0.39. A few QLQ-C30 score differences were clinically relevant, indicating better outcomes in emotional functioning, general health, constipation, and fatigue for women with screen-detected BC. CONCLUSIONS In the Netherlands, women with screen-detected BC reported statistically significant and better QoL than women with clinically detected BC. However, clinical relevance of the differences is limited.
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Affiliation(s)
- Abyan Irzaldy
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands.
| | - Johannes D M Otten
- IQ Health Science Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lindy M Kregting
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands
- IQ Health Science Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Helena M Verkooijen
- Division of Imaging & Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Nicolien T van Ravesteyn
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands
| | - Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands
| | - Annemiek Doeksen
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | | | - Daniel J Evers
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Miranda F Ernst
- Department of Surgery, Alexander Monro Hospital, Bilthoven, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 40 NA-24, Rotterdam, 3015 GD, The Netherlands
| | - Mireille J M Broeders
- IQ Health Science Department, Radboud University Medical Centre, Nijmegen, The Netherlands
- Dutch Expert Centre for Screening, Nijmegen, The Netherlands
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Ten Velde DE, Duijm LEM, van der Sangen MJC, Schipper RJ, Tjan-Heijnen VCG, Vreuls W, Strobbe LJA, Voogd AC. Long-term trends in incidence, characteristics and prognosis of screen-detected and interval cancers in women participating in the Dutch breast cancer screening programme. Br J Cancer 2024; 130:1561-1570. [PMID: 38467826 PMCID: PMC11059155 DOI: 10.1038/s41416-024-02633-7] [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: 11/03/2023] [Revised: 02/18/2024] [Accepted: 02/20/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND No studies are available in which changes over time in characteristics and prognosis of patients with interval breast cancers (ICs) and screen-detected breast cancers (SDCs) have been compared. The aim was to study these trends between 1995 and 2018. METHODS All women with invasive SDCs (N = 4290) and ICs (N = 1352), diagnosed in a southern mammography screening region in the Netherlands, were included and followed until date of death or 31 December 2022. RESULTS The 5-year overall survival rate of women with SDCs increased from 91.4% for those diagnosed in 1995-1999 to 95.0% for those diagnosed in 2013-2018 (P < 0.001), and from 74.8 to 91.6% (P < 0.001) in the same periods for those with ICs. A similar trend was observed for the 10-year survival rates. After adjustment for changes in tumour characteristics, the hazard ratio (HR) for overall survival was 0.47 (95% confidence interval (CI): 0.38-0.59) for women with SDCs diagnosed in the period 2013-2018, compared to the women diagnosed in the period 1995-1999. For the women with ICs this HR was 0.27 (95% CI: 0.19-0.40). CONCLUSION The prognosis of women with ICs has improved rapidly since 1995 and is now almost similar to that of women with SDCs.
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Affiliation(s)
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | | | | | - Willem Vreuls
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands.
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands.
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Aga SS, Yasmeen N, Al-Mansour M, Khan MA, Nissar S, Khawaji B, Awadh A, Alasmari MM, Abushouk A. Knowledge, awareness and attitude towards breast cancer: Risk factors, signs and screening among Health and Allied students: A prospective study. J Family Med Prim Care 2024; 13:1804-1824. [PMID: 38948630 PMCID: PMC11213396 DOI: 10.4103/jfmpc.jfmpc_1720_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 07/02/2024] Open
Abstract
Introduction Breast cancer (BC) is the second most common cancer in Saudi women. Therefore, understanding BC and its related risk factors, symptoms, and screening is critical for early detection and intervention. The current study was meant to explore the knowledge, awareness, and attitude (KAA) gap in BC: risk factors, symptoms, and screening. Material and Methods This cross-sectional investigation was carried out with Health Professions Students (HPS) using a predesigned and validated study questionnaire to examine HPS knowledge and attitudes concerning BC and associated risk factors, symptoms, and screening. Results A total of 277 female students responded to the survey. The frequency of correct answers for the BC knowledge questions varied from the lowest of 27.8% to the highest of 88.8%, with only 5 out of 15 questions (33.3%) answered correctly by more than 60% of the participants, displaying poor knowledge and awareness of BC. A majority (>60%) of the participants identified only 7 of the 18 risk factors of BC correctly, whereas 11 of the 13 early warning signs of BC were identified correctly by the majority (>60%) of the participants. Among the participants, only 26.4% were aware of the breast cancer screening center, but 94.6% of them agreed that early detection of breast cancer is important and 82.7% agreed to participate in the screening program if offered. Conclusion Participants' knowledge and awareness of BC were found to be relatively low; however, their attitudes towards BC screening were positive. As a result, it is critical to develop effective education programs, curricular activities, and awareness campaigns to address the lack of awareness of BC and to have an appropriate response to screening to reduce disease burden.
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Affiliation(s)
- Syed S. Aga
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Molecular Diseases and Diagnostics Division, Infinity Biochemistry Pvt. Ltd, Sajjad Abad, Chattabal, Srinagar, Kashmir, India
| | - Nusrath Yasmeen
- Department of Pharmacy, College of Nursing, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mubarak Al-Mansour
- Department of Medical Education, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Adult Medical Oncology, Princess Noorah Oncology Center, King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Muhammad A. Khan
- Department of Medical Education, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Saniya Nissar
- Molecular Diseases and Diagnostics Division, Infinity Biochemistry Pvt. Ltd, Sajjad Abad, Chattabal, Srinagar, Kashmir, India
| | - Bader Khawaji
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdullah Awadh
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Department of Medical Education, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Moudi M. Alasmari
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Amir Abushouk
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Schumann L, Hadwiger M, Eisemann N, Katalinic A. Lead-Time Corrected Effect on Breast Cancer Survival in Germany by Mode of Detection. Cancers (Basel) 2024; 16:1326. [PMID: 38611004 PMCID: PMC11010975 DOI: 10.3390/cancers16071326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: Screen-detected breast cancer patients tend to have better survival than patients diagnosed with symptomatic cancer. The main driver of improved survival in screen-detected cancer is detection at earlier stage. An important bias is introduced by lead time, i.e., the time span by which the diagnosis has been advanced by screening. We examine whether there is a remaining survival difference that could be attributable to mode of detection, for example, because of higher quality of care. (2) Methods: Women with a breast cancer (BC) diagnosis in 2000-2022 were included from a population-based cancer registry from Schleswig-Holstein, Germany, which also registers the mode of cancer detection. Mammography screening was available from 2005 onwards. We compared the survival for BC detected by screening with symptomatic BC detection using Kaplan-Meier, unadjusted Cox regressions, and Cox regressions adjusted for age, grading, and UICC stage. Correction for lead time bias was carried out by assuming an exponential distribution of the period during which the tumor is asymptomatic but screen-detectable (sojourn time). We used a common estimate and two recently published estimates of sojourn times. (3) Results: The analysis included 32,169 women. Survival for symptomatic BC was lower than for screen-detected BC (hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.21-0.25). Adjustment for prognostic factors and lead time bias with the commonly used sojourn time resulted in an HR of 0.84 (CI: 0.75-0.94). Using different sojourn times resulted in an HR of 0.73 to 0.90. (4) Conclusions: Survival for symptomatic BC was only one quarter of screen-detected tumors, which is obviously biased. After adjustment for lead-time bias and prognostic variables, including UICC stage, survival was 27% to 10% better for screen-detected BC, which might be attributed to BC screening. Although this result fits quite well with published results for other countries with BC screening, further sources for residual confounding (e.g., self-selection) cannot be ruled out.
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Affiliation(s)
- Laura Schumann
- Institute of Social Medicine and Epidemiology, University of Luebeck, 23562 Luebeck, Germany (N.E.); (A.K.)
| | - Moritz Hadwiger
- Institute of Social Medicine and Epidemiology, University of Luebeck, 23562 Luebeck, Germany (N.E.); (A.K.)
| | - Nora Eisemann
- Institute of Social Medicine and Epidemiology, University of Luebeck, 23562 Luebeck, Germany (N.E.); (A.K.)
| | - Alexander Katalinic
- Institute of Social Medicine and Epidemiology, University of Luebeck, 23562 Luebeck, Germany (N.E.); (A.K.)
- Institute of Cancer Epidemiology, University of Luebeck, 23562 Luebeck, Germany
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5
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de Munck L, Eijkelboom AH, Otten JDM, Broeders MJM, Siesling S. Method of primary breast cancer detection and the disease-free interval, adjusting for lead time. J Natl Cancer Inst 2024; 116:370-378. [PMID: 37935443 PMCID: PMC10919328 DOI: 10.1093/jnci/djad230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Little is known about the impact of screen-detected breast cancer compared with clinically detected breast cancer on the disease-free interval (ie, free from locoregional recurrences, distant metastasis, contralateral breast cancer). Moreover, it is thought that most studies overestimate the beneficial effect of screening, as they do not adjust for lead time. We investigated the association between method of breast cancer detection and disease-free interval, taking lead time into account. METHODS Women aged 50-76 years, diagnosed with breast cancer between 2005 and 2008 were selected from the Netherlands Cancer Registry. Women diagnosed in 2005 were divided into screen-detected and clinically detected cancer and had a follow-up of 10 years (2005 cohort). Women diagnosed in 2006-2008 were divided into screen-detected, interval, and nonscreen-related cancer and had a follow-up of 5 years (2006-2008 cohort). A previously published method was used to adjust for lead time. Analyses were repeated correcting for confounding variables instead of lead time. RESULTS The 2005 cohort included 6215 women. Women with screen-detected cancer had an improved disease-free interval compared with women with clinically detected cancer (hazard ratio [HR] = 0.77, 95% confidence interval [CI] = 0.68 to 0.87). The 2006-2008 cohort included 15 176 women. Women with screen-detected or interval cancer had an improved disease-free interval compared with women with nonscreen-related cancer (HR = 0.76, 95% CI = 0.66 to 0.88; HR = 0.88, 95% CI = 0.78 to 0.99, respectively). Correcting for confounders instead of lead time did not change associations. CONCLUSION Women with screen-detected cancer had an improved disease-free interval compared with women with a nonscreen-related or clinically detected cancer, after correction for lead time.
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Affiliation(s)
- Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Anouk H Eijkelboom
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Johannes D M Otten
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mireille J M Broeders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
- Dutch Expert Centre for Screening, Nijmegen, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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6
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Jonsson H, Andersson A, Mao Z, Nyström L. Age-specific differences in tumour characteristics between screen-detected and non-screen-detected breast cancers in women aged 40-74 at diagnosis in Sweden from 2008 to 2017. J Med Screen 2024:9691413241237616. [PMID: 38454634 DOI: 10.1177/09691413241237616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To analyze differences between screen-detected and non-screen-detected invasive breast cancers by tumour characteristics and age at diagnosis in the nationwide population-based mammography screening program in Sweden. METHODS Data were retrieved from the National Quality Register for Breast Cancer for 2008-2017. Logistic regression analysis was used to estimate the likelihood for a tumour to be screen-detected by tumour characteristics and age group at diagnosis. RESULTS In total there were 51,429 invasive breast cancers in the target age group for mammography screening of 40-74 years. Likelihood of screen detection decreased with larger tumour size, lymph node metastases, higher histological grade and distant metastasis. Odds ratios (ORs) for negative oestrogen (ER) and progesterone (PgR) were 0.41 and 0.57; for positive HER2, 0.62; for Ki-67 high versus low, 0.49. Molecular sub-types had OR of 0.56, 0.40 and 0.28, respectively, for luminal B-like, HER2-positive and triple negative versus luminal A-like. Adjusting for tumour size (T), lymph node status (N), age, year and county at diagnosis slightly elevated the ORs. Statistically significant interactions between tumour characteristics and age were found (p < 0.05) except for ER and PgR. The age group 40-49 deviated most from the other age groups. CONCLUSIONS Our study demonstrates that screen-detected invasive breast cancers had more favourable tumour characteristics than non-screen-detected after adjusting for age, year and county of diagnosis, and even after adjusting for T and N. The trend towards favourable tumour characteristics was less pronounced in the 40-49 age group compared to the other age groups, except for ER and PgR.
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Affiliation(s)
- Håkan Jonsson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Anne Andersson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Zheng Mao
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Lennarth Nyström
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Bhargava S, Gjesvik J, Thy J, Larsen M, Hofvind S. Breast cancer-specific survival among immigrants and non-immigrants invited to BreastScreen Norway. J Migr Health 2024; 9:100222. [PMID: 39263378 PMCID: PMC11390177 DOI: 10.1016/j.jmh.2024.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 09/03/2023] [Accepted: 02/28/2024] [Indexed: 09/13/2024] Open
Abstract
Introduction We have previously shown that immigrants have lower attendance in BreastScreen Norway than non-immigrants and that non-Western immigrants have lower incidence of breast cancer, but more advanced disease. Purpose To compare breast cancer-specific survival for immigrants versus non-immigrants diagnosed with screen-detected or symptomatic breast cancer. Material and methods We analyzed data from 28,320 women aged 50-69 diagnosed with breast cancer after being invited to BreastScreen Norway. We divided women into three groups; non-immigrants, immigrants from Western countries and immigrants from non-Western countries. We stratified our analyses according to detection mode (screen-detected breast cancer, interval cancer and cancer detected outside screening), and used cox regression to model the association between immigrants/non-immigrants and time to breast cancer death. Results Among screen-detected breast cancers, 28.7% were histologic grade 3 among immigrants from non-Western countries compared to 21.3% among non-immigrants. Interval cancers and cancers detected outside screening had larger tumor diameter and a higher percentage were histologic grade 3 and lymph node positive among immigrants from non-Western countries compared to non-immigrants. Hazard ratio (95% confidence interval) adjusted for age and year of diagnosis for time to breast cancer death compared to non-immigrants was 0.70 (0.39-1.27) for immigrants from Western countries and 0.52 (0.23-1.17) for immigrants from non-Western countries. Conclusion Despite more advanced histopathological tumor characteristics among immigrants from non-Western countries compared to non-immigrants, we did not observe statistically significant differences in breast-cancer specific survival between the two groups. Keeping in mind the low number of breast cancer deaths and possible overestimation of survival among immigrants, this might imply that equity in outcome can be achieved through adequate follow-up and treatment despite inequal access.
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Affiliation(s)
- Sameer Bhargava
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Jonas Gjesvik
- Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
| | - Jonas Thy
- Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
| | - Marthe Larsen
- Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
| | - Solveig Hofvind
- Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
- Department of Health and Care Sciences, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
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Mandelblatt JS, Schechter CB, Stout NK, Huang H, Stein S, Hunter Chapman C, Trentham-Dietz A, Jayasekera J, Gangnon RE, Hampton JM, Abraham L, O’Meara ES, Sheppard VB, Lee SJ. Population simulation modeling of disparities in US breast cancer mortality. J Natl Cancer Inst Monogr 2023; 2023:178-187. [PMID: 37947337 PMCID: PMC10637022 DOI: 10.1093/jncimonographs/lgad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence. METHODS Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy. RESULTS Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness. CONCLUSION Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.
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Affiliation(s)
- Jeanne S Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program at Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Clyde B Schechter
- Departments of Family and Social Medicine and of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Natasha K Stout
- Department of Population Sciences, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Hui Huang
- Department of Data Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Sarah Stein
- Department of Population Sciences, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Christina Hunter Chapman
- Department of Radiation Oncology, Section of Health Services Research, Baylor College of Medicine and Health Policy, Quality and Informatics Program at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Lab, National Institute on Minority Health and Health Disparities, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Ronald E Gangnon
- Departments of Population Health Sciences and of Biostatistics and Medical Informatics and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - John M Hampton
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ellen S O’Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Sandra J Lee
- Department of Data Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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Vratanar B, Pohar Perme M. Evaluating cancer screening programs using survival analysis. Biom J 2023; 65:e2200344. [PMID: 37278228 DOI: 10.1002/bimj.202200344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/23/2023] [Accepted: 05/15/2023] [Indexed: 06/07/2023]
Abstract
The main purpose of cancer screening programs is to provide early treatment to patients that are diagnosed with cancer on a screening test, thus increasing their chances of survival. To test this hypothesis directly, one should compare the survival of screen-detected cases to the survival of their counterparts not included to the program. In this study, we develop a general notation and use it to formally define the comparison of interest. We explain why the naive comparison between screen-detected and interval cases is biased and show that the total bias that arises in this case can be decomposed as a sum of lead time bias, length time bias, and bias due to overdetection. With respect to the estimation, we show what can be estimated using existing methods. To fill in the missing gap, we develop a new nonparametric estimator that allows us to estimate the survival of the control group, that is, the survival of cancer cases that would be screen-detected among those not included to the program. By joining the proposed estimator with existing methods, we show that the contrast of interest can be estimated without neglecting any of the biases. Our approach is illustrated using simulations and empirical data.
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Affiliation(s)
- Bor Vratanar
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Pohar Perme
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Nik Ab Kadir MN, Mohd Hairon S, Ab Hadi IS, Yusof SN, Muhamat SM, Yaacob NM. A Comparison between the Online Prognostic Tool PREDICT and myBeST for Women with Breast Cancer in Malaysia. Cancers (Basel) 2023; 15:cancers15072064. [PMID: 37046725 PMCID: PMC10093426 DOI: 10.3390/cancers15072064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
The PREDICT breast cancer is a well-known online calculator to estimate survival probability. We developed a new prognostic model, myBeST, due to the PREDICT tool’s limitations when applied to our patients. This study aims to compare the performance of the two models for women with breast cancer in Malaysia. A total of 532 stage I to III patient records who underwent surgical treatment were analysed. They were diagnosed between 2012 and 2016 in seven centres. We obtained baseline predictors and survival outcomes by reviewing patients’ medical records. We compare PREDICT and myBeST tools’ discriminant performance using receiver-operating characteristic (ROC) analysis. The five-year observed survival was 80.3% (95% CI: 77.0, 83.7). For this cohort, the median five-year survival probabilities estimated by PREDICT and myBeST were 85.8% and 82.6%, respectively. The area under the ROC curve for five-year survival by myBeST was 0.78 (95% CI: 0.73, 0.82) and for PREDICT was 0.75 (95% CI: 0.70, 0.80). Both tools show good performance, with myBeST marginally outperforms PREDICT discriminant performance. Thus, the new prognostic model is perhaps more suitable for women with breast cancer in Malaysia.
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Affiliation(s)
- Mohd Nasrullah Nik Ab Kadir
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Imi Sairi Ab Hadi
- Breast and Endocrine Surgery Unit, Department of Surgery, Hospital Raja Perempuan Zainab II, Ministry of Health Malaysia, Kota Bharu 15586, Kelantan, Malaysia
| | - Siti Norbayah Yusof
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Federal Territory of Putrajaya, Malaysia
| | - Siti Maryam Muhamat
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Federal Territory of Putrajaya, Malaysia
| | - Najib Majdi Yaacob
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
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11
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Basappa SN, Finney Rutten LJ, Hruska CB, Olson JE, Jacobson DJ, Rhodes DJ. Breast Cancer Mode of Detection in a Population-Based Cohort. Mayo Clin Proc 2023; 98:278-289. [PMID: 36737116 PMCID: PMC9907001 DOI: 10.1016/j.mayocp.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 09/01/2022] [Accepted: 10/07/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate how breast cancers come to clinical attention (mode of detection [MOD]) in a population-based cohort, determine the relative frequency of different MODs, and characterize patient and tumor characteristics associated with MOD. PATIENTS AND METHODS We used the Rochester Epidemiology Project to identify women ages 40 to 75 years with a first-time diagnosis of breast cancer from May 9, 2017, to May 9, 2019 (n=500) in a 9-county region in Minnesota. We conducted a retrospective medical record review to ascertain the relative frequency of MODs, evaluating differences between screening mammography vs all other MODs by breast density and cancer characteristics. Multiple logistic regression was conducted to examine the likelihood of MOD for breast density and stage of disease. RESULTS In our population-based cohort, 162 of 500 breast cancers (32.4%) were detected by MODs other than screening mammography, including 124 (24.8%) self-detected cancers. Compared with women with mammography-detected cancers, those with MODs other than screening mammography were more frequently younger than 50 years of age (P=.004) and had higher-grade tumors (P=.007), higher number of positive lymph nodes (P<.001), and larger tumor size (P<.001). Relative to women with mammography-detected cancers, those with MODs other than screening mammography were more likely to have dense breasts (odds ratio, 1.87; 95% CI, 1.20 to 2.92; P=.006) and advanced cancer at diagnosis (odds ratio, 3.58; 95% CI, 2.29 to 5.58; P<.001). CONCLUSION One-third of all breast cancers in this population were detected by MODs other than screening mammography. Increased likelihood of nonmammographic MODs was observed among women with dense breasts and advanced cancer.
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Affiliation(s)
- Susanna N Basappa
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Lila J Finney Rutten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Carrie B Hruska
- Division of Medical Physics, Department of Radiology, Mayo Clinic, Rochester, MN
| | - Janet E Olson
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Debra J Jacobson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Deborah J Rhodes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Yale New Haven Health, New Haven, CT.
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12
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Moger TA, Holen Å, Hanestad B, Hofvind S. Costs and Effects of Implementing Digital Tomosynthesis in a Population-Based Breast Cancer Screening Program: Predictions Using Results from the To-Be Trial in Norway. PHARMACOECONOMICS - OPEN 2022; 6:495-507. [PMID: 35796950 PMCID: PMC9283618 DOI: 10.1007/s41669-022-00343-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although several studies from Europe and the US have shown promising screening results favoring digital breast tomosynthesis compared with standard digital mammography (DM), both costs and effects of implementing tomosynthesis in routine screening programs remain uncertain. The cost effectiveness of using tomosynthesis in routine screening is debated in the literature, and model inputs from randomized trials are lacking. Using parameters mainly from a randomized controlled trial (the To-Be trial), we simulated costs and effects of implementing tomosynthesis in the national screening program BreastScreen Norway. METHODS The To-Be trial was performed in Bergen from 2016 to 2017 within BreastScreen Norway, where females were randomized to either digital breast tomosynthesis including synthetic mammograms (DBT) or DM. The trial was followed by a cohort study offering all females DBT in 2018-2019. The trial included over 37,000 females, and allowed for estimation of short-term costs and effects related to screening, recall examinations and cancer detection. Using these and recent Norwegian estimates for 10-year stage-specific survival and treatment costs, the cost effectiveness of replacing DM with DBT in BreastScreen Norway was simulated in a decision tree model with probabilistic sensitivity analyses. Outcomes included false-positive screening results, screen-detected and interval cancers, stage at diagnosis, all-cause deaths, life-years gained, costs at recall and treatment and incremental cost-effectiveness ratio. RESULTS The estimated additional cost of DBT was €8.10. Simulating ten rounds of screening from 2018 and 10-year survival and costs, 500 deaths were averted and 2300 life-years gained at an additional screening cost of €29 million for females screened with DBT versus DM. Taking over-diagnosis, recall and treatment costs into account, DBT was dominant in the deterministic analysis. The incremental cost-effectiveness ratio indicated cost savings of €1400 per life-year gained. Probabilistic sensitivity analyses showed that DBT was cost effective in over 50% of the simulations at all willingness-to-pay levels per life-year gained, and in 80% of the simulations at levels above €22,000. If willingness-to-pay levels up to €35,000 were assumed, DBT would be cost effective in over 50% of the simulations for additional costs of DBT of up to €32, almost four times the estimated additional cost of €8.10. CONCLUSION DBT may be cost effective if implemented in BreastScreen Norway. However, generalizability of results could depend on factors varying between countries, such as recall rates, program sensitivity and specificity, treatment cost and willingness-to-pay levels.
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Affiliation(s)
- Tron Anders Moger
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Åsne Holen
- Section for Breast Screening, Cancer Registry of Norway, Oslo, Norway
| | | | - Solveig Hofvind
- Section for Breast Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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13
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Johansson AL, Larønningen S, Skovlund CW, Kristiansen MF, Mørch LS, Friis S, Johannesen TB, Myklebust TÅ, Skog A, Pettersson D, Birgisson H, Virtanen A, Malila N, Pitkäniemi J, Tanskanen T, Tryggvadóttir L, Ursin G, Lambe M. The impact of the COVID-19 pandemic on cancer diagnosis based on pathology notifications: A comparison across the Nordic countries during 2020. Int J Cancer 2022; 151:381-395. [PMID: 35419824 PMCID: PMC9087674 DOI: 10.1002/ijc.34029] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/06/2022]
Abstract
The severity of the COVID-19 pandemic and subsequent mitigation strategies have varied across the Nordic countries. In a joint Nordic population-based effort, we compared patterns of new cancer cases and notifications between the Nordic countries during 2020. We used pathology notifications to cancer registries in Denmark, the Faroe Islands, Finland, Iceland, Norway and Sweden to determine monthly numbers of pathology notifications of malignant and in-situ tumors from January to December 2020 compared to 2019 (2017-2019 for Iceland and the Faroe Islands). We compared new cancer cases per month based on unique individuals with pathology notifications. In April and May 2020, the numbers of new malignant cases declined in all Nordic countries, except the Faroe Islands, compared to previous year(s). The largest reduction was observed in Sweden (May: -31.2%, 95% CI -33.9, -28.3), followed by significant declines in Finland, Denmark and Norway, and a non-significant decline in Iceland. In Denmark, Norway, Sweden and Finland the reporting rates during the second half of 2020 rose to almost the same level as in 2019. However, in Sweden and Finland, the increase did not compensate for the spring decline (annual reduction -6.2% and -3.6%, respectively). Overall, similar patterns were observed for in-situ tumors. The COVID-19 pandemic led to a decline in rates of new cancer cases in Sweden, Finland, Denmark and Norway, with the most pronounced reduction in Sweden. Possible explanations include the severity of the pandemic, temporary halting of screening activities and changes in healthcare seeking behaviour.
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Affiliation(s)
- Anna Lv Johansson
- Cancer Registry of Norway, Oslo, Norway.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Marnar Fríðheim Kristiansen
- Center of Health Science, Faculty of Health Sciences, Tórshavn, Faroe Islands.,National Hospital of the Faroe Islands, Tórshavn, Faroe Islands
| | - Lina Steinrud Mørch
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - Søren Friis
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | | | - Tor Åge Myklebust
- Cancer Registry of Norway, Oslo, Norway.,Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Anna Skog
- Cancer Registry of Norway, Oslo, Norway
| | | | - Helgi Birgisson
- Cancer Registry of Iceland, Icelandic Cancer Society, Reykjavik, Iceland
| | - Anni Virtanen
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
| | - Nea Malila
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
| | - Janne Pitkäniemi
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland.,Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland.,Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tomas Tanskanen
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
| | - Laufey Tryggvadóttir
- Cancer Registry of Iceland, Icelandic Cancer Society, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Regional Cancer Center Central Sweden, Uppsala, Sweden
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14
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Hjerkind KV, Johansson ALV, Trewin CB, Russnes HG, Ursin G. Incidence of breast cancer subtypes in immigrant and non-immigrant women in Norway. Breast Cancer Res 2022; 24:4. [PMID: 35012613 PMCID: PMC8751256 DOI: 10.1186/s13058-021-01498-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/20/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Breast cancer incidence differs between non-immigrants and immigrants from low- and middle-income countries. This study investigates whether immigrants also have different subtype-specific incidences. METHODS We used national health registries in Norway and calculated subtype-specific incidence rate ratios (IRRs) for invasive breast cancer among women aged 20-75 and 20-49 years between 2005 and 2015. Immigrant groups were classified by country of birth broadly defined based on WHO regional groupings. Subtype was defined using estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (HER2) status as luminal A-like (ER+ PR+ HER2-), luminal B-like/HER2- (ER+ PR- HER2-), luminal B-like/HER2+ (ER+ PR any HER2+), HER2+ (ER-PR-HER2+) and triple-negative breast cancer (TNBC) (ER-PR-HER2-). RESULTS Compared to non-immigrants, incidence of the luminal A-like subtype was lower in immigrants from Sub-Saharan Africa (IRR 0.43 95% CI 0.28-0.66), South East Asia (IRR 0.63 95% CI 0.51-0.79), South Asia (IRR 0.67 95% CI 0.52-0.86) and Eastern Europe (IRR 0.86 95% CI 0.76-0.99). Immigrants from South Asia had higher rates of HER2 + tumors (IRR 2.02 95% CI 1.26-3.23). The rates of TNBC tended to be similar regardless of region of birth, except that women from South East Asia had an IRR of 0.54 (95% CI 0.32-0.91). CONCLUSIONS Women from Eastern Europe, Sub-Saharan Africa and Asia had different subtype-specific incidences compared to women from high-income countries (including non-immigrants). These differences in tumor characteristics between immigrant groups should be taken into consideration when planning preventive or screening strategies.
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Affiliation(s)
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 171 77, Stockholm, Sweden
- Cancer Registry of Norway, Postbox 5313, 0304, Majorstuen, Oslo, Norway
| | - Cassia B Trewin
- Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Hege G Russnes
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, 0424, Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424, Oslo, Norway
| | - Giske Ursin
- Cancer Registry of Norway, Postbox 5313, 0304, Majorstuen, Oslo, Norway.
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.
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15
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Wang H, Donnan P, Macaskill EJ, Jordan L, Thompson A, Evans A. A pre-operative prognostic model predicting all cause and cause specific mortality for women presenting with invasive breast cancer. Breast 2021; 61:11-21. [PMID: 34891035 DOI: 10.1016/j.breast.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE The aim of this study is to develop a pre-operative prognostic model based on known pre-operative factors. METHODS A database of ultrasound (US) lesions undergoing biopsy documented US lesion size, stiffness, and patient source prospectively. Women with invasive cancer presenting between 2010 and 2015 were the study group. Breast and axillary core results and ER, PR and HER receptor status were collected prospectively. Assessment of US skin thickening, US distal enhancement and presence of chronic kidney disease (CKD) was performed retrospectively. Patient survival and cause of death were ascertained from computer records. Predictive models for (i) all-cause mortality (ACM) and (ii) breast cancer death (BCD) were built and then validated using bootstrap k-fold cross-validation. A comparison of predictive performance was made between a full cause-specific Cox model, a sub cause-specific Cox model, and a full Fine-Gray sub-distribution hazard model. RESULTS 1136 patients were included in the study. The median follow-up time was 6.2 years. 125 (11%) women died from breast cancer and 155 (14%) died from other causes. For the prediction of BCD, the cause-specific Cox sub-model performed the best. The time dependent AUC begins above 0.91 in year one to 3 reducing to 0.83 in year 6. The factors included in the Cox sub model were tumour size, skin thickening, source of detection, tumour grade, ER status, pre-operative nodal metastasis and CKD. CONCLUSION We have shown that a model based on preoperative factors can predict BCD. Such prediction if externally validated and incorporating treatment data could be useful for treatment planning and patient counselling.
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Affiliation(s)
- Huan Wang
- Population Health and Genomics, School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Peter Donnan
- Medical School Division of Population Health Sciences Within the Medical Research Institute, University of Dundee Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | | | - Lee Jordan
- Histopathology Breast Unit, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Alastair Thompson
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, United States; Population Health and Genomics, School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Andy Evans
- Mail Box 4, Ninewells Medical School, University of Dundee, Dundee, DD1 9SY, UK.
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16
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Hernández-García M, Molina-Barceló A, Vanaclocha-Espi M, Zurriaga Ó, Pérez-Gómez B, Aragonés N, Amiano P, Altzibar JM, Castaño-Vinyals G, Sala M, Ederra M, Martín V, Gómez-Acebo I, Vidal C, Tardón A, Marcos-Gragera R, Pollán M, Kogevinas M, Salas D. Differences in breast cancer-risk factors between screen-detected and non-screen-detected cases (MCC-Spain study). Cancer Causes Control 2021; 33:125-136. [PMID: 34817770 PMCID: PMC8739309 DOI: 10.1007/s10552-021-01511-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 10/15/2021] [Indexed: 12/14/2022]
Abstract
Purpose The variation in breast cancer (BC)-risk factor associations between screen-detected (SD) and non-screen-detected (NSD) tumors has been poorly studied, despite the interest of this aspect in risk assessment and prevention. This study analyzes the differences in breast cancer-risk factor associations according to detection method and tumor phenotype in Spanish women aged between 50 and 69. Methods We examined 900 BC cases and 896 controls aged between 50 and 69, recruited in the multicase–control MCC-Spain study. With regard to the cases, 460 were detected by screening mammography, whereas 144 were diagnosed by other means. By tumor phenotype, 591 were HR+, 153 were HER2+, and 58 were TN. Lifestyle, reproductive factors, family history of BC, and tumor characteristics were analyzed. Logistic regression models were used to compare cases vs. controls and SD vs. NSD cases. Multinomial regression models (controls used as a reference) were adjusted for case analysis according to phenotype and detection method. Results TN was associated with a lower risk of SD BC (OR 0.30 IC 0.10–0.89), as were intermediate (OR 0.18 IC 0.07–0.44) and advanced stages at diagnosis (OR 0.11 IC 0.03–0.34). Nulliparity in postmenopausal women and age at menopause were related to an increased risk of SD BC (OR 1.60 IC 1.08–2.36; OR 1.48 IC 1.09–2.00, respectively). Nulliparity in postmenopausal women was associated with a higher risk of HR+ (OR 1.66 IC 1.15–2.40). Age at menopause was related to a greater risk of HR+ (OR 1.60 IC 1.22–2.11) and HER2+ (OR 1.59 IC 1.03–2.45) tumors. Conclusion Reproductive risk factors are associated with SD BC, as are HR+ tumors. Differences in BC-risk factor associations according to detection method may be related to prevailing phenotypes among categories. Supplementary Information The online version contains supplementary material available at 10.1007/s10552-021-01511-4.
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Affiliation(s)
- Marta Hernández-García
- Cancer and Public Health Area, Foundation for the Promotion of Health and Biomedical Research of Valencia Region(FISABIO), Avda. Catalunya 21, 46020, Valencia, Spain
| | - Ana Molina-Barceló
- Cancer and Public Health Area, Foundation for the Promotion of Health and Biomedical Research of Valencia Region(FISABIO), Avda. Catalunya 21, 46020, Valencia, Spain.
| | - Mercedes Vanaclocha-Espi
- Cancer and Public Health Area, Foundation for the Promotion of Health and Biomedical Research of Valencia Region(FISABIO), Avda. Catalunya 21, 46020, Valencia, Spain
| | - Óscar Zurriaga
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, University of Valencia, Avda. Vicent Andrés Estellés, s/n, 46100, Burjassot, Valencia, Spain
- Joint Research Unit on Rare Diseases, FISABIO-UVEG, Avda. Catalunya 21, 46020, Valencia, Spain
- Directorate General of Public Health, Avda. Catalunya 21, 46020, Valencia, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Pérez-Gómez
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Department of Epidemiology of Chronic Diseases, National Center of Epidemiology, Carlos III Health Institute (ISCIII), Avda. Monforte de Lemos 5, 28029, Madrid, Spain
| | - Nuria Aragonés
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Epidemiology Section, Public Health Division, Department of Health of Madrid, C/San Martín de Porres, 6, 28035, Madrid, Spain
| | - Pilar Amiano
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Epidemiology of Chronic and Communicable Diseases Group, Biodonostia Health Research Institute, Doctor Begiristain, s/n, 20014, San Sebastián, Spain
- Sub Directorate for Public Health and Addictions of Gipuzkoa, Ministry of Health of the Basque Government, 2013, San Sebastian, Spain
| | - Jone M Altzibar
- Epidemiology of Chronic and Communicable Diseases Group, Biodonostia Health Research Institute, Doctor Begiristain, s/n, 20014, San Sebastián, Spain
- ISGlobal, Barcelona Institute for Global Health, Doctor Aiguader 88, 08003, Barcelona, Spain
| | - Gemma Castaño-Vinyals
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- ISGlobal, Barcelona Institute for Global Health, Doctor Aiguader 88, 08003, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Doctor Aiguader 88, 08003, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Plaça de la Mercè, 10-12, 08002, Barcelona, Spain
| | - María Sala
- IMIM (Hospital del Mar Medical Research Institute), Doctor Aiguader 88, 08003, Barcelona, Spain
- Research Network on Health Services in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - María Ederra
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Navarra Public Health Institute, C/ Leyre, 15, 31003, Navarra, Spain
- IdiSNA, Navarra Institute for Health Research, C/Irunlarrea, 3, 31008, Pamplona, Spain
| | - Vicente Martín
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- The Research Group in Gene - Environment and Health Interactions (GIIGAS), Biomedicine Institute (IBIOMED), University of León, Vegazana Campus, s/n, 24071, León, Spain
| | - Inés Gómez-Acebo
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Cantabria University- IDIVAL, C/Cardenal Herrera Oria, s/n, Santander, 39011, Cantabria, Spain
| | - Carmen Vidal
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Cancer Screening Unit, Catalan Institute of Oncology, Duran I Reynals Hospital, Avda. de La Gran Via de L'Hospitalet, 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
- Early Detection of Cancer Research Group, EPIBELL Program, Bellvitge Biomedical Research Institute, Avda. de La Granvia de L'Hospitalet, 199, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Adonina Tardón
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Oncology Institute (IUOPA), University of Oviedo, Edificio Santiago Gascón, Campus El Cristo B, 33006, Oviedo, Spain
| | - Rafael Marcos-Gragera
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Oncology. Sant Ponç, Avda de França, 0, 17007, Girona, Spain
- Descriptive Epidemiology, Genetics and Cancer Prevention Group, [Girona Biomedical Research Institute] IDIBGI, C/ del Dr. Castany, s/n, Salt, 17190, Girona, Spain
| | - Marina Pollán
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- National Center of Epidemiology Directorate, Carlos III Health Institute (ISCIII), Avda. Monforte de Lemos 5, 28029, Madrid, Spain
| | - Manolis Kogevinas
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- ISGlobal, Barcelona Institute for Global Health, Doctor Aiguader 88, 08003, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Doctor Aiguader 88, 08003, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Plaça de la Mercè, 10-12, 08002, Barcelona, Spain
| | - Dolores Salas
- Cancer and Public Health Area, Foundation for the Promotion of Health and Biomedical Research of Valencia Region(FISABIO), Avda. Catalunya 21, 46020, Valencia, Spain
- Directorate General of Public Health, Avda. Catalunya 21, 46020, Valencia, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
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17
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Chen Y, Klingen TA, Aas H, Wik E, Akslen LA. Tumor-associated lymphocytes and macrophages are related to stromal elastosis and vascular invasion in breast cancer. J Pathol Clin Res 2021; 7:517-527. [PMID: 34076969 PMCID: PMC8363927 DOI: 10.1002/cjp2.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/25/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023]
Abstract
The tumor microenvironment plays a critical role in breast cancer progression. Here, we investigated tumor-infiltrating lymphocytes (TILs) and associations with macrophage numbers, tumor stromal elastosis, vascular invasion, and tumor detection mode. We performed a population-based retrospective study using data from The Norwegian Breast Cancer Screening Program in Vestfold County (2004-2009), including 200 screen-detected and 82 interval cancers. The number of TILs (CD45+, CD3+, CD4+, CD8+, and FOXP3+) and tumor-associated macrophages (CD163+) was counted using immunohistochemistry on tissue microarray slides. Lymphatic and blood vessel invasion (LVI and BVI) were recorded using D2-40 and CD31 staining, and the amount of elastosis (high/low) was determined on regular HE-stained slides. High numbers of all TIL subsets were associated with LVI (p ≤ 0.04 for all), and high counts of several TIL subgroups (CD8+, CD45+, and FOXP3+) were associated with BVI (p ≤ 0.04 for all). Increased levels of all TIL subsets, except CD4+, were associated with estrogen receptor-negative tumors (p < 0.001) and high tumor cell proliferation by Ki67 (p < 0.001). Furthermore, high levels of all TIL subsets were associated with high macrophage counts (p < 0.001) and low-grade stromal elastosis (p ≤ 0.02). High counts of CD3+, CD8+, and FOXP3+ TILs were associated with interval detected tumors (p ≤ 0.04 for all). Finally, in the luminal A subgroup, high levels of CD3+ and FOXP3+ TILs were associated with shorter recurrence-free survival, and high counts of FOXP3+ were linked to reduced breast cancer-specific survival. In conclusion, higher levels of different TIL subsets were associated with stromal features such as high macrophage counts (CD163+), presence of vascular invasion, absence of stromal elastosis, as well as increased tumor cell proliferation and interval detection mode. Our findings support a link between immune cells and vascular invasion in more aggressive breast cancer. Notably, presence of TIL subsets showed prognostic value within the luminal A category.
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Affiliation(s)
- Ying Chen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of PathologyVestfold HospitalTønsbergNorway
- Department of PathologyOslo University HospitalOsloNorway
| | - Tor Audun Klingen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of PathologyVestfold HospitalTønsbergNorway
| | - Hans Aas
- Department of SurgeryVestfold HospitalTønsbergNorway
| | - Elisabeth Wik
- Centre for Cancer Biomarkers CCBIO, Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of PathologyHaukeland University HospitalBergenNorway
| | - Lars A Akslen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of PathologyHaukeland University HospitalBergenNorway
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18
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Seely JM, Peddle SE, Yang H, Chiarelli AM, McCallum M, Narasimhan G, Zakaria D, Earle CC, Fung S, Bryant H, Nicholson E, Politis C, Berg W. Breast Density and Risk of Interval Cancers: The Effect of Annual Versus Biennial Screening Mammography Policies in Canada. Can Assoc Radiol J 2021; 73:90-100. [PMID: 34279132 DOI: 10.1177/08465371211027958] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Regular screening mammography reduces breast cancer mortality. However, in women with dense breasts, the performance of screening mammography is reduced, which is reflected in higher interval cancer rates (ICR). In Canada, population-based screening mammography programs generally screen women biennially; however, some provinces and territories offer annual mammography for women with dense breast tissue routinely and/or on recommendation of the radiologist. This study compared the ICRs in those breast screening programs with a policy of annual vs. those with biennial screening for women with dense breasts. Among 148,575 women with dense breasts screened between 2008 to 2010, there were 288 invasive interval breast cancers; screening programs with policies offering annual screening for women with dense breasts had fewer interval cancers 63/70,814 (ICR 0.89/1000, 95% CI: 0.67-1.11) compared with those with policies of usual biennial screening 225/77,761 (ICR 1.45 /1000 (annualized), 95% CI: 1.19-1.72) i.e. 63% higher (p = 0.0016). In screening programs where radiologists' screening recommendations were able to be analyzed, a total of 76,103 women were screened, with 87 interval cancers; the ICR was lower for recommended annual (65/69,650, ICR 0.93/1000, 95% CI: 0.71, 1.16) versus recommended biennial screening (22/6,453, ICR 1.70/1000 (annualized), 95%CI: 0.70, 2.71)(p = 0.0605). Screening program policies of annual as compared with biennial screening in women with dense breasts had the greatest impact on reducing interval cancer rates. We review our results in the context of current dense breast notification in Canada.
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Affiliation(s)
- Jean Morag Seely
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Radiology and Surgery, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Huiming Yang
- Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Megan McCallum
- Government of the Northwest Territories, Yellowknife, Northwest Territories, Canada
| | | | | | - Craig C Earle
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Sharon Fung
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Heather Bryant
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Erika Nicholson
- Canadian Partnership Against Cancer, Halifax, Nova Scotia, Canada
| | - Chris Politis
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Wendie Berg
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
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19
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Qu P, Liu X, Huang Y, Feng Z, Wang X, Dai H, Zhang L, Song F, Li H, Zheng H, Song F, Chen K. Detection rate is not higher for women with BBD history in breast cancer screening. J Public Health (Oxf) 2021; 43:333-340. [PMID: 31774529 DOI: 10.1093/pubmed/fdz147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To investigate whether women with benign breast disease (BBD) history have higher breast cancer detection rate in screening. METHODS We reviewed data for 33 001 female participants in Multi-modality Independent Screening Trial (MIST). Corresponding data for 6823 breast cancer patients were retrieved from the Tianjin Breast Cancer Cases Cohort (TBCCC) and analyzed for comparison. RESULTS The breast cancer detection rate was 2.83‰ among women with BBD history and 3.28‰ in women without. Moreover, the proportion of carcinoma in situ (CIS) was also lower in women with BBD history than women without (7.69 versus 20.31%). In contrast, analysis of TBCCC data revealed a higher proportion of CIS in patients with BBD history (5.05%) than patients without (3.26%). Our data showed that a larger proportion of women with BBD history had undergone previous breast examinations. Additionally, among participants diagnosed with both breast cancer and BBD in MIST, we found a lower proportion of CIS in women with BBD history (11.76%) compared to women without (32.14%). CONCLUSIONS Women with BBD history were not found to have higher detection rate in breast cancer screening. Women with BBD history were more likely to be proactive in seeking breast examinations and to have breast cancer be diagnosed in clinic.
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Affiliation(s)
- Penghuan Qu
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Xueou Liu
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China.,GCP Center Office, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin 300041, P. R. China
| | - Yubei Huang
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Ziwei Feng
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Xin Wang
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Hongji Dai
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Liwen Zhang
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Fangfang Song
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Haixin Li
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China.,Department of Cancer Biobank, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Hong Zheng
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Fengju Song
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
| | - Kexin Chen
- Department of Epidemiology and Biostatistics, National Clinical Research Center for Cancer, Key Laboratory of Molecular Cancer Epidemiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P. R. China
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20
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Klingen TA, Chen Y, Aas H, Wik E, Akslen LA. Fibulin-2 expression associates with vascular invasion and patient survival in breast cancer. PLoS One 2021; 16:e0249767. [PMID: 33836007 PMCID: PMC8034712 DOI: 10.1371/journal.pone.0249767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/24/2021] [Indexed: 12/02/2022] Open
Abstract
Stromal elastosis is related to good prognosis in breast cancer and fibulin-2 helps to stabilize elastic fibers in basement membranes. Here, we examined the level of perivascular fibulin-2 expression in relation to elastosis content, vascular invasion, molecular subtypes, tumour detection mode, and patient prognosis in breast cancer. We performed a population based retrospective study of invasive breast cancers from the Norwegian Breast Screening Program (Vestfold County, 2004-2009) including 200 screen-detected and 82 interval cancers. Perivascular fibulin-2 staining was semi-quantitatively graded based on immunohistochemistry (1-3) and dichotomized as high expression (grade 2-3) and low expression (grade 1). Elastosis content was graded on a 4-tiered scale and dichotomized as high (score 3) and low (score 0-2) expression, whereas lymphatic (LVI) and blood vessel invasion (BVI) were recorded as absent or present by immunohistochemistry. High perivascular fibulin-2 expression was strongly related to stromal elastosis (p<0.001), and inversely associated with BVI and LVI (p<0.001 for both). High fibulin-2 was associated with luminal breast cancer subgroups (p<0.001) and inversely with interval cancers compared with screen-detected tumours (p<0.001). By univariate analysis, low perivascular fibulin-2 was associated with reduced recurrence-free survival (p = 0.002) and disease specific survival (p = 0.019). Low perivascular fibulin-2 expression was strongly related to vascular invasion, low stromal elastosis, non-luminal breast cancer subtypes, interval presentation, and adverse prognosis.
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Affiliation(s)
- Tor A. Klingen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, Section for Pathology, University of Bergen, Bergen, Norway
- Department of Pathology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ying Chen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, Section for Pathology, University of Bergen, Bergen, Norway
- Department of Pathology, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Hans Aas
- Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Elisabeth Wik
- Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, Section for Pathology, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Lars A. Akslen
- Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, Section for Pathology, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
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21
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Castellano CR, Aguilar Angulo PM, Hernández LC, González-Carrato PSC, González RG, Alvarez J, Chacón JI, Ruiz J, Fuentes Guillén MÁ, Gutiérrez Ávila G. Breast cancer mortality after eight years of an improved screening program using digital breast tomosynthesis. J Med Screen 2021; 28:456-463. [PMID: 33775181 PMCID: PMC8573629 DOI: 10.1177/09691413211002556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess screening quality metrics and to describe mortality rates eight years after redesign of breast cancer screening and diagnosis pathways, and the introduction of digital breast tomosynthesis. SETTING Breast Unit of the Toledo Health Area in the region of Castilla-La Mancha (Spain). METHODS We recorded screening metrics and mortality data following the introduction of digital breast tomosynthesis in 2011 for screening and diagnosis pathways. We then compared the mortality between Toledo Health Area and the rest of Castilla-La Mancha, where digital breast tomosynthesis is not available. RESULTS All screening quality metrics improved following the introduction of digital breast tomosynthesis. The cancer detection rate significantly increased from 2.3 (95% confidence interval (CI): 1.9-3.6) to 4.5 per 1000 women (95% CI: 3.2-5.2) on average between the periods 2005-2009 and 2015-2018, while the recall rate significantly decreased from 7.0% (95% CI: 6.8%-8.2%) to 2.6% (95% CI: 2.0%-3.6%). Comparing breast cancer mortality rates for 2014-2018 in the Toledo Health Area with the rest of Castilla-La Mancha, which had similar cancer treatment access and management protocols but without digital breast tomosynthesis, the crude mortality rate was 17.79 (95% CI: 15.38 -20.19) vs. 24.76 per 100,000 (95% CI: 26.12-23.39), respectively. The cumulative risk of death was also significantly lower for the Toledo Health Area than for Castilla-La Mancha. CONCLUSION The introduction of digital breast tomosynthesis improved screening quality indicators. Breast cancer mortality simultaneously decreased with respect to the rest of Castilla-La Mancha. Further research is needed to assess the long-term results, and the role that the redesign may have played in reducing mortality.
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Affiliation(s)
| | | | | | | | | | - Justo Alvarez
- Breast Unit - Surgery Service, Virgen de la Salud Hospital, Toledo, Spain
| | | | - Juan Ruiz
- Breast Unit - Anatomic Pathology Service, Virgen de la Salud Hospital, Toledo, Spain
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22
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Larsen M, Lilleborge M, Vigeland E, Hofvind S. Self-reported symptoms among participants in a population-based screening program. Breast 2020; 54:56-61. [PMID: 32927237 PMCID: PMC7495098 DOI: 10.1016/j.breast.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A limited number of studies have explored the association between self-reported symptoms and the risk of breast cancer among participants of population based screening programs. METHODS We performed descriptive statistics on recall, screen-detected and interval cancer, positive predictive value and histopathological tumour characteristics by symptom group (asymptomatic, lump, and skin or nipple changes) as reported from 785,642 women aged 50-69 when they attended BreastScreen Norway 1996-2016. Uni- and multivariable mixed effects logistic regression models were used to analyze the association between symptom group and screen-detected or interval cancer. Results were presented as odds ratios and 95% confidence intervals (CI). RESULTS A lump or skin/nipple change was reported in 6.2% of the 3,307,697 examinations. The rate of screen-detected cancers per 1000 examinations was 45.2 among women with a self-reported lump and 5.1 among asymptomatic women. Adjusted odds ratio of screen-detected cancer was 10.1 (95% CI: 9.3-11.1) and 2.0 (95% CI: 1.6-2.5) for interval cancer among women with a self-reported lump versus asymptomatic women. Tumour diameter, histologic grade and lymph node involvement of screen-detected and interval cancer were less prognostically favourable for women with a self-reported lump versus asymptomatic women. CONCLUSION Despite targeting asymptomatic women, 6.2% of the screening examinations in BreastScreen Norway was performed among women who reported a lump or skin/nipple change when they attended screening. The odds ratio of screen-detected cancer was higher for women with versus without symptoms. Standardized follow-up guidelines might be beneficial for screening programs in order to take care of women reporting signs or symptoms of breast cancer when they attend screening.
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Affiliation(s)
- Marthe Larsen
- Section for Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Marie Lilleborge
- Section for Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Einar Vigeland
- Department of Radiology, Vestfold Hospital, Tønsberg, Norway
| | - Solveig Hofvind
- Section for Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
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23
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Hofvind S, Sebuødegård S, Botteri E. Response to Zahl. J Natl Cancer Inst 2020; 112:1175. [DOI: 10.1093/jnci/djaa130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Solveig Hofvind
- Section for Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Sofie Sebuødegård
- Section for Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Norwegian National Advisory Unit on Women’s Health, Women’s Clinic, Oslo University Hospital, Oslo, Norway
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24
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Holsbø E, Olsen KS. Metastatic Breast Cancer and Pre-Diagnostic Blood Gene Expression Profiles-The Norwegian Women and Cancer (NOWAC) Post-Genome Cohort. Front Oncol 2020; 10:575461. [PMID: 33178605 PMCID: PMC7594625 DOI: 10.3389/fonc.2020.575461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/28/2020] [Indexed: 01/16/2023] Open
Abstract
Breast cancer patients with metastatic disease have a higher incidence of deaths from breast cancer than patients with early-stage cancers. Recent findings suggest that there are differences in immune cell function between metastatic and non-metastatic cases, even years before diagnosis. We have analyzed whole blood gene expression by Illumina bead chips in blood samples taken using the PAXgene blood collection system up to two years before diagnosis. The final study sample included 197 breast cancer cases and 197 age-matched controls. We defined a causal directed acyclic graph to guide a Bayesian data analysis to estimate the risk of metastasis associated with the expression of all genes and with relevant sets of genes. We ranked genes and gene sets according to the sign probability for excess risk. Among the screening detected cancers, 82% were without metastasis, compared to 53% of between-screening detected cancers. Among the highest ranking genes and gene sets associated with metastasis risk, we identified plasmacytiod dentritic cell function, the SLC22 family of transporters, and glutamine metabolism as potential links between the immune system and metastasis. We conclude that there may be potentially wide-reaching differences in blood gene expression profiles between metastatic and non-metastatic breast cancer cases up to two years before diagnosis, which warrants future study.
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Affiliation(s)
- Einar Holsbø
- Department of Computer Science, UiT The Arctic University of Norway, Tromsø, Norway
| | - Karina Standahl Olsen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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25
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Binhussien BF, Ghoraba M. Awareness of breast cancer screening and risk factors among Saudi females at family medicine department in security forces hospital, Riyadh. J Family Med Prim Care 2019; 7:1283-1287. [PMID: 30613512 PMCID: PMC6293920 DOI: 10.4103/jfmpc.jfmpc_286_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives: To describe the level of knowledge about breast cancer screening and breast cancer risk factors according to sociodemographic characteristics and to know the most common source of their knowledge among the females participating in this study. Patients and Methods: A cross-sectional descriptive study conducted through distributing validated pretested Arabic questionnaire. The sample are Saudi adult females age 18–55 years attending the Family Medicine Department at Security Forces Hospital for healthcare services or accompanying patients. Results: Of 384 participants, 57% were aware that lump or thickening in the breast could be a sign of breast cancer and 68% knew bleeding or discharge from nipple as a warning sign of breast cancer. Fortunately, 291 women (75.8%) have a good knowledge about breast cancer risk factors, and only 93 women (24.4%) have poor knowledge. Regarding knowledge about the screening of breast cancer, 60.9% knew breast self-examination and clinical breast examination (CBE) are the methods of early detection of breast cancer. About 53.1% of women have heard about CBE. Conclusion: All the participants showed sufficient knowledge about the risk factors and symptoms of breast cancer but insufficient knowledge about screening methods. These findings are encouraging for public awareness about how to screen themselves and guidance to health authorities for developing effective breast healthcare programs in the entire Kingdom for the all-female population.
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Affiliation(s)
| | - Medhat Ghoraba
- Family Medicine Center, Security Forces Hospital, Riyadh, Saudi Arabia
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26
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Aromaa-Häyhä A, Auvinen P, Sarkeala T, Heinävaara S, Lamminmäki A, Malila N, Kataja V. Improved diagnostics and change of tumour characteristics in breast cancer: a retrospective study over two decades. Acta Oncol 2018; 57:1331-1338. [PMID: 29882462 DOI: 10.1080/0284186x.2018.1479073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Generally, screen-detected cancers have more favourable tumour characteristics than clinically detected or symptomatic cancers. Less is known, whether the tumour characteristics of breast cancer have changed over time into more favourable in general and whether the changes have been similar in all ages. MATERIAL AND METHODS The aim of this study was to explore the change of breast cancer characteristics in parallel to the implementation of modern diagnostic methods in three age groups over four 5-year time periods between 1992 and 2011. The data from 942 primary breast cancers in one university hospital district in Finland were combined with data from the Finnish Cancer Registry and the Mass Screening Registry. The association of favourable tumour characteristics with time period, age group and diagnostic methods was explored. RESULTS The most discernible secular change was the increase in oestrogen (ER)-positive cancers in every consecutive time period. The risk for ER positivity in the second, third and fourth period was 2- to 2.71-fold compared to the first period. An increase in small tumours and node-negative tumours was detected during the most recent years of data collection. The secular changes were observed in all age groups; however, overall ER positivity was most frequent among women beyond screening age and small tumours among screening-aged women. The increase in small and node-negative tumours could partly be explained by the implementation of new radiological methods. CONCLUSIONS This study detected a secular change of tumour characteristics into more favourable irrespective of age group. If the trend continues, it seems that we are going to have a breast cancer population of mainly small ER-positive breast cancers in the future forcing to rethink the therapeutic approach.
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Affiliation(s)
| | - Päivi Auvinen
- Centre of Oncology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | | | | | | | - Nea Malila
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Vesa Kataja
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Jyväskylä Central Hospital, Central Finland Health Care District, Jyväskylä, Finland
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27
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Braun B, Khil L, Tio J, Krause-Bergmann B, Fuhs A, Heidinger O, Hense HW. Differences in Breast Cancer Characteristics by Mammography Screening Participation or Non-Participation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:520-527. [PMID: 30149831 PMCID: PMC6131365 DOI: 10.3238/arztebl.2018.0520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 04/06/2018] [Accepted: 04/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The goal of the German Mammography Screening Program (MSP) is to enable the early detection and less intensive treatment of breast cancer. We compared tumor characteristics and prognostic markers in breast cancers that were detected by screening in the MSP, in the interval after a negative screening, or among non-participants in screening. METHODS This retrospective series includes all of the 1531 cases of invasive and in situ breast cancer (DCIS, ductal carcinoma in situ) that were newly diagnosed in two certified breast care centers in Münster in the period 2006-2012 among women in the MSP target population. Complete information on the tumor characteristics, tumor biology, and primary surgical treatment were available for all cases. The mode of cancer detection was determined from the state cancer registry of North Rhine-Westphalia. Due to the retrospective design of this case series, there was no randomized allocation. RESULTS The 874 cases of breast cancer among MSP participants (714 detected by screening, 160 in the interval after a negative screen) and the 657 cases among non-participants arose in women of similar age (mean, 60.2 versus 59.3 years). MSP participants with breast cancer had DCIS more commonly than non-participants did (23% versus 13%); invasive carcinomas were smaller (74% versus 55% in the T1 stage), less commonly node-positive (25% versus 31%), less commonly high-grade (19% versus 27%), and less commonly triple-negative (7% versus 12%); MSP participants received neoadjuvant treatment less frequently (2% versus 8%) and more frequently underwent breast-conserving surgery (75% versus 62%). They less commonly had a guideline-based indication for adjuvant chemotherapy (46% versus 52%). CONCLUSION MSP participants with invasive breast cancer can generally be treated with less intensive surgical and systemic therapy than non-participants, even if interval cancers are also taken into account. Future studies should also investigate quality of life after a diagnosis of invasive carcinoma in screening participants.
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Affiliation(s)
- Bettina Braun
- Institute of Epidemiology and Social Medicine, University of Münster; State Cancer Registry of North Rhine-Westphalia, Bochum; Breast Care Center, Department of Gynecology and Obstetrics, University Hospital Münster; Department for Breast Diseases, St. Franziskus Hospital, Münster
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28
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Screening status, tumour subtype, and breast cancer survival: a national population-based analysis. Breast Cancer Res Treat 2018; 172:133-142. [PMID: 30006795 DOI: 10.1007/s10549-018-4877-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 05/31/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE We examined whether demographic and tumour characteristics (including subtype) were different for women with breast cancer diagnosed via mammography screening compared with women with interval breast cancers, lapsed attenders of the screening programme and non-participants of the screening programme. In addition, we explored whether there were survival differences between the groups, taking into account lead time bias. METHODS We used linked data from National Cancer Registry Ireland and the national breast screening programme BreastCheck. Multinomial logistic regression was used to test the association of covariates with screening status. For survival analysis, we corrected the survival time for screen-detected cases for lead time bias, examined Kaplan-Meier curves and then used Cox regression to investigate differences in survival by screening status. RESULTS Subtype (HER2 over-expressing, triple negative), stage (III/IV), grade (poor), having co-morbidities, area of deprivation, smoking status and age were associated with having interval cancer or being a non-participant of the screening programme in the multivariable model. After correcting for lead time bias, and adjusting for variables associated with screening status, there was no evidence that risk of breast-cancer death for women with screen-detected cancer was different from women with interval cancer (HR = 0.76, 95% CI 0.56-1.03), non-participants (HR = 1.07, 95% CI 0.84-1.37) and lapsed attenders (HR = 0.97, 95% CI 0.65-1.45). CONCLUSIONS Screening status was strongly associated with subtype and this association persisted after adjustment for covariates including tumour stage and grade. After correcting for lead-time bias and adjusting for stage, subtype, grade and socio-demographic variables, no significant survival difference was demonstrated for women with screen-detected cancer in the 5-year period post-diagnosis. Since we are adjusting for stage, subtype and other variables, the lack of difference between these groups would be expected but has not been demonstrated in studies which do not correct for lead time bias.
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Hofvind S, Sagstad S, Sebuødegård S, Chen Y, Roman M, Lee CI. Interval Breast Cancer Rates and Histopathologic Tumor Characteristics after False-Positive Findings at Mammography in a Population-based Screening Program. Radiology 2018; 287:58-67. [DOI: 10.1148/radiol.2017162159] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Solveig Hofvind
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
| | - Silje Sagstad
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
| | - Sofie Sebuødegård
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
| | - Ying Chen
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
| | - Marta Roman
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
| | - Christoph I. Lee
- From the Cancer Registry of Norway, PO 5313 Majorstuen, 0304 Oslo, Norway (S.H., S. Sagstad, S. Sebuødegård); Department of Pathology, Akershus Universitetssykehus HF, Lorenskog, Norway (Y.C.); Department of Epidemiology and Evaluation, Hospital del Mar Medical Research Institute, Barcelona, Spain (M.R.); and Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, Wash (C.I.L.)
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O’Cearbhaill RM, Hembrecht S, Devane LA, Rothwell J, Evoy D, Geraghty J, McCartan DP, McNally S, O’Doherty A, McDermott EW, Prichard RS. Breast screening in symptomatic women over 35 years of age: improvements in service efficiency. Ir J Med Sci 2018; 188:55-58. [DOI: 10.1007/s11845-018-1794-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/14/2018] [Indexed: 11/28/2022]
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Lilleborge M, Hofvind S, Sebuødegård S, Hauge R. Optimizing performance of BreastScreen Norway using value of information in graphical models. Stat Med 2018; 37:1531-1549. [DOI: 10.1002/sim.7601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/19/2017] [Accepted: 11/30/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Marie Lilleborge
- Norwegian Computing Center; Postbox 114 Blindern 0314 Oslo Norway
| | - Solveig Hofvind
- Cancer Registry of Norway; Postbox 5313 Majorstuen 0304 Oslo Norway
| | | | - Ragnar Hauge
- Norwegian Computing Center; Postbox 114 Blindern 0314 Oslo Norway
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