Should breast cancer survivors be excluded from, or invited to, organised mammography screening programmes?

The multicenter experience in the multidisciplinary Italian breast units: a review and update

A breast unit is a multidisciplinary center specialized in the management of women with breast diseases, including breast cancer (BC). It represents a care path, passing from screening activities to diagnostic investigations, from surgery to the definition of the therapeutic strategy, from psychophysical rehabilitation to long-term checks (follow-up), and up to genetic counseling. Since 2006, following a resolution issued by the European Parliament to urge member states to activate multidisciplinary breast centers by 2016, work has been underway throughout Italy to improve the management of women with BC. In Italy, the State-Regions agreement was signed on 18 December 2014, sanctioning the establishment of breast units. These centers must adhere to specific quality criteria and requirements. In 2020, the experts of the EUSOMA group (European Society of Breast Cancer Specialists), in their latest document published, expanded the requirements of the breast units. Furthermore, Senonetwork was founded in 2012 with the aim of allowing BC to be treated in breast units that comply with European requirements to ensure equal treatment opportunities for all Italian women. Indeed, the available data indicate that the BC patient has a greater chance of better treatment in the breast units with a multidisciplinary team, thus increasing the survival rate with a better quality of life, compared to those managed in nonspecialized structures. The present review is a perspective on the current Italian reality of breast units, updated with the available literature and the most recent epidemiological data from Senonetwork and AgeNaS.

Integrating mammography screening programmes into specialist breast centres in Italy: insights from a national survey of Senonetwork breast centres

Background

Despite recommendations, mammography screening is often insufficiently integrated into specialist breast centres. A national, cross-sectional, voluntary, online survey on this issue was carried out among the Italian breast centres associated with Senonetwork, the Italian network of breast cancer services.

Methods

A 73-item questionnaire was created, pre-tested and piloted. Centres integrating and not integrating a screening programme were compared using the unified theory of acceptance and use of technology (UTAUT) model. Centres’ clustering was performed using the Gower’s distance metric. Groups and clusters were compared with the equality-of-means test.

Results

The response rate was 82/128 (65%). Overall, 84% (69/82) breast centres reported a collaboration with a screening programme in performing and/or reading mammograms and in the diagnostic work-up of women with abnormal screening results. The same proportion was observed among those centres responding to all questions (62/74). Performance expectancies (or the perceived usefulness of integration in terms of clinical quality, patient convenience, ease of job, and professional growth), satisfaction and motivation were higher in those centres collaborating with the screening programme. Effort expectancy indicators (or the degree to which the respondents believe that the integration is easy to implement) and those concerning the existence of facilitating conditions were lower both in centres collaborating and not collaborating with the screening programme. Among the former, six clusters of centres, distributed from ‘no integration’ to ‘high’, were identified. In cluster analysis, the highest level of integration was associated with higher agreement that integration eases the job, offers better opportunities for professional growth, and makes the working environment more satisfactory. The least integrated cluster assigned the lowest score to the statement that local health authority made available the resources needed.

Conclusions

While confirming the positive effects of integrating screening programmes into breast centres, this survey has brought to light specific difficulties that must be faced. The results provide insights into the importance of integration focusing on the perspectives of professional career and motivation. The deficiency of facilitating conditions to integration is modifiable. Screening professionals’ societies may have a role as initiators of the integration. Other supporting actions may be included in health laws at the national and regional level.

Participation in breast cancer screening among breast cancer survivors -A nationwide register-based cohort study

The aim of this study was to analyse if breast cancer survivors without other breast imaging surveillance attend population-based screening differently than women not previously diagnosed with breast cancer. Further, to analyse if any differences depended on the women's age and years since previous cancer diagnosis. The study was a register-based retrospective cohort study of all women invited to participate in the national breast cancer screening programme in 2015-2016. Participation rates were calculated for breast cancer survivors without breast imaging within 21 months (2-4 years, 4-6 years, 6-10 years and more than 10 years after diagnosis) and for women without previous breast cancer. Relative differences in participation rates between the two groups were calculated. A total of 679,990 women were included in the study (2.6% breast cancer survivors). For breast cancer survivors, participation rates increased with increasing number of years since the previous cancer diagnosis peaking at 80.3% if the cancer diagnosis was more than 10 years ago. For women with no previous breast cancer, participation rate was 80.3%. The relative difference in participation was highest close to the breast cancer diagnosis and for the youngest women participation rates remained lower among breast cancer survivors even more than 10 years after the diagnosis. In conclusion, regardless of age and years since previous breast cancer diagnosis, breast cancer survivors had lower or similar participation rates than women with no previous cancer diagnosis. This indicated that as many as one fifth of the breast cancer survivors are at risk of inadequate surveillance.

Breast screening for survivors of breast cancer: A systematic review

There is a large and growing population of women who have a personal history of breast cancer (PHBC). This systematic review was undertaken to explore the outcomes of surveillance mammography in breast cancer survivors, and to examine the evidence for screening these women within an organized population-based screening program. We searched Cochrane Central Register of Controlled Trials (CENTRAL Issue 6, 2015), OVID MEDLINE and EMBASE (January 2012 to June 22, 2015) for English-language studies of surveillance of the target population. A study author extracted study outcomes, which were audited by a research assistant. One systematic review and 5 primary studies were included. These showed that surveillance mammography may reduce breast cancer-specific mortality through early/asymptomatic detection (Hazard Ratio for those without compared to with symptoms:HR: 0.64, 95% CI 0.55 - 0.74). Three studies showed that semi-annual mammography is likely not of greater benefit than annual mammography. No evidence was found to suggest that surveillance mammography for women with a PHBC should not be conducted within an organized screening program. The small evidence-base had a high level of heterogeneity in populations, interventions and outcomes. Based on this review, organized screening programs should reassess their guidelines on surveillance mammography and consider including women with a PHBC.

Recommendations for breast imaging follow-up of women with a previous history of breast cancer: position paper from the Italian Group for Mammography Screening (GISMa) and the Italian College of Breast Radiologists (ICBR) by SIRM

Women who were previously treated for breast cancer (BC) are an important particular subgroup of women at intermediate BC risk. Their breast follow-up should be planned taking in consideration a 1.0-1.5 % annual rate of loco-regional recurrences and new ipsilateral or contralateral BCs during 15-20 years, and be based on a regional/district invitation system. This activity should be carried out by a Department of Radiology integrating screening and diagnostics in the context of a Breast Unit. We recommend the adoption of protocols dedicated to women previously treated for BC, with a clear definition of responsibilities, methods for invitation, site(s) of visits, methods for clinical and radiological evaluation, follow-up duration, role and function of family doctors and specialists. These women will be invited to get a mammogram in dedicated sessions starting from the year after the end of treatment. The planned follow-up duration will be at least 10 years and will be defined on the basis of patient's age and preferences, taking into consideration organizational matters. Special agreements can be defined in the case of women who have their follow-up planned at other qualified centers. Dedicated screening sessions should include: evaluation of familial/personal history (if previously not done) for identifying high-risk conditions which could indicate a different screening strategy; immediate evaluation of mammograms by one or, when possible, two breast radiologists with possible addition of supplemental mammographic views, digital breast tomosynthesis, clinical breast examination, breast ultrasound; and prompt planning of possible further workup. Results of these screening sessions should be set apart from those of general female population screening and presented in dedicated reports. The following research issues are suggested: further risk stratification and effectiveness of follow-up protocols differentiated also for BC pathologic subtype and molecular classification, and evaluation of different models of survivorship care, also in terms of cost-effectiveness.

Active approach for breast cancer genetic counseling during radiotherapy: long-term psychosocial and medical impact

Genetic counseling and DNA testing (GCT) for breast cancer is increasingly being actively offered to newly diagnosed patients. Little is known about the consequences of such an approach. Therefore, the long-term psychosocial and medical impact of referring breast cancer patients for GCT during an early phase of treatment was studied. A group of 112 breast cancer patients who had been actively offered GCT during adjuvant radiotherapy 7-14 years earlier, returned a self-report questionnaire. We compared their experiences with a group of 127 breast cancer patients who had not met the criteria for GCT. In total, 239 women participated in this long-term follow-up study (72% response rate). Nearly 75% of them had received regular mammography surveillance in the past 3 years. Preventive surgery was reported more often in the counseling group (specifically in the BRCA1/2 mutation carriers). Like the comparative group, only a minority of patients who had received GCT were experiencing high levels of depression (5%) or psychological distress (14%). Breast cancer patients can be actively approached and referred for GCT at the beginning of their radiotherapy without a threat to psychological functioning in the long term.

Practices that reduce the Latina survival disparity after breast cancer

OBJECTIVES

Latina breast cancer patients are 20 percent more likely to die within 5 years after diagnosis compared with white women, even though they have a lower incidence of breast cancer, lower general mortality rates, and some better health behaviors. Existing data only examine disparities in the utilization of breast cancer care; this research expands the study question to which utilization factors drive the shorter survival in Latina women compared with white women.

METHODS

This longitudinal linked Surveillance Epidemiology and End Results (SEER)-Medicare cohort study examined early stage breast cancer patients diagnosed between 1992 and 2000 and followed for 5-11 years after diagnosis (N=44,999). Modifiable utilization factors included consistent visits to primary care providers and to specialists after diagnosis, consistent post-diagnosis mammograms, and receipt of initial care consistent with current standards of care.

RESULTS

Of the four utilization factors potentially driving this disparity, a lack of consistent post-diagnosis mammograms was the strongest driver of the Latina breast cancer survival disparity. Consistent mammograms attenuated the hazard of death from 23% [hazard ratio, HR, (95% confidence interval, 95%CI)=1.23 (1.1,1.4)] to a nonsignificant 12% [HR (95%CI)=1.12 (0.7,1.3)] and reduced the excess hazard of death in Latina women by 55%. Effect modification identified that visits to primary care providers have a greater protective impact on the survival of Latina compared to white women [HR (95%CI)=0.9 (0.9,0.9)].

CONCLUSIONS

We provide evidence that undetected new or recurrent breast cancers due to less consistent post-diagnosis mammograms contribute substantially to the long-observed Latina survival disadvantage. Interventions involving primary care providers may be especially beneficial to this population.