Monitoring and evaluation of breast cancer screening programmes: selecting candidate performance indicators

Early performance measures following regular versus irregular screening attendance in the population-based screening program for breast cancer in Norway

OBJECTIVE

Irregular attendance in breast cancer screening has been associated with higher breast cancer mortality compared to regular attendance. Early performance measures of a screening program following regular versus irregular screening attendance have been less studied. We aimed to investigate early performance measures following regular versus irregular screening attendance.

METHODS

We used information from 3,302,396 screening examinations from the Cancer Registry of Norway. Examinations were classified as regular or irregular. Regular was defined as an examination 2 years ± 6 months after the prior examination, and irregular examination >2 years and 6 months after prior examination. Performance measures included recall, biopsy, screen-detected and interval cancer, positive predictive values, and histopathological tumor characteristics.

RESULTS

Recall rate was 2.4% (72,429/3,070,068) for regular and 3.5% (8217/232,328) for irregular examinations. The biopsy rate was 1.0% (29,197/3,070,068) for regular and 1.7% (3825/232,328) for irregular examinations, while the rate of screen-detected cancers 0.51% (15,664/3,070,068) versus 0.86% (2003/232,328), respectively. The adjusted odds ratio was 1.53 (95% CI: 1.49-1.56) for recall, 1.73 (95% CI: 1.68-1.80) for biopsy, and 1.68 (95% CI: 1.60-1.76) for screen-detected cancer after irregular examinations compared to regular examinations. The proportion of lymph node-positive tumors was 20.1% (2553/12,719) for regular and 25.6% (426/1662) for irregular examinations.

CONCLUSION

Irregular attendance was linked to higher rates of recall, needle biopsies, and cancer detection. Cancers detected after irregular examinations had less favorable histopathological tumor characteristics compared to cancers detected after regular examinations. Women should be encouraged to attend screening when invited to avoid delays in diagnosis.

Comparisons of assessment pathways after abnormal mammography screening in Denmark, Norway, and Spain

PURPOSE

To ensure high-quality screening programmes and effective utilization of resources, it is important to monitor how cancer detection is affected by different strategies performed at recall assessment. This study aimed to describe procedures performed at recall assessment and compare and evaluate the performance of the assessment in Denmark, Norway, and Spain in terms of screen-detected cancer (SDC) and interval cancer (IC) rates.

METHODS

We included women aged 50-69 years from Denmark, Norway, and Spain, who were recalled for assessment after screening mammography, and recorded all procedures performed during six months after diagnosis, and the timing of the procedures. Women were followed for two years and screen-detected and interval cancer, and sensitivity of recall was calculated and compared.

RESULTS

In total, data from 24,645 Danish, 30,050 Norwegian, and 41,809 Spanish women were included in the study. Most of the women had some assessment within 2 months in all three countries. SDC rates were higher in Denmark (0.57) and Norway (0.60) compared to Spain (0.38), as were the IC rates, i.e. 0.25 and 0.18 vs. 0.12, respectively. The sensitivity of the diagnostic follow-up was somewhat higher in Denmark (98.3%) and Norway (98.2%), compared to Spain (95.4%), but when excluding non-invasive assessment pathways, the sensitivities were comparable.

CONCLUSION

This comparison study showed variation in the assessment procedures used in the three countries as well as the SDC and IC rates and the sensitivity of recall.

Evaluation der Hautkrebsfrüherkennung in Deutschland - Teilnahme, Tumordetektion und Intervalltumoren auf Grundlage von GKV-Daten

Hintergrund und Ziele

Die steigende Hautkrebshäufigkeit in Deutschland hat den Bedarf an sekundärpräventiven Maßnahmen erhöht. Hierfür wurde zum 01.07.2008 ein gesetzliches Hautkrebsscreening für Versicherte ab 35 Jahren eingeführt. Ziel dieses Arbeitspakets im Innovationsfonds‐Projekt „Perspektiven einer multimodalen Evaluation der Hautkrebsfrüherkennung“ (Pertimo) war die Erprobung einer Evaluation des Hautkrebsscreenings anhand von Sekundärdaten.

Patienten und Methodik

Datengrundlage waren gesetzlich Versicherte der DAK‐Gesundheit ab 35 Jahren, die zum 31.12.2010 versichert waren und bis Ende 2015 nachbeobachtet wurden. Die Raten der Teilnahme sowie der im Hautkrebsscreening entdeckten Hauttumoren (Tumordetektionen) und der Intervalltumoren, welche innerhalb von zwei Jahren nach einem befundfreien Hautkrebsscreening auftraten, wurden berechnet.

Ergebnisse

Die zweijährliche Hautkrebsscreening‐Inanspruchnahmerate in 2014 und 2015 lag bei Frauen bei 33,6% und bei Männern bei 32,6%. Von den Gescreenten hatten 4,2% im Zuge des Hautkrebsscreenings einen Hautkrebsbefund (Tumordetektion). Von allen inzidenten Hautkrebsdiagnosen (2012–2015) wurden 50,1% im Hautkrebsscreening entdeckt. Bei 1,5% der Versicherten mit Hautkrebsscreening ohne Befund wurde in den folgenden zwei Jahren ein inzidenter Hauttumor diagnostiziert (Intervalltumor).

Schlussfolgerungen

Die Daten der gesetzlichen Krankenversicherung bildeten das Hautkrebsscreening‐Geschehen in Deutschland ab und verdeutlichten die Wichtigkeit von Dermatologen im Screeningprozess. Die Analyse lieferte wichtige neue Erkenntnisse.

Evaluation of skin cancer screening in Germany - participation, tumor detection and interval tumors based on SHI data

BACKGROUND AND GOALS

The rising incidence of skin cancer in Germany has increased the need for secondary prevention measures. For this purpose, a statutory skin cancer screening for insured persons aged 35 and older was introduced on 1 June 2008. The aim of this work package in the Innovation Fund project "Perspectives of a multimodal evaluation of early skin cancer detection" (Pertimo) was to test an evaluation of skin cancer screening using secondary data.

PATIENTS AND METHODS

The data basis was statutory insured persons of the DAK Health from the age of 35 who were insured as of 31 December 2010 and were followed up until the end of 2015. The rates of participation, skin tumors detected in skin cancer screening (tumor detections), and interval tumors that occurred within two years after a finding-free skin cancer screening were calculated.

RESULTS

The biennial skin cancer screening take-up rate in 2014 and 2015 was 33.6% for women and 32.6% for men. Of those screened, 4.2% had a skin cancer finding (tumor detection) in the course of skin cancer screening. Of all incident skin cancer diagnoses (2012-2015), 50.1% were detected in skin cancer screening. In 1.5% of the insured persons with skin cancer screening without findings, an incidental skin tumor was diagnosed in the following two years (interval tumor).

CONCLUSIONS

The data from the statutory health insurance mapped the skin cancer screening occurrence in Germany and highlighted the importance of dermatologists in the screening process. The analysis provided important new insights.

A nomogram for predicting breast cancer based on hematologic and ultrasound parameters

BACKGROUND

The aim of this study was to investigate the ultrasound and hematological indicators, subsequently utilizing them to predict breast cancer and construct predictive models and columnar plots.

METHODS

The clinical data of 200 patients with breast tumors receiving ultrasound and blood tests at Henan Provincial People's Hospital from January 2020 to January 2023 were collected. Patients were divided into training and validation sets at a 6:4 ratio using R language. Variables were screened using logistic regression, and a nomogram predicting breast cancer probability was constructed based on the training set. The predictive performance of the nomogram was evaluated in the validation set through receiver operating characteristic, calibration and decision curves. Model robustness was validated by bootstrap resampling.

RESULTS

Regression analysis revealed that maximum blood flow velocity within the breast mass ≥ 16.395 m/s, perfusion index ≥ 1.505, cancer antigen 15-3 ≥ 39.620 U/m, cancer antigen 125 ≥ 42.30 U/ml, carcinoembryonic antigen ≥ 6.520 ng/ml, Adler blood flow classification II & III, breast calcification present, and diameter of the lump > 2 cm were independent risk factors for breast cancer. Based on these ultrasonic parameters and blood indicators, the developed nomogram demonstrated excellent discrimination in both the training set (AUC = 0.917) and validation set (AUC = 0.844). The calibration plot showed high consistency between the nomogram-predicted and the actual results. Decision curve analysis indicated higher net benefit of this model.

CONCLUSIONS

The nomogram developed in this study demonstrated solid predictive abilities for breast malignancy, indicating potential clinical value pending further research.

Interval cancer audit and disclosure in breast screening programmes: An international survey

OBJECTIVE AND SETTING

Accurate monitoring of interval cancers is important both for quality improvement and education and is a key parameter of breast screening quality assurance. Issues in relation to communication regarding interval cervical cancer in the Irish cervical screening programme were found, prompting interval cancer process review in all cancer screening programmes. An international survey to examine international consensus on interval breast cancer audit processes was conducted to inform Irish processes.

METHODS

A survey of 24 international population-based breast screening programmes was done to determine which undertook audit of interval breast cancer; if yes, they were asked (1) how they undertake audit, (2) if they obtain individual consent for audit and inform women of audit results, and (3) if disclosure of audit results occurs.

RESULTS

Response was 71% (17/24). Of these, 71% (12/17) have a programmatic audit process to calculate the interval cancer rate (ICR). Of these, ten also carry out radiological reviews, three using a blinded review. Two inform patients that audit is taking place; two provide choice to be in the audit; nine state that routine screening consent covers audit. For two of the five that have an open disclosure policy for medical incidents, this policy applies to screening interval cancers. One other country/region has an open disclosure policy for category 3 interval cancers only. Five have legal protection for interval cancers arising in the screened population.

CONCLUSION

While consistency in providing aggregate programmatic audits exists, there is no consistent approach to individual interval cancer reviews or results disclosure.

The GIN-McMaster guideline tool extension for the integration of quality improvement and quality assurance in guidelines: a description of the methods for its development

BACKGROUND AND OBJECTIVES

Our objective was to develop an extension of the widely used GIN-McMaster Guideline Development Checklist and Tool for the integration of quality assurance and improvement (QAI) schemes with guideline development.

METHODS

We used a mixed-methods approach incorporating evidence from a systematic review, an expert workshop and a survey of experts to iteratively create an extension of the checklist for QAI through three rounds of feedback. As a part of this process, we also refined criteria of a good guideline-based quality indicator.

RESULTS

We developed a 40-item checklist extension addressing steps for the integration of QAI into guideline development across the existing 18 topics and created one new topic specific to QAI. The steps span from 'organization, budget, planning and training', to updating of QAI and guideline implementation.

CONCLUSION

The tool supports integration of QAI schemes with guideline development initiatives and it will be used in the forthcoming integrated European Commission Initiative on Colorectal Cancer. Future work should evaluate this extension and QAI items requiring additional support for guideline developers and links to QAI schemes.

Factors influencing participation in breast cancer screening in an urban setting. A study of organized and individual opportunistic screening among potentially active and retired women in the city of Nice

Participation in breast cancer screening in urban settings is poor. Identifying factors accounting for participation and non-participation is essential to target priority areas, tackle health inequalities and suggest innovative approaches. We studied organized and individual opportunistic participation in breast cancer screening within the 144 aggregated units for statistical information (Ilôts regroupés pour l'information statistique: IRIS) of the city of Nice from 2019 to 2021. In each IRIS was assessed a local human development index, among potentially active women aged 50 to 59 years and retired women aged 60 to 74 years. Modelling participation and non-participation in screening according to the IRIS units' socio-economical characteristics was performed using the SURE method (Seemingly Unrelated Regression Equations). Over a 2-year period, 24,396 breast screening tests were conducted (11,173 as organised screening, 13,223 as individual opportunistic screening). The local human development index was positively correlated with the two types of screening, respectively. Access to public transport facilitated participation. Managerial status was negatively correlated with organised screening. Single working women had a higher risk of non-participation. With regard to their socio-economic characteristics, screening rates were lower than expected in 16 IRIS units in the city of Nice. Local human development index, access to public transport, family and professional context appear to be associated with breast cancer screening in an urban setting. An innovative approach targeting these factors is called for to reduce health inequalities.

Evaluation of participation and performance indicators in a breast cancer screening program in Saudi Arabia

OBJECTIVES

To evaluate early performance indicators for breast cancer screening at the King Abdulaziz University Hospital in Saudi Arabia.

METHODS

This study retrospectively evaluated data from women who underwent their first breast cancer screening program in Jeddah, Saudi Arabia between 2012 and 2019. Data on screening results were used to estimate performance indicators and generate descriptive statistics.

RESULTS

Of the 16000 women invited from 2012 to 2019, a total of 1911 (11.9%) participated. The majority of women (68.8%) were between 40 and 55 years old. Based on the screening process results, 26.6%, 40.1%, 9.7%, 1.3%, 0.7%, and 5.2% of women had BI-RADS scores of R1, R2, R3, R4, R5, and R0 respectively. The remaining 16.3% did not have mammogram records. The recall rate, or the percentage of women who underwent further evaluation, was 19.9%; 18.9% underwent a biopsy procedure. In addition, 1.6% of women had cancer screen-detected, although only 0.7% were diagnosed with breast cancer.

CONCLUSION

In light of the low participation and high recall rates, it is essential that the screening program utilizes performance indicators to optimize resource utilization and ensure the quality of the service provided. Additionally, a national framework and standardized performance indicators could mitigate this problem for other cancer screening programs.

Impact of the COVID-19 pandemic on breast cancer screening indicators in a Spanish population-based program: a cohort study

Background:

To assess the effect of the COVID-19 pandemic on performance indicators in the population-based breast cancer screening program of Parc de Salut Mar (PSMAR), Barcelona, Spain.

Methods:

We conducted a before-and-after, study to evaluate participation, recall, false positives, the cancer detection rate, and cancer characteristics in our screening population from March 2020 to March 2021 compared with the four previous rounds (2012–2019). Using multilevel logistic regression models, we estimated the adjusted odds ratios (aORs) of each of the performance indicators for the COVID-19 period, controlling by type of screening (prevalent or incident), socioeconomic index, family history of breast cancer, and menopausal status. We analyzed 144,779 invitations from 47,571women.

Results:

During the COVID-19 period, the odds of participation were lower in first-time invitees (aOR = 0.90 [95% CI = 0.84–0.96]) and in those who had previously participated regularly and irregularly (aOR = 0.63 [95% CI = 0.59–0.67] and aOR = 0.95 [95% CI = 0.86–1.05], respectively). Participation showed a modest increase in women not attending any of the previous rounds (aOR = 1.10 [95% CI = 1.01–1.20]). The recall rate decreased in both prevalent and incident screening (aOR = 0.74 [95% CI = 0.56–0.99] and aOR = 0.80 [95% CI = 0.68–0.95], respectively). False positives also decreased in both groups (prevalent aOR = 0.92 [95% CI = 0.66–1.28] and incident aOR = 0.72 [95% CI = 0.59–0.88]). No significant differences were observed in compliance with recall (OR = 1.26, 95% CI = 0.76–2.23), cancer detection rate (aOR = 0.91 [95% CI = 0.69–1.18]), or cancer stages.

Conclusions:

The COVID-19 pandemic negatively affected screening attendance, especially in previous participants and newcomers. We found a reduction in recall and false positives and no marked differences in cancer detection, indicating the robustness of the program. There is a need for further evaluations of interval cancers and potential diagnostic delays.

Funding:

This study has received funding by grants PI19/00007 and PI21/00058, funded by Instituto de Salud Carlos III (ISCIII) and cofunded by the European Union and Grant RD21/0016/0020 funded by Instituto de Salud Carlos III and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia (MRR).

Mammography self-evaluation online test for screening readers: an Italian Society of Medical Radiology (SIRM) initiative

OBJECTIVES

To report and analyse the characteristics and performance of the first cohort of Italian radiologists completing the national mammography self-evaluation online test established by the Italian Society of Medical Radiology (SIRM).

METHODS

A specifically-built dataset of 132 mammograms (24 with screen-detected cancers and 108 negative cases) was preliminarily tested on 48 radiologists to define pass thresholds (62% sensitivity and 86% specificity) and subsequently made available online to SIRM members during a 13-month timeframe between 2018 and 2019. Associations between participants' characteristics, pass rates, and diagnostic accuracy were then investigated with descriptive statistics and univariate and multivariable regression analyses.

RESULTS

A total of 342 radiologists completed the test, 151/342 (44.2%) with success. All individual variables, except gender, showed a significant correlation with pass rates and diagnostic sensitivity, confirmed by univariate logistic regression, while only involvement in organised screening programs and number of mammograms read per year showed a positive association with specificity at univariate logistic regression. In the multivariable regression analysis, fewer variables remained significant: > 3000 mammograms read per year for success rate; female gender, public practice setting, and higher experience self-judgement for sensitivity; no variables were significantly associated with specificity.

CONCLUSIONS

This national self-evaluation test effectively differentiated multiple aspects of mammographic reading experience, but specific breast imaging experience was shown not to strictly guarantee good diagnostic accuracy. Due to its easy use and the validity of obtained results, this test could be extended to all Italian breast radiologists, regardless of their experience, also as a Breast Unit accreditation criterion.

KEY POINTS

• This self-evaluation test was found to be able to differentiate various degrees of mammographic interpretation experience. • Breast cancer screening readers should undergo a self-assessment test, since experience parameters alone do not guarantee diagnostic ability.

Five-year annual incidence and clinico-molecular features of breast cancer after the last negative screening mammography at age 68-69

OBJECTIVE

The European Commission Initiative on Breast Cancer recommendation for triennial screening of women aged 70-74 is based on very weak evidence. A cohort of Italian women who had their last biennial screening mammography at age 68-69 was followed up for 5 years, assumed to represent the interval to another hypothetical screening mammography, in order to determine the annual proportional incidence of interval breast cancer.

METHODS

The cohort included 118,370 women. They had their last mammography between 1997 and 2008. Incident breast cancers were identified by record-linking the cohort with the regional breast cancer registry. The expected incidence in the age range 65-74 was estimated with an age-period-cohort model. The number of interval cancers was divided by the expected number to obtain their proportional incidence.

RESULTS

Overall, there were 298,658 woman-years at risk with 371 interval cancers versus 988.8 expected. In the first, second, third, fourth, and fifth interval year, the proportional incidence was 0.09 (95% confidence interval, 0.06-0.13), 0.32 (0.25-0.39), 0.60 (0.49-0.73), 0.75 (0.60-0.92), and 0.81 (0.60-1.07), respectively. Between the second and the fifth year, tumour stage and molecular subtype did not change significantly.

CONCLUSION

Though not supported by these findings, the proposal of triennial screening for women aged 70-74 merits further research, because the 95% confidence interval of the third-year proportional incidence of interval cancer included 0.50-the maximum limit considered acceptable for women aged 50-69.

KEY POINTS

• The third-year incidence of breast cancer relative to the expected one was 0.60 (95% confidence interval, 0.49-0.73). • Between the second and the fifth year, tumour stage and molecular subtype did not change significantly (p >0.10). • The proposal of a 3-year screening interval at age 70-74 merits further evaluation.

A European Model for an Organised Risk-stratified Early Detection Programme for Prostate Cancer

CONTEXT

Overdiagnosis as the argument to stop prostate cancer (PCa) screening is less valid since the introduction of new technologies such as risk calculators (RCs) and magnetic resonance imaging (MRI). These new technologies result in fewer unnecessary biopsy procedures and fewer cases of both overdiagnosis and underdetection. Therefore, we can now adequately respond to the growing and urgent need for a structured risk assessment to detect PCa early.

OBJECTIVE

To provide expert discussion on the existing evidence for a previously published risk-stratified strategy regarding an organised population-based early detection programme for PCa.

EVIDENCE ACQUISITION

The proposed algorithm for early detection of PCa emerged from expert consensus by the authors based on available evidence derived from a nonsystematic review of the current literature using Medline/PubMed, Cochrane Library database, ClinicalTrials.gov, ISRCTN Registry, and the European Association of Urology guidelines on PCa.

EVIDENCE SYNTHESIS

Although not confirmed by the highest level of evidence, current literature and guidelines point towards an algorithm for early detection of PCa that starts with risk-based prostate-specific antigen (PSA) testing, followed by multivariable risk stratification with RCs. All men who are classified to be at intermediate and high risk are then offered prostate MRI. The combined data from RCs and MRI results can be used to select men for prostate biopsy. Low-risk men return to a risk-based safety net that includes individualised PSA-interval tests and, if necessary, repeated MRI. Depending on local availability, the use of the different risk stratification tools may be adapted.

CONCLUSIONS

We present a risk-stratified algorithm for an organised population-based early detection programme for clinically significant PCa. Although the proposed strategy has not yet been analysed prospectively, it exploits and may even improve the most important available benefits of "PSA-only" screening studies, while at the same time reduces unnecessary biopsies and overdiagnosis by using new risk stratification tools.

PATIENT SUMMARY

This paper presents a personalised strategy that enables selective early detection of prostate cancer by combining prostate-specific antigen (interval) testing' prediction models (risk calculators), and magnetic resonance imaging scans. This will likely lead to reduced prostate cancer-related morbidity and mortality, while reducing the need for prostate biopsy and limiting overdiagnosis.

Retrospective analysis of the effect on interval cancer rate of adding an artificial intelligence algorithm to the reading process for two-dimensional full-field digital mammography

Interval cancers are a commonly seen problem in organized breast cancer screening programs and their rate is measured for quality assurance. Artificial intelligence algorithms have been proposed to improve mammography sensitivity, in which case it is likely that the interval cancer rate would decrease and the quality of the screening system could be improved. Interval cancers from negative screening in 2011 and 2012 of one regional unit of the national German breast cancer screening program were classified by a group of radiologists, categorizing the screening digital mammography with diagnostic images as true interval, minimal signs, false negative and occult cancer. Screening mammograms were processed using a detection algorithm based on deep learning. Of the 29 cancer cases available, artificial intelligence identified eight out of nine of those classified as minimal signs, all six false negatives and none of the true interval and occult cancers. Sensitivity for lesions judged to be already present in screening mammogram was 93% (95% confidence interval 68-100) and sensitivity for any interval cancer was 48% (95% confidence interval 29-67). Using an artificial intelligence algorithm as an additional reading tool has the potential to reduce interval cancers. How and if this theoretical advantage can be reached without a negative effect on recall rate is a challenge for future research.