Tailored Screening for Breast Cancer in Premenopausal Women: Not Just Looking at Sensitivity, But Aiming to Reduce Burden

Volumetric breast density and risk of advanced cancers after a negative screening episode: a cohort study

BACKGROUND

We evaluated the association between volumetric breast density (BD) and risk of advanced cancers after a negative screening episode.

METHODS

A cohort of 16,752 women aged 49-54 years at their first screening mammography in the Florence screening programme was followed for breast cancer (BC) incidence until the second screening round. Volumetric BD was measured using fully automated software. The cumulative incidence of advanced cancer after a negative screening episode (including stage II or more severe cancer during the screening interval - on average 28 months - and at the subsequent round) was calculated separately for Volpara density grade (VDG) categories.

RESULTS

BC incidence gradually increased with the increas in BD: 3.7‰, 5.1‰, 5.4‰ and 9.1‰ in the VDG categories 1-4, respectively (p trend < 0.001). The risk of advanced cancers after a negative screening episode was 1.0‰, 1.3‰, 1.1‰, and 4.2‰ (p trend = 0.003). The highest BD category, compared with the other three together, has double the invasive BC risk (RR = 2.0; 95% CI 1.5-2.8) and almost fourfold risk of advanced cancer (RR = 3.8; 95% CI 1.8-8.0).

CONCLUSION

BD has a strong impact on the risk of advanced cancers after a negative screening episode, the best early surrogate of BC mortality. Therefore, our results suggest that screening effectiveness is quite different among BD categories.

Presence, characteristics and equity of access to breast cancer screening programmes in 27 European countries in 2010 and 2014. Results from an international survey

The European Union Council Recommendation of 2 December 2003 on cancer screening suggests the implementation of organised, population-based breast cancer screening programmes based on mammography every other year for women aged 50 to 69years, ensuring equal access to screening, taking into account potential needs for targeting particular socioeconomic groups. A European survey on coverage and participation, and key organisational and policy characteristics of the programmes, targeting years 2010 and 2014, was undertaken in 2014. Overall, 27 countries contributed to this survey, 26 of the 28 European Union member states (92.9%) plus Norway. In 2014, 25 countries reported an ongoing population-based programme, one country reported a pilot programme and another was planning a pilot. In eight countries, the target age range was broader than that proposed by the Council Recommendation, and in three countries the full range was not covered. Fifteen countries reported not reaching some vulnerable populations, such as immigrants, prisoners and people without health insurance, while 22 reported that participation was periodically monitored by socioeconomic variables (e.g. age and territory). Organised, population-based breast cancer screening programmes based on routine mammograms are in place in most EU member states. However, there are still differences in the way screening programmes are implemented, and participation by vulnerable populations should be encouraged.

The Balance Sheet of Benefits and Harms of Breast Cancer Population-Based Screening in Europe: Outcome Research, Practice and Future Challenges

Breast cancer screening programs are still object of harsh debate. In 2012, the Independent UK Panel reviewed the benefits and harms of mammography screening based on randomized trials and the EUROSCREEN Working Group reviewed European observational outcome studies. The conclusion was that screening programs should continue, while acknowledging that harms, such as the occurrence of false-positive results and overdiagnosis, can have a negative impact on a woman's life. Information on the balance sheet of the benefits and harms of breast cancer screening should help women and their physicians to make an informed choice. The future challenge for breast screening programs is to assess the feasibility, acceptability, effectiveness and impact of risk-based screening in order to maximize benefit-to-harm ratios.

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

BACKGROUND

The prevalence of breast cancer in developed countries has steadily risen over recent decades. Immediate and long-term health needs of patients, including preventive care and screening services, are receiving increasing attention. A question still unresolved is whether breast cancer survivors should receive mammographic surveillance in the clinical or screening setting and, thus, whether they should be excluded from, or invited to, organised mammography screening programmes. The objective of this article is to discuss the many contradictory aspects of this matter.

DISCUSSION

Problems with mammographic surveillance of breast cancer survivors include: weak evidence of a reduction in mortality; lack of evidence in favour of one setting or the other; lack of evidence-based guidelines for the frequency and duration of surveillance; disproportionate emphasis placed on the first few years post-treatment, probably dictated by surgical and oncological priorities; a variety of screening policies, as these women are permanently or temporarily or partially excluded from many - but not all - organised screening programmes worldwide; an even greater disparity in follow-up protocols used in the clinical setting; a paucity of data on compliance to mammographic surveillance in both settings; and a difficulty in coordinating the roles of health care providers. In the future, the use of mammography in breast cancer survivors will be influenced by the inclusion of women aged > 69 years in organised screening programmes and the implementation of multidisciplinary breast units, and will probably be investigated by research activities on individual risk assessment and risk-tailored screening. In the interim, current problems can be partially alleviated with some technical solutions in screening data recording, patient flows, and care coordination.

SUMMARY

Mammographic surveillance of breast cancer survivors is situated at the crossroads of numerous different specialist areas of breast cancer control and management. The solutions for current problems probably lie in some important modifications in the conventional screening procedure that are underway or under study. These developments appear to be directed towards a partial modification of the screening rationale, with an adaptation to meet the diversified breast care needs of women. The complexity of the matter constitutes a call to action for several entities to eliminate the barriers to effective research in this field.