Breast carcinoma detection modes and death in a female population in relation to population-based mammography screening

Purpose

Associations between population-based screening, breast carcinoma detection modes and breast carcinoma death have not been studied using nationwide data at individual level. We evaluated these in Finland, where invitational age is gradually expanding from 50–59 to 50–69 years in 2008–2017. We also predicted breast carcinoma patterns in 2020 to assess the impact of changing invitational policy on breast carcinoma incidence and mortality.

Methods

The data included breast carcinomas in 2000–2010 (n = 48 040), and deaths due to these carcinomas (n = 4722). We divided carcinomas into those detected before or after the screening age, and those detected at the screening age. The latter was further divided into screen-detected and interval carcinomas, and carcinomas in the non-attendees. The prediction of future patterns was based on incidence data from the ten-year period 1998–2007 preceding the period of expanding invitational age in the national programme.

Results

Approximately 13% of in situ carcinomas were detected before, 29% after, and 57% at the screening age. In invasive cancers, the percentages were 16%, 42%, and 42%, respectively. At the screening age, more than half of invasive cancers were screening-detected, one quarter interval cancers, and one out of six cancers in the non-attendees. Almost 60% of breast cancer deaths were due to cancers detected after the screening age. By 2020, breast cancers detected at the screening age will increase from 42% to 65%, and breast cancers detected by screening from 23% to 38%.

Conclusions

The study demonstrates a novel approach to examine associations between breast carcinoma incidence and mortality within and outside population-based screening. The results show mammography screening having a distinct role in overall breast carcinoma incidence and mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-348) contains supplementary material, which is available to authorized users.

Stillbirth, early death and neonatal morbidity among offspring of female cancer survivors

BACKGROUND

Increased awareness of the adverse effects of cancer treatments has prompted the development of fertility preserving regimens for the growing population of cancer survivors who desire to have children of their own.

MATERIAL AND METHODS

We conducted a registry-based study to evaluate the risk of stillbirth, early death and neonatal morbidity among children of female cancer survivors (0-34 years at diagnosis) compared with children of female siblings. A total of 3501 and 16 908 children of female cancer patients and siblings, respectively, were linked to the national medical birth and cause-of-death registers.

RESULTS

The risk of stillbirth or early death was not significantly increased among offspring of cancer survivors as compared to offspring of siblings: the risk [Odds Ratio (OR)] of early neonatal death, i.e. mortality within the first week was 1.35, with a 95% confidence interval (CI) of 0.58-3.18, within 28 days 1.40, 95% CI 0.46-4.24 and within the first year of life 1.11, 95% CI 0.64-1.93 after adjustment for the main explanatory variables. All these risk estimates were reduced towards one after further adjustment for duration of pregnancy. Measures of serious neonatal morbidity were not significantly increased among the children of survivors. However, there was a significant increase in the monitoring of children of cancer survivors for neonatal conditions (OR 1.56, 95% CI 1.35-1.80), which persisted even after correcting for duration of pregnancy, that might be related to parental cancer and its treatment or increased surveillance among the children.

CONCLUSION

Offspring of cancer survivors were more likely to require monitoring or care in a neonatal intensive care unit, but the risk of early death or stillbirth was not increased after adjustment for prematurity. Due to the rarity of the mortality outcomes studied, collaborative studies may be helpful in ruling out the possibility of an increased risk among offspring of cancer survivors.

Pregnancy incidence and outcome among patients with cervical intraepithelial neoplasia: a retrospective cohort study

OBJECTIVE

To investigate the effect of cervical intraepithelial neoplasia (CIN) treatment on incidence of pregnancy and pregnancy outcome.

DESIGN

Retrospective cohort study.

SETTING

Helsinki University Central Hospital, Finland, the sole reference centre in the Helsinki-Uusimaa region for women referred for colposcopy.

POPULATION

A cohort of 6179 women treated for CIN between 1974 and 2001, and a randomly selected, age- and municipality-matched, reference population of 30,436 women.

METHODS

Based on nationwide registers, all women were followed-up for pregnancy outcomes until death, emigration, sterilization, or until the end of 2004.

MAIN OUTCOME MEASURES

Incidence of any pregnancy, livebirths, miscarriages, extrauterine pregnancies, molar pregnancies, and terminations of pregnancies (TOPs) before and after CIN treatment, estimated by calculating hazard ratios (HRs) with stratified Cox regression and Poisson regression.

RESULTS

After CIN treatment, both incidence of pregnancy (HR 1.20; 95% CI 1.15-1.26; P < 0.001) and incidence of livebirths (HR 1.12; 95% CI 1.06-1.18; P < 0.001) were higher among the treated women than among the reference population. Before treatment, only incidence of pregnancy had been elevated among those treated (HR 1.06; 95% CI 1.04-1.09; P < 0.001). The incidence of extrauterine pregnancies and of TOPs was significantly elevated among those treated both before and after CIN treatment.

CONCLUSIONS

No clear evidence emerged of adverse effects resulting from the CIN treatment itself, because the women treated had more pregnancies and more children than their reference population. TOPs and extrauterine pregnancies were more common among the treated women already before the CIN treatment.

Future lung cancer incidence in Poland and Finland based on forecasts on hypothetical changes in smoking habits

OBJECTIVE

the aim is to estimate the future lung cancer incidence in Poland and Finland based on forecasts on hypothetical changes in smoking habits.

MATERIAL AND METHODS

data on population, lung cancer and smoking prevalence come from known sources. The simulation model utilized for forecasting was based on smoothing the smoking habit - specific risk ratios estimated for males and females in Europe.

RESULTS

depending on the analyzed scenario in 2030 in Poland mortality rates among men would range from 8 to 125/10(5) and among women from 7 to 47/10(5); in Finland among men 5 to 60/10(5) and among women 4 to 22/10(5).

CONCLUSIONS

the results obtained clearly indicate that cutting down on the number of smokers translates directly into a considerable reduction of the lung cancer incidence rate.

Preterm delivery among female survivors of childhood, adolescent and young adulthood cancer

We studied the deliveries of female cancer survivors and female siblings in a population-based setting in Finland. Nationwide cancer and birth registries were merged to identify 1,309 first postdiagnosis deliveries of early-onset (diagnosed under age 35) female patients with cancer and 5,916 first deliveries of female siblings occurring in 1987-2006. Multiple logistic regression models were used to estimate risk of preterm (<37 weeks), low birth weight (<2500 g) and small-for-gestational-age deliveries. The risk of preterm delivery among cancer survivors compared with siblings was overall increased [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.14-1.85], the increase in risk being visible in all diagnostic age groups. Risk of low birth weight (LBW) was also significantly increased (OR 1.68; 95% CI 1.29-2.18) but not after adjustment for duration of pregnancy (OR 1.11; 95% CI 0.76-1.64). Neither was the risk of small-for-gestational-age (SGA) increased. The risk of preterm delivery was most pronounced in survivors delivering 10 years or more after diagnosis. Site-specific analyses indicated that survivors of germ cell tumors and central nervous system (CNS) tumors were at increased risk of preterm delivery, although numbers were small. In childhood survivors, kidney tumors formed the main cause of preterm delivery. Pediatric, adolescent and young adult cancer survivors are at risk for preterm delivery. Heightened surveillance is recommended especially for Wilms', germ cell and CNS tumor survivors. Such adverse pregnancy outcomes can occur a decade or more after cancer diagnosis, indicating a continued need for obstetric awareness, surveillance and counseling in former patients with cancer.

A case-control study on hormone therapy as a risk factor for breast cancer in Finland: Intrauterine system carries a risk as well

The purpose of this study was to evaluate the association between postmenopausal hormone therapy (HT) and the risk for breast cancer in recently postmenopausal Finnish women. All Finnish women with first invasive breast cancer diagnosed between the ages of 50 and 62 years during 1995-2007 (n = 9,956) were identified from the Finnish Cancer Registry. For each case, 3 controls of the same age were retrieved from the Finnish Population Register. The cases and controls were linked to the national medical reimbursement register to assess the use of HT. The odds ratios (ORs) and 95% confidence intervals (CIs) for breast cancer were calculated with conditional logistic regression analysis, adjusting for parity, age at the first birth and health care district. Estradiol-only therapy (991 users with breast cancer, n) or oral progestagen (n = 138) was not accompanied by an increased risk. Estradiol-progestagen therapy (EPT) (n = 1,731) was associated with an elevated risk in the whole series (OR 1.36; 95% CI 1.27-1.46). The risk became detectable in less than 3 years of use. Continuous EPT use tended to be associated with a higher risk for breast cancer than the sequential EPT use. The use of tibolone (n = 80) (1.36; 1.15-1.96), a levonorgestrel-releasing intrauterine system (LNG-IUS) alone (n = 154) (1.45; 1.97-1.77) or as a complement to estradiol (n = 137) (2.15; 1.72-2.68) was also associated with an increased risk. The association between HT use and the risk for breast cancer shows a large variation between various forms of HT, and also the use of LNG-IUS may carry a risk.

Probability of parenthood after early onset cancer: a population-based study

We evaluated in a population-based setting the postdiagnosis parenthood among survivors compared with the fertility patterns of siblings. Cancer patients aged 0-34 years at diagnosis were identified from the Finnish Cancer Registry (N = 25,784), and their siblings (N = 44,611) by registry linkage. Further linkage identified the offspring of the patient and sibling cohorts. The relative probabilities of parenthood for first and second births separately were estimated for male and female survivors in different diagnostic age-groups and subsites using a Cox proportional hazards model, with age as the time variable and adjusting for the birth cohort of parents. In addition, estimates were calculated for 5 diagnostic eras in all subsites combined. Compared to siblings, both female and male cancer survivors were less likely to parent at least 1 child (RR 0.46, 95% CI 0.44-0.48 and RR 0.57, 95% CI 0.54-0.60, respectively). The relative probability of parenthood was especially low in male childhood cancer survivors and female young adult cancer survivors. However, cancer patients were only slightly less likely than siblings to parent a second child, with RR 0.91, 95% CI 0.86-0.97 and RR 0.95, 95% CI 0.89-1.01 for females and males, respectively. The relative probability of parenthood increased over calendar time among young adult cancer patients. The relative probability of parenthood following early onset cancer was overall significantly reduced by approximately 50%. Parenting a second child, however, was not reduced among pediatric and adolescent survivors, and only slightly reduced among early adulthood cancer survivors compared to siblings.

Prevalence of oncogenic human papillomavirus infection in an organised screening population in Finland

A persistent high-risk human papillomavirus (hrHPV) infection is a necessary condition for developing a cervical intraepithelial neoplasia and cervical cancer. The viral aetiology in cervical carcinogenesis has stimulated attempts to use HPV DNA detection in cervical cancer screening. In Finland there is an ongoing study assessing the benefits of primary HPV DNA testing in the setting of centrally organised mass screening for cervical cancer. Here we present the age-specific prevalence of hrHPV infection and associated sociodemographic factors of 16,895 women aged 25-65 years attending the 5-yearly cervical cancer screening between years 2003 and 2004. The overall hrHPV prevalence rate was 7.5%. The peak prevalence at the age group of 25-29 was 24.1% decreasing steadily thereafter to approximately 2.9% in women aged 65 years. Young age and marital status were the main determinants for oncogenic HPV types. Our study confirms the inverse relationship between age and hrHPV prevalence reported in many developed countries. As our prevalence rates and hence background risk for cervical cancer are not lower than in other European countries, it is likely that our lowest cervical cancer burden in Europe is due to health care actions justifying the organised cervical cancer screening.

Baseline psychosocial predictors of survival in localized melanoma

OBJECTIVE

There is no certainty about the contributing factors or the psychological processes involved in cancer progression. Many studies have suffered from poor theoretical basis, methodological flaws, and only one or few psychosocial factors investigated at a time. We examined the simultaneous contribution of several theory-based psychosocial elements to survival time in melanoma.

METHODS

A consecutive sample of patients with localized (Clarke II-IV) melanoma (N=59) were evaluated with validated questionnaires on coping with cancer, anger expression, perceived social support, noncancer life stresses, and domains of quality of life (QOL) 3-4 months after diagnosis. Cox regression analyses were used to determine the predictors of survival time from the date of diagnosis to the date of death or the last follow-up.

RESULTS

After controlling for age, gender, and Breslow depth for the tumor, the baseline psychological variables related to the cancer-prone Type C response pattern, namely, anger nonexpression (repression), hopelessness, and better single-item self-reported QOL predicted shorter survival. Before hopelessness was added to the model, the amount of depressive symptoms and heavy perceived impact of diagnosis were also predictive. In addition, longer survival was strongly predicted by Cognitive Escape-Avoidance coping, which included items close to the concept of denial/minimizing.

CONCLUSION

Anger nonexpression, hopelessness, and overpositive reporting of QOL--all proposed to include in the Type C response style or reflect emotional nonexpression--seem to comprise a set of factors that reduce survival, whereas denial/minimizing response to the diagnosis as such predicts longer survival.

Cancer free survival after CIN treatment: Comparisons of treatment methods and histology

OBJECTIVE

Cervical cancer is one of the most lethal cancers among women worldwide. Women are treated and followed-up in several different manners. Long-term studies of cancer or death risks after different methods of treatment or after different initial histology are scarce.

METHODS

A retrospective cohort study with 7466 women treated of CIN between 1974 and 2001 in Helsinki University Hospital followed-up until the end of 2003. The Cox model was used to determine differences in cancer free or overall survival between women treated of CIN with different methods or after different initial grade of CIN.

RESULTS

Twenty-two cases of invasive cervical cancer (ICC) and 57 cases of CIN 3 after treatment of CIN were observed. There were no statistically significant differences in ICC free survival between different treatment methods or initial grade of CIN. In CIN 3 free survival, the hazard ratios for the 57 cases of CIN 3, when cold knife coagulation (CKC) was set as the reference, were 0.22 for laser, 0.55 for cryotherapy and 0.31 for LEEP. In CIN 3+ (CIN 3 or ICC) free survival, the hazard ratios of 79 CIN 3+ cases (CKC reference) were 0.25 for laser, 0.50 for cryotherapy and 0.27 for LEEP. There were no differences in overall survival between different grades of initial CIN.

CONCLUSIONS

The CKC seems to be the least favorable in terms of both further cancer and CIN 3 risk. The follow-up has to be well organized because the post-treatment cancer risk is independent of the initial grade of CIN.

Baseline psychosocial predictors of survival in localised breast cancer

Despite the large number of studies on the impact of psychosocial factors on breast cancer progression, there is no certainty about the contributing factors or processes involved. We investigated the relative impacts of socioeconomic, psychological, and psychosocial factors on survival in breast cancer. A consecutive sample of 102 patients (participation 82%) under 72 years of age with locoregional breast cancer completed validated questionnaires on coping with cancer, emotional expression (anger), perceived available support, noncancer life stresses, and quality of life 3-4 months after diagnosis. Survival times were measured from the date of diagnosis to the date of relapse and further to the date of death or date of last follow-up. Cumulative Cox regression analyses were carried out. After controlling for biological prognostic factors, age, and baseline treatment, longer survival was predicted by a long education and a minimising-related coping, while shorter survival was predicted by emotional defensiveness (antiemotionality), behavioural-escape coping, and a high level of perceived support. A shorter event-free time was also predicted by unemployment and depressive symptoms. Cancer survival is affected by a complex combination of psychosocial factors, among which minimising predicts a favourable prognosis and anger nonexpression and escape behaviour an unfavourable prognosis. Higher socioeconomic status is associated with longer survival. High scores in well-being scales may reflect emotional nonexpression.

Comparison of different approaches to incidence prediction based on simple interpolation techniques

The paper compares three different methods for performing disease incidence prediction based on simple interpolation techniques. The first method assumes that the age-period specific numbers of observed cases follow a Poisson distribution and the other two methods assume a normal distribution for the incidence rates. The main emphasis of the paper is on assessing the reliability of the three methods. For this purpose, ex post predictions produced by each method are checked for different cancer sites using data from the Cancer Control Region of Turku in Finland. In addition, the behaviour of the estimators of predicted expected values and prediction intervals, crucial for investigation of the reliability of prediction, are assessed using a simulation study. The prediction method making use of the Poisson assumption appeared to be the most reliable of the three approaches. The simulation study found that the estimator of the length of the prediction interval produced by this method has the smallest coverage error and is the most precise.

A simple non-linear model in incidence prediction

A simple model is proposed for incidence prediction. The model is non-linear in parameters but linear in time, following models in environmental cancer epidemiology. Assuming a Poisson distribution for the age and period specific numbers of incident cases approximate confidence and prediction intervals are calculated. The major advantage of this model over current models is that age-specific predictions can be made with greater accuracy. The model also preserves in the period of prediction the age pattern of incidence rates existing in the data. It may be fitted with any package which includes an iteratively reweighted least squares algorithm, for example GLIM. Cancer incidence predictions for the Stockholm-Gotland Oncological Region in Sweden are presented as an example.

Evaluation of certain risk factors for lung cancer in Cracow (Poland)--a case-control study

The relationship of lung cancer risk to cigarette smoking, occupational exposure, air pollution at permanent residence and usual frequency of consumption of fruits and vegetables was analysed in a case control study in Cracow, Poland. The cases were 176 male lung cancer patients diagnosed in 1992-1994 with histological confirmation of the diagnosis, obtained from the population-based Cracow Cancer Registry, and 341 controls randomly selected from the general population. Classification of exposure to outside air pollution was based on measured level of total suspended particular matter and sulphur dioxide by particular districts of town (from 1973 to 1980). Except calculation of odds ratios for male lung cancer associated with exposures among all study subjects, the association between lung cancer risk and frequency of consumption of fruit and vegetables was examined among drinkers of vodka above average. Risk of lung cancer was increased significantly with increasing number of pack-years of smoking (OR = 18.7 for more than 40 pack-years). The significant inverse association of frequent usual consumption of boiled vegetables was present both among all subjects and among vodka drinkers (OR = 4.6 and 12.5, respectively, for a rare consumption). The risk of male lung cancer was negatively associated with the level of air pollution but positively with the percentage of occupationally exposed. Our study provides no evidence of a significant harmful effect of air pollution and found a strong inverse association between frequent fruit and vegetables consumption and lung cancer risk.

Cancer survival in Estonian migrants to Sweden

OBJECTIVE

To quantify the eventual extra loss of life incurred to cancer patients in Estonia compared with those in Sweden that was possibly attributable to differences in society.

DESIGN

Population based survival of cancer patients in Estonia was compared with that of Estonian immigrants to Sweden and that of all cancer patients in Sweden. The cancer sites studied were female breast and ovary, male lung and prostate, and male and female stomach and colon.

SETTING

Data on incident cases of cancer were obtained from the population based Swedish and Estonian cancer registries.

PARTICIPANTS

Data from Estonian patients in Sweden, Estonian patients in Estonia, and patients from the total Swedish population were included in the study.

MAIN RESULTS

Differences in survival among the three populations, controlling for follow-up time and age at diagnosis, were observed in breast, colon, lung, ovarian, and prostate cancers. The survival rates of Estonians living in Sweden and the total population of Sweden were better than that of the Estonians living in Estonia. For cancers of the breast and prostate, the excess mortality in the older age group (75 and above) was much greater in Estonia than in the other populations.

CONCLUSIONS

Most differences in cancer survival between Estonian and Swedish populations studied could be attributed to a longer delay in diagnosis, and also to inferior treatment (including access to treatment) in Estonia compared with Sweden. Estonia's lag in socioeconomic development, particularly in its public health organisation and funding, is probably the main source of the differences observed.

[Ovarian cancer and selected life style habits]

Analysis of population based case-control study performed in Cracow Poland in 1988-1990 on 81 cases of histologically proven epithelial ovarian cancer and 162 age matched controls have shown that frequent consumption of legumes was associated with significantly decreased risk. Smoking and drinking of vodka were not significant related to ovary cancer risk.