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Smith J, Cvejic E, Houssami N, Schonberg MA, Vincent W, Naganathan V, Jansen J, Dodd RH, Wallis K, McCaffery KJ. Randomized Trial of Information for Older Women About Cessation of Breast Cancer Screening Invitations. J Gen Intern Med 2024:10.1007/s11606-024-08656-3. [PMID: 38409512 DOI: 10.1007/s11606-024-08656-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/24/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Older women receive no information about why Australia's breast screening program (BreastScreen) invitations cease after 74 years. We tested how providing older women with the rationale for breast screening cessation impacted informed choice (adequate knowledge; screening attitudes aligned with intention). METHODS In a three-arm online randomized trial, eligible participants were females aged 70-74 years who had recently participated in breast screening (within 5 years), without personal breast cancer history, recruited through Qualtrics. Participants read a hypothetical scenario in which they received a BreastScreen letter reporting no abnormalities on their mammogram. They were randomized to receive the letter: (1) without any rationale for screening cessation (control); (2) with screening cessation rationale in printed-text form (e.g., downsides of screening outweigh the benefits after age 74); or (3) with screening cessation rationale presented in an animation video form. The primary outcome was informed choice about continuing/stopping breast screening beyond 74 years. RESULTS A total of 376 participant responses were analyzed. Compared to controls (n = 122), intervention arm participants (text [n = 132] or animation [n = 122]) were more likely to make an informed choice (control 18.0%; text 32.6%, p = .010; animation 40.5%, p < .001). Intervention arm participants had more adequate knowledge (control 23.8%; text 59.8%, p < .001; animation 68.9%, p < .001), lower screening intentions (control 17.2%; text 36.4%, p < .001; animation 49.2%, p < .001), and fewer positive screening attitudes regarding screening for themselves in the animation arm, but not in the text arm (control 65.6%; text 51.5%, p = .023; animation 40.2%, p < .001). CONCLUSIONS Providing information to older women about the rationale for breast cancer screening cessation increased informed decision-making in a hypothetical scenario. This study is an important first step in improving messaging provided by national cancer screening providers direct to older adults. Further research is needed to assess the impact of different elements of the intervention and the impact of providing this information in clinical practice, with more diverse samples. TRIAL REGISTRATION ANZCTRN12623000033640.
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Affiliation(s)
- Jenna Smith
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nehmat Houssami
- The Daffodil Centre, The University of Sydney, a joint venture with the Cancer Council NSW, Sydney, NSW, Australia
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Wendy Vincent
- BreastScreen NSW, Sydney Local Health District, Sydney, NSW, Australia
| | - Vasi Naganathan
- Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, Australia
- Department of Geriatric Medicine, Centre for Education and Research On Ageing, Concord Hospital, Concord, NSW, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Rachael H Dodd
- The Daffodil Centre, The University of Sydney, a joint venture with the Cancer Council NSW, Sydney, NSW, Australia
| | - Katharine Wallis
- General Practice Clinical Unit, Medical School, The University of Queensland, Brisbane, QLD, Australia
| | - Kirsten J McCaffery
- Edward Ford Building (A27), The University of Sydney, Sydney, NSW, Australia.
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Gram EG, Siersma V, Brodersen JB. Long-term psychosocial consequences of false-positive screening mammography: a cohort study with follow-up of 12-14 years in Denmark. BMJ Open 2023; 13:e072188. [PMID: 37185642 PMCID: PMC10151842 DOI: 10.1136/bmjopen-2023-072188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To compare the long-term psychosocial consequences of mammography screening among women with breast cancer, normal results and false-positive results. DESIGN A matched cohort study with follow-up of 12-14 years. SETTING Denmark from 2004 to 2019. PARTICIPANTS 1170 women who participated in the Danish mammography screening programme in 2004-2005. INTERVENTION Mammography screening for women aged 50-69 years. OUTCOME MEASURES We assessed the psychosocial consequences with the Consequences Of Screening-Breast Cancer, a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions. RESULTS Across all 14 psychosocial outcomes, women with false-positive results averagely reported higher psychosocial consequences compared with women with normal findings. Mean differences were statistically insignificant except for the existential values scale: 0.61 (95% CI (0.15 to 1.06), p=0.009). Additionally, women with false-positive results and women diagnosed with breast cancer were affected in a dose-response manner, where women diagnosed with breast cancer were more affected than women with false-positive results. CONCLUSION Our study suggests that a false-positive mammogram is associated with increased psychosocial consequences 12-14 years after the screening. This study adds to the harms of mammography screening. The findings should be used to inform decision-making among the invited women and political and governmental decisions about mammography screening programmes.
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Affiliation(s)
- Emma Grundtvig Gram
- Center of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Primary Health Care Research Unit, Region Zealand, Denmark
| | - Volkert Siersma
- Center of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - John Brandt Brodersen
- Center of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Primary Health Care Research Unit, Region Zealand, Denmark
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Gram EG, Knudsen SW, Brodersen JB, Jønsson ABR. Women's experiences of age-related discontinuation from mammography screening: A qualitative interview study. Health Expect 2023; 26:1096-1106. [PMID: 36807965 PMCID: PMC10154894 DOI: 10.1111/hex.13723] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/20/2023] Open
Abstract
INTRODUCTION In Denmark, women are discontinued from mammography screening at age 69 due to decreased likelihood of benefits and increased likelihood of harm. The risk of harm increases with age and includes false positives, overdiagnosis and overtreatment. In a questionnaire survey, 24 women expressed unsolicited concerns about being discontinued from mammography screening due to age. This calls for further investigation of experiences related to discontinuation from screening. METHODS We invited the women, who had left comments on the questionnaire, to participate in in-depth interviews with the purpose to explore their reactions, preferences, and conceptions about mammography screening and discontinuation. The interviews lasted 1-4 h and were followed up with a telephone interview 2 weeks after the initial interview. RESULTS The women had high expectations of the benefits of mammography screening and felt that participation was a moral obligation. Following that, they perceived the screening discontinuation as a result of societal age discrimination and consequently felt devalued. Further, the women perceived the discontinuation as a health threat, felt more susceptible to late diagnosis and death, and therefore sought out new ways to control their risk of breast cancer. CONCLUSION Our findings indicate that the age-related discontinuation from mammography screening might be of more importance than previously assumed. This study raises important questions about screening ethics, and we encourage research to explore this in other settings. PATIENT AND PUBLIC CONTRIBUTION This study was conducted as a result of the women's unsolicited concerns about being discontinued from screening. This particular group contributed to the study with their own statements, interpretations and perspectives on the discontinuation of screening, and the initial analysis of data was discussed with the women during follow-up interviews.
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Affiliation(s)
- Emma G Gram
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Primary Health Care Research Unit, Region Zealand, Denmark
| | - Sigrid W Knudsen
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - John Brandt Brodersen
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Primary Health Care Research Unit, Region Zealand, Denmark.,The Research Unit for General Practice, Department of Social Medicine, University of Tromsø, Tromsø, Norway
| | - Alexandra Brandt R Jønsson
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of People and Technology, Roskilde University, Roskilde, Denmark.,The Research Unit for General Practice, Department of Social Medicine, University of Tromsø, Tromsø, Norway
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Smith J, Dodd RH, Wallis KA, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. General practitioners' views and experiences of communicating with older people about cancer screening: a qualitative study. Fam Pract 2022:cmac126. [PMID: 36334011 DOI: 10.1093/fampra/cmac126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Older adults should be supported to make informed decisions about cancer screening. However, it is unknown how general practitioners (GPs) in Australia communicate about cancer screening with older people. AIM To investigate GPs' views and experiences of communicating about cancer screening (breast, cervical, prostate, and bowel) with older people (≥70 years). DESIGN AND SETTING Qualitative, semi-structured interviews, Australia. METHOD Interviews were conducted with GPs practising in Australia (n = 28), recruited through practice-based research networks, primary health networks, social media, and email invitation. Interviews were audio-recorded and analysed thematically using Framework Analysis. RESULTS Findings across GPs were organized into 3 themes: (i) varied motivation to initiate cancer screening discussions; some GPs reported that they only initiated screening within recommended ages (<75 years), others described initiating discussions beyond recommended ages, and some experienced older patient-initiated discussions; (ii) GPs described the role they played in providing screening information, whereby detailed discussions about the benefits/risks of prostate screening were more likely than other nationally funded screening types (breast, cervical, and bowel); however, some GPs had limited knowledge of recommendations and found it challenging to explain why screening recommendations have upper ages; (iii) GPs reported providing tailored advice and discussion based on personal patient preferences, overall health/function, risk of cancer, and previous screening. CONCLUSIONS Strategies to support conversations between GPs and older people about the potential benefits and harms of screening in older age and rationale for upper age limits to screening programmes may be helpful. Further research in this area is needed.
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Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Katharine A Wallis
- General Practice Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation Hospital, Concord, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Kirsten J McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Attena F, Abagnale L, Avitabile A. Online information about mammography screening in Italy from 2014 to 2021. BMC Womens Health 2022; 22:132. [PMID: 35477449 PMCID: PMC9044849 DOI: 10.1186/s12905-022-01718-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background Many studies have reported that the information women receive about the risk-to-benefit ratio of breast cancer screening is still scarce and biased toward benefit. In a study we conducted in 2014, we analysed online documents about breast cancer screening that were addressed to the general female public. In the present study, we used the same methodology to verify if the information provided to women was improved. Methods We evaluated documents addressed to the general female public and posted on the Internet by the Italian national and regional public health services. False-positive and false-negative screening results, biopsy-proven false-positive results, interval cancer, overdiagnosis, radiation exposure, and decrease in risk of mortality were analysed. In addition, quantitative data were searched. Results In 2021, the most frequently reported information was reduction in breast cancer mortality (58.2%). The most frequently reported risk was a false-positive mammogram (42.5%). Similar frequency rates were reported for interval cancer, false-negative result, and radiation exposure (35.8%, 31.3%, and 28.3%, respectively). Overdiagnosis and biopsy-proven false-positive result were the less reported risks (20.1% and 10.4%). Thirteen documents provided quantitative data about reduction of mortality risk (16.7%), and only 19 provided quantitative data about risks or harms (8.4%). Almost all organisations sent letters of invitation to women (92.5%) and provided screening free of charge (92.5%). The most recommended was biennial screening for women aged between 50 and 69 years (48.5%). Compared with the information in 2014, that in 2021 showed some improvements. The most marked improvements were in the numbers of reports on overdiagnosis, which increased from 8.0 to 20.1%, and biopsy-proven false-positive result, which increased from 1.4 to 10.4%. Regarding the benefits of breast cancer screening, reduced mortality risk became increasingly reported from 2014 (34.5%) to 2021 (58.2%). Conversely, quantitative data remained scarce in 2021. Conclusions Moderate improvements in information were observed from 2014 to 2021. However, the information on breast cancer screening in documents intended for women published on Italian websites remain scarce.
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Affiliation(s)
- Francesco Attena
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Luciano Armanni, 5, 80138, Naples, Italy.
| | - Lucia Abagnale
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Luciano Armanni, 5, 80138, Naples, Italy
| | - Angela Avitabile
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Luciano Armanni, 5, 80138, Naples, Italy
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Wu H, Wong K, Lu SE, Broggio J, Zhang L. Changing Trends in the Proportional Incidence and Five-year Net Survival of Screened and Non-screened Breast Cancers among Women During 1995-2011 in England. JOURNAL OF CLINICAL AND TRANSLATIONAL PATHOLOGY 2022; 2:23-30. [PMID: 35403174 PMCID: PMC8994161 DOI: 10.14218/jctp.2022.00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Uptake of breast cancer screening has been decreasing in England since 2007. However, the associated factors are unclear. On the other hand, survival among breast cancer patients have recently increased. We conducted a quasi-experimental analysis to test whether the trend-change in proportional incidence of non-screened cancers coincided with that in five-year net-survival. METHODS We extracted population-based proportional incidence and age-standardized five-year net-survival data from Public Health England that included English women with invasive breast cancer diagnosed during 1995-2011 (linked to death certificates, followed through 2016). Piece-wise log-linear models with change-point/joinpoint were used to estimate temporal trends. RESULTS Among 254,063 women in England with invasive breast cancer diagnosed during 1995-2011, there was downward-to-upward trend-change in proportional incidence of non-screened breast cancers (annual percent change [APC]=5.6 after 2007 versus APC=-3.5 before 2007, p<0.001) in diagnosis-year 2007, when a steeper upward-trend in age-standardized five-year net survival started (APC=5.7 after 2007/2008 versus APC=0.3 before 2007/2008, p<0.001). Net-survival difference of screened versus non-screened cancers also significantly narrowed (18% in 2007/2008 versus 5% in 2011). Similar associations were found in all strata of race, cancer stage, grade, and histology, except in Black patients or patients with stage I, stage III, or grade I cancer. CONCLUSIONS There was a downward-to-upward trend-change in proportional incidence of non-screened breast cancers in 2007 that coincided with a steeper upward-trend in age-standardized five-year net survival among English women in 2007. Survival benefits of breast cancer screening decreased during 2007-2011. The data support reduction of breast cancer screening in some patients, but future validation studies are warranted.
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Affiliation(s)
- Haiyan Wu
- Health Data Research UK London, UCL Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, UK
| | - Kwok Wong
- National Cancer Registration and Analysis Service, Public Health England, Birmingham B3 2PW, UK
| | - Shou-En Lu
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - John Broggio
- National Cancer Registration and Analysis Service, Public Health England, Birmingham B3 2PW, UK
| | - Lanjing Zhang
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Pathology, Princeton Medical Center, Plainsboro, NJ, USA
- Department of Biological Sciences, Rutgers University, Newark, NJ, USA
- Department of Chemical Biology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
- Correspondence to: Lanjing Zhang, Department of Pathology, Princeton Medical Center, 1 Plainsboro Rd, Plainsboro, NJ 08536, USA. Tel: +1-609-853-6833, Fax: +1-609-853-6841,
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Bucchi L, Ravaioli A, Baldacchini F, Giuliani O, Mancini S, Vattiato R, Rossi PG, Campari C, Canuti D, Di Felice E, de Bianchi PS, Ferretti S, Bertozzi N, Falcini F. Five-year annual incidence and clinico-molecular features of breast cancer after the last negative screening mammography at age 68-69. Eur Radiol 2021; 32:834-841. [PMID: 34363132 DOI: 10.1007/s00330-021-08129-9] [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: 02/19/2021] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Lauro Bucchi
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
| | - Alessandra Ravaioli
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy.
| | - Flavia Baldacchini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
| | - Orietta Giuliani
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
| | - Silvia Mancini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
| | - Rosa Vattiato
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cinzia Campari
- Cancer Screening Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Debora Canuti
- Department of Health, Regional Administration, Emilia-Romagna Region, Bologna, Italy
| | - Enza Di Felice
- Department of Health, Regional Administration, Emilia-Romagna Region, Bologna, Italy
| | | | - Stefano Ferretti
- University of Ferrara and Local Health Authority, Ferrara, Italy
| | - Nicoletta Bertozzi
- Department of Health, Regional Administration, Emilia-Romagna Region, Bologna, Italy
| | - Fabio Falcini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori"), Meldola, Forlì, Italy
- Local Health Authority, Forlì, Italy
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Hersch J, Barratt A, McGeechan K, Jansen J, Houssami N, Dhillon H, Jacklyn G, Irwig L, McCaffery K. Informing Women About Overdetection in Breast Cancer Screening: Two-Year Outcomes From a Randomized Trial. J Natl Cancer Inst 2021; 113:1523-1530. [PMID: 33871631 PMCID: PMC8562961 DOI: 10.1093/jnci/djab083] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/06/2021] [Accepted: 04/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Supporting well-informed decisions about breast cancer screening requires communicating that inconsequential disease may be detected, leading to overdiagnosis and overtreatment. Having previously shown that telling women about overdetection improved informed choice, we investigated effects on screening knowledge and participation over 2 years. METHODS We conducted a community-based, parallel-group, randomized controlled trial in Australia. Participants were women aged 48-50 years, without personal or strong family history of breast cancer, who had not undergone mammography in the past 2 years. We randomly assigned 879 women to receive the intervention decision aid (evidence-based information on overdetection, breast cancer mortality reduction, and false-positives) or control decision aid (identical but without overdetection information). We interviewed 838 women postintervention and recontacted them for follow-up at 6 months and 1 and 2 years. Main outcomes for this report are screening knowledge and participation. RESULTS We interviewed 790, 746, and 712 participants at 6 months, 1, and 2 years, respectively. The intervention group demonstrated superior knowledge throughout follow-up. After 2 years, conceptual knowledge was adequate in 123 (34.4%) of 358 women in the intervention group compared with 71 (20.1%) of 354 control participants(odds ratio = 2.04, 95% confidence interval = 1.46 to 2.85). Groups were similar in total screening participation (200 [55.1%] vs 204 [56.0%]; = 0.97, 95% confidence interval = 0.73 to 1.29). CONCLUSIONS A brief decision aid produced lasting improvement in women's understanding of potential consequences of screening, including overdetection, without changing participation rates. These findings support the use of decision aids for breast cancer screening.
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Affiliation(s)
- Jolyn Hersch
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia,Centre for Medical Psychology and Evidence-based Decision-making, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Sydney Health Literacy Lab, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Correspondence to: Jolyn Hersch, PhD, School of Public Health, Edward Ford Building A27, The University of Sydney, NSW 2006, Australia (e-mail: )
| | - Alexandra Barratt
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia
| | - Kevin McGeechan
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia,Centre for Medical Psychology and Evidence-based Decision-making, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Sydney Health Literacy Lab, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Department of General Practice, Care and Public Health Research Institute (CAPHRI) School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Nehmat Houssami
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia
| | - Haryana Dhillon
- Centre for Medical Psychology and Evidence-based Decision-making, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Gemma Jacklyn
- Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia
| | - Les Irwig
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia
| | - Kirsten McCaffery
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Wiser Healthcare: A Research Collaboration for Reducing Overdiagnosis and Overtreatment, The University of Sydney, Sydney, NSW, Australia,Centre for Medical Psychology and Evidence-based Decision-making, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia,Sydney Health Literacy Lab, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Pape R, Spuur KM, Wilkinson JM, Umo P. Correlation of the BI-RADS assessment categories of Papua New Guinean women with mammographic parenchymal patterns, age and diagnosis. J Med Radiat Sci 2020; 67:269-276. [PMID: 32936540 PMCID: PMC7754014 DOI: 10.1002/jmrs.422] [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: 03/05/2020] [Accepted: 07/31/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Women with increased breast density are at increased risk of breast cancer. The aim of this research is to evidence for the first time the mammographic breast findings of Papua New Guinean (PNG) women and the relationship between Breast Imaging-Reporting and Data System (BI-RADS) assessment, mammographic parenchymal patterns (MPPs) and age. METHODS A retrospective analysis of 1357 mammograms of women imaged at the Pacific International Hospital (PIH) from August 2006 to July 2010 was undertaken. Mammographic findings were categorised using the BI-RADS Atlas® 5th Edition. MPPs were recorded for each woman using the Tabár Pattern I-V classification system. Age was recorded in years. Statistical analysis was by descriptive analysis and Kruskal-Wallis with Dunn's post-test and Spearman's rho correlation for inferential analysis. RESULTS True pathological findings (benign and malignant); BI-RADS 2-5 were noted in 111 women (8.2%); 1242 (91.5%) were negative. BI-RADS categories for malignancy were reported in 16 (88.9%) of women aged 30 to 60 years. The lower risk Tabár Type I, II and III MPPs were associated with 94.4% (n = 17) of malignancies. Linear correlations between variables were weak and not statistically significant: age and Tabár pattern r = 0.031, P = 0.0261; age and BI-RADS r = 0.018, P = 0.517; Tabár pattern and BI-RADS r = 0.020, P = 0.459 (n = 1357). CONCLUSION There was no correlation demonstrated between BI-RADS category, age and MPP. Importantly, there was no correlation demonstrated between BI-RADS categories 4 and 5 for breast malignancy and high-risk Tabár Type IV and V MPPs. The results of this study again reflect that the incidence of breast cancer in PNG cannot be explained by breast density and suggest that any formalised screening program in PNG has a target age group aimed at women younger than that of Western screening programs.
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Affiliation(s)
- Ruth Pape
- School of Medicine and Health SciencesDiscipline of Medical Imaging ScienceUniversity of Papua New GuineaBorokoNCDPapua New Guinea
- Pacific International HospitalBorokoNCDPapua New Guinea
| | - Kelly Maree Spuur
- Faculty of ScienceSchool of Dentistry & Health SciencesCharles Sturt UniversityWagga WaggaNSWAustralia
| | - Jenny Maree Wilkinson
- Faculty of ScienceSchool of Dentistry & Health SciencesCharles Sturt UniversityWagga WaggaNSWAustralia
| | - Pius Umo
- Pacific International HospitalBorokoNCDPapua New Guinea
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10
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Smith J, Dodd RH, Hersch J, Cvejic E, McCaffery K, Jansen J. Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: a randomised online trial of older adults in Australia. BMJ Open 2020; 10:e034061. [PMID: 32532766 PMCID: PMC7295415 DOI: 10.1136/bmjopen-2019-034061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess different strategies for communicating to older adults about stopping cancer screening. DESIGN 4 (recommendation statement about stopping screening)×(2; time) online survey-based randomised controlled trial. SETTING Australia. PARTICIPANTS 271 English-speaking participants, aged 65-90, screened for breast/prostate cancer at least once in past decade. INTERVENTIONS Time 1: participants read a scenario in which their general practitioner (GP) informed them about the potential benefits and harms of cancer screening, followed by double-blinded randomisation to one of four recommendation statements to stop screening: control ('this screening test would harm you more than benefit you'), health status ('your other health issues should take priority'), life expectancy framed positively ('this test would not help you live longer') and negatively ('you may not live long enough to benefit'). Time 2: in a follow-up scenario, the GP explained why guidelines changed over time (anchoring bias intervention). MEASURES Primary outcomes: screening intention and cancer anxiety (10-point scale, higher=greater intention/anxiety), measured at both time points. SECONDARY OUTCOMES trust (in their GP, the information provided, the Australian healthcare system), decisional conflict and knowledge of the information presented. RESULTS 271 participants' responses analysed. No main effects were found. However, screening intention was lower for the negatively framed life expectancy versus health status statement (6.0 vs 7.1, mean difference (MD)=1.1, p=0.049, 95% CI 0.0 to 2.2) in post hoc analyses. Cancer anxiety was lower for the negatively versus positively framed life expectancy statement (4.8 vs 5.8, MD=1.0, p=0.025, 95% CI 0.1 to 1.9). The anchoring bias intervention reduced screening intention (MD=0.8, p=0.044, 95% CI 0.6 to 1.0) and cancer anxiety (MD=0.3, p=0.002, 95% CI 0.1 to 0.4) across all conditions. CONCLUSION Older adults may reduce their screening intention without reporting increased cancer anxiety when clinicians use a more confronting strategy communicating they may not live long enough to benefit and add an explicit explanation why the recommendation has changed. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001306202; Results).
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Affiliation(s)
- Jenna Smith
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Erin Cvejic
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
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11
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Stiggelbout A, Copp T, Jacklyn G, Jansen J, Liefers GJ, McCaffery K, Hersch J. Women's Acceptance of Overdetection in Breast Cancer Screening: Can We Assess Harm-Benefit Tradeoffs? Med Decis Making 2019; 40:42-51. [PMID: 31722605 PMCID: PMC6985988 DOI: 10.1177/0272989x19886886] [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: 11/22/2022]
Abstract
Background. Breast cancer screening has been presented to women as mostly positive for decades, despite voices raising issues related to harms since its introduction. Public communications about breast cancer screening tended to use persuasive techniques aimed at maximizing uptake. Concern about the harm of overdetection is more recent, and awareness of overdetection among the public is limited. We aimed to assess the impact of extensive information on treatment following overdetection in breast screening on women’s acceptance of screening, and to assess correlates of acceptance. Methods. We performed an online survey among women aged 45-75 from the general public in the Netherlands and Australia, asking women their maximum acceptable ratio of overdetection, per breast cancer death avoided, for four treatment scenarios (randomized order): mastectomy; lumpectomy; lumpectomy plus radiotherapy; lumpectomy plus radiotherapy and hormone therapy. The effect of treatment was assessed using General Linear Models, controlling for socio-demographics, experience, and psychological characteristics. Results. Four-hundred Australian and 403 Dutch women responded. Around half of the women would always screen, even at a 6:1 overdetection-to-death-avoided ratio. Acceptance was highest for the lumpectomy scenario, decreasing with more invasive treatment. In multivariate analyses the effect of treatment remained (p<0.001). Higher acceptance was seen for women with children (p=0.04), screening experience (p<0.001), and less understanding of overdetection (p<0.001). A learning effect was seen: acceptance was highest for the first scenario shown. Conclusions. Acceptance of overdetection was high, but decreased after the first scenario and with invasiveness of treatment. This provides a first indication that with more knowledge and understanding, women may move from uncritical acceptance of screening towards a more informed decision that involves a trade-off of the benefits and harms.
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Affiliation(s)
- Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Gemma Jacklyn
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Gerrit-Jan Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
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12
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Degeling C, Barratt A, Aranda S, Bell R, Doust J, Houssami N, Hersch J, Sakowsky R, Entwistle V, Carter SM. Should women aged 70-74 be invited to participate in screening mammography? A report on two Australian community juries. BMJ Open 2018; 8:e021174. [PMID: 29903796 PMCID: PMC6009633 DOI: 10.1136/bmjopen-2017-021174] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To elicit informed views from Australian women aged 70-74 regarding the acceptability of ceasing to invite women their age to participate in government-funded mammography screening (BreastScreen). DESIGN Two community juries held in 2017. SETTING Greater Sydney, a metropolis of 4.5 million people in New South Wales, Australia. PARTICIPANTS 34 women aged 70-74 with no personal history of breast cancer, recruited by random digit dialling and previously randomly recruited list-based samples. MAIN OUTCOMES AND MEASURES Jury verdict and rationale in response to structured questions. We transcribed audio-recorded jury proceedings and identified central reasons for the jury's decision. RESULTS The women's average age was 71.5 years. Participants were of diverse sociocultural backgrounds, with the sample designed to include women of lower levels of educational attainment. Both juries concluded by majority verdict (16-2 and 10-6) that BreastScreen should continue to send invitations and promote screening to their age group. Reasons given for the majority position include: (1) sending the invitations shows that society still cares about older women, empowers them to access preventive health services and recognises increasing and varied life expectancy; (2) screening provides women with information that enables choice and (3) if experts cannot agree, the conservative approach is to maintain the status quo until the evidence is clear. Reasons for the minority position were the potential for harms through overdiagnosis and misallocation of scarce health resources. CONCLUSIONS Preventive programmes such as mammography screening are likely to have significant symbolic value once they are socially embedded. Arguments for programme de-implementation emphasising declining benefit because of limited life expectancy and the risks of overdiagnosis seem unlikely to resonate with healthy older women. In situations where there is no consensus among experts on the value of established screening programmes, people may strongly prefer receiving information about their health and having the opportunity make their own choices.
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Affiliation(s)
- Chris Degeling
- Research for Social Change, University of Wollongong, Wollongong, New South Wales, Australia
- Wiser Healthcare, Sydney, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sanchia Aranda
- The Cancer Council Australia, Sydney, New South Wales, Australia
| | - Robin Bell
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ruben Sakowsky
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Vikki Entwistle
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Stacy M Carter
- Research for Social Change, University of Wollongong, Wollongong, New South Wales, Australia
- Wiser Healthcare, Sydney, Australia
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13
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Zhang X, Lin X, Tan Y, Zhu Y, Wang H, Feng R, Tang G, Zhou X, Li A, Qiao Y. A multicenter hospital-based diagnosis study of automated breast ultrasound system in detecting breast cancer among Chinese women. Chin J Cancer Res 2018; 30:231-239. [PMID: 29861608 DOI: 10.21147/j.issn.1000-9604.2018.02.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective The automated breast ultrasound system (ABUS) is a potential method for breast cancer detection; however, its diagnostic performance remains unclear. We conducted a hospital-based multicenter diagnostic study to evaluate the clinical performance of the ABUS for breast cancer detection by comparing it to handheld ultrasound (HHUS) and mammography (MG). Methods Eligible participants underwent HHUS and ABUS testing; women aged 40-69 years additionally underwent MG. Images were interpreted using the Breast Imaging Reporting and Data System (BI-RADS). Women in the BI-RADS categories 1-2 were considered negative. Women classified as BI-RADS 3 underwent magnetic resonance imaging to distinguish true- and false-negative results. Core aspiration or surgical biopsy was performed in women classified as BI-RADS 4-5, followed by a pathological diagnosis. Kappa values and agreement rates were calculated between ABUS, HHUS and MG. Results A total of 1,973 women were included in the final analysis. Of these, 1,353 (68.6%) and 620 (31.4%) were classified as BI-RADS categories 1-3 and 4-5, respectively. In the older age group, the agreement rate and Kappa value between the ABUS and HHUS were 94.0% and 0.860 (P<0.001), respectively; they were 89.2% and 0.735 (P<0.001) between the ABUS and MG, respectively. Regarding consistency between imaging and pathology results, 78.6% of women classified as BI-RADS 4-5 based on the ABUS were diagnosed with precancerous lesions or cancer; which was 7.2% higher than that of women based on HHUS. For BI-RADS 1-2, the false-negative rates of the ABUS and HHUS were almost identical and were much lower than those of MG. Conclusions We observed a good diagnostic reliability for the ABUS. Considering its performance for breast cancer detection in women with high-density breasts and its lower operator dependence, the ABUS is a promising option for breast cancer detection in China.
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Affiliation(s)
- Xi Zhang
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xi Lin
- Department of Ultrasound, State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China
| | - Yanjuan Tan
- Department of Ultrasound, the First People's Hospital of Hangzhou, Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou 310006, China
| | - Ying Zhu
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China
| | - Hui Wang
- Department of Ultrasound, Xin Hua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Ruimei Feng
- Department of Cancer Prevention Research, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China
| | - Guoxue Tang
- Department of Ultrasound, State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China
| | - Xiang Zhou
- Department of Interventional Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Anhua Li
- Department of Ultrasound, State Key Laboratory of Oncology in Southern China, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China
| | - Youlin Qiao
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Prevalence of incidental breast cancer and precursor lesions in autopsy studies: a systematic review and meta-analysis. BMC Cancer 2017; 17:808. [PMID: 29197354 PMCID: PMC5712106 DOI: 10.1186/s12885-017-3808-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/21/2017] [Indexed: 01/11/2023] Open
Abstract
Background Autopsy studies demonstrate the prevalence pool of incidental breast cancer in the population, but estimates are uncertain due to small numbers in any primary study. We aimed to conduct a systematic review of autopsy studies to estimate the prevalence of incidental breast cancer and precursors. Methods Relevant articles were identified through searching PubMed and Embase from inception up to April 2016, and backward and forward citations. We included autopsy studies of women with no history of breast pathology, which included systematic histological examination of at least one breast, and which allowed calculation of the prevalence of incidental breast cancer or precursor lesions. Data were pooled using logistic regression models with random intercepts (non-linear mixed models). Results We included 13 studies from 1948 to 2010, contributing 2363 autopsies with 99 cases of incidental cancer or precursor lesions. More thorough histological examination (≥20 histological sections) was a strong predictor of incidental in-situ cancer and atypical hyperplasia (OR = 126·8 and 21·3 respectively, p < 0·001), but not invasive cancer (OR = 1·1, p = 0·75). The estimated mean prevalence of incidental cancer or precursor lesion was 19·5% (0·85% invasive cancer + 8·9% in-situ cancer + 9·8% atypical hyperplasia). Conclusion Our systematic review in ten countries over six decades found that incidental detection of cancer in situ and breast cancer precursors is common in women not known to have breast disease during life. The large prevalence pool of undetected cancer in-situ and atypical hyperplasia in these autopsy studies suggests screening programs should be cautious about introducing more sensitive tests that may increase detection of these lesions.
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