Reduced rates of cancer-related worries and mortality associated with guideline surveillance after breast cancer therapy

Follow-up strategy and survival for five common cancers: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the effectiveness of intensive follow-up after curative intent treatment for five common solid tumours, in terms of survival and treatment of recurrences.

METHODS

A systematic literature search was conducted, identifying comparative studies on follow-up for colorectal, lung, breast, upper gastro-intestinal and prostate cancer. Outcomes of interest were overall survival (OS), cancer specific survival (CSS), and treatment of recurrences. Random effects meta-analyses were conducted, with particular focus on studies at low risk of bias.

RESULTS

Fourteen out of 63 studies were considered to be at low risk of bias (8 colorectal, 4 breast, 0 lung, 1 upper gastro-intestinal, 1 prostate). These studies showed no significant impact of intensive follow-up on OS (hazard ratio, 95% confidence interval) for colorectal (0.99; 0.92-1.06), breast 1.06 (0.92-1.23), upper gastro-intestinal (0.78; 0.51-1.19) and prostate cancer (1.00; 0.86-1.16). No impact on CSS (hazard ratio, 95% confidence interval) was found for colorectal cancer (0.94; 0.77-1.16). CSS was not reported for other cancer types. Intensive follow-up increased the rate of curative treatment (relative risk; 95% confidence interval) for colorectal cancer recurrences (1.30; 1.05-1.61), but not for upper gastro-intestinal cancer recurrences (0.92; 0.47-1.81). For the other cancer types, no data on treatment of recurrences was available in low risk studies.

CONCLUSION

For colorectal and breast cancer, high quality studies do not suggest an impact of intensive follow-up strategies on survival. Colorectal cancer recurrences are more often treated locally after intensive follow-up. For other cancer types evaluated, limited high quality research on follow-up is available.

Assessment of guideline adherence in breast cancer management among oncologists in Nigeria

BACKGROUND

Breast cancer management is evolving by the day and new discoveries is shifting the scale to more positive result mostly in developed countries and this is being reported and updated in the treatment guidelines to bridge the knowledge gaps and allow for global standardised management protocol. This study assessed the adherence to the breast cancer guideline use among oncologists in Nigeria, reviewing the commonly used guidelines, factors for the choice, effects on treatment and barriers to usage.

METHODOLOGY

A proforma was sent by mail to the oncologist in Nigeria assessing their socio-demographic characteristics, knowledge of guidelines, use of guidelines, barriers to use of guidelines and benefits of guideline use and all the those that completed the survey within 1-month period were included in the study.

RESULTS

A total of 109 oncologist responded to the survey with mean age of 42 years, mean year of oncology practice was 10 years. Sixty-four percent were consultants and 38% residents-in-training. All respondents were aware of breast cancer guidelines and 92.2% had used it in treatment decision making. The commonest used being National Comprehensive Cancer Network guideline in 87.4% and 82.6% had a choice guideline/institution adopted. The major reason for referring to a choice guideline by 66% of respondents was to gain access to evidence-based results and the major barrier to guideline use in 56% of cases was non compatibility with available resources.

CONCLUSION

The study revealed high level of adherence to breast cancer guideline use among oncologists in Nigeria but there is need for more awareness about the locally developed ones like sub-Saharan adapted version and institutional based breast cancer treatment guidelines so as to address the barrier of disparities in target population and resources availability.

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization

OBJECTIVE

We sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.

METHODS

We included surveillance mammograms (1997-2017) in asymptomatic women with a personal history of breast cancer diagnosed at age ≥18 years (1996-2016) from 103 Breast Cancer Surveillance Consortium facilities. We examined facility-level variability in examination indication. We modeled the relative risk (RR) and 95% confidence intervals (CIs) at the examination level of a (1) nonscreening indication and (2) surveillance interval ≤9 months using Poisson regression with fixed effects for facility, stage, diagnosis age, surgery, examination year, and time since diagnosis.

RESULTS

Among 244,855 surveillance mammograms, 69.5% were coded with a screening indication, 12.7% short-interval follow-up, and 15.3% as evaluation of a breast problem. Within a facility, the proportion of examinations with a screening indication ranged from 6% to 100% (median 86%, interquartile range 79%-92%). Facilities varied the most for examinations in the first 5 years after diagnosis, with 39.4% of surveillance mammograms having a nonscreening indication. Within a facility, breast conserving surgery compared with mastectomy (RR = 1.64; 95% CI = 1.60-1.68) and less time since diagnosis (1 year versus 5 years; RR = 1.69; 95% CI = 1.66-1.72; 3 years versus 5 years = 1.20; 95% CI = 1.18-1.23) were strongly associated with a nonscreening indication with similar results for ≤9-month surveillance interval. Screening indication and >9-month surveillance intervals were more common in more recent years.

CONCLUSION

Variability in surveillance indications across facilities in the United States supports including indications beyond screening in studies evaluating surveillance mammography effectiveness and demonstrates the need for standardization.

Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors

PURPOSE

The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors.

METHODS

Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities.

RESULTS

FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178).

CONCLUSIONS

FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs.

IMPLICATIONS FOR CANCER SURVIVORS

FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

Pattern of relapse in low-risk breast cancer patients followed within a community care network

International guidelines have set the frame and methods of patients' surveillance after early breast cancer (BC) treatment. Since 1998, delegation of low-risk BC patients follow-up to nonhospital practitioners has been developed within a care network in the Paris region. We used the Gynecomed care network digital database to describe the characteristics of oncological events which occurred in the cohort, and to assess the quality of BC follow-up in relapsing patients. Events were defined as any local, contralateral, or metastatic recurrence, as well as second cancer or death due to any cause. We developed a ranked evaluation method of our surveillance program. Among the 3019 patients followed in the network, 116 (4.3%) patients had 116 events. Median follow-up was 7.1 years (0-51). First events were local-regional relapses, contralateral BCs, metastatic events, second primaries in respectively 52, 26, 14, 24 cases. During the first 5 years, 68.4% of surveillance visits were performed on time, 13.5% were behind schedule and 18.1% were not performed, while 79.1% of mammographies were performed on time, 7.7% behind schedule, and 13.2% were not performed. On schedule examinations allowed diagnosis of 77% of the local-regional, ipsilateral relapses or contralateral BCs, including 38 (69%) discovered by mammographies and 17 (31%) by clinical examination. A nonhospital practitioner care network is able to comply with good surveillance practices and deliver high quality surveillance, in accordance with international guidelines. Delegation of low-risk BC surveillance to nonhospital practitioners is reliable.

Long-term surveillance mammography and mortality in older women with a history of early stage invasive breast cancer

Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥ 65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥ 5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥ 1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥ 1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.

Options for early breast cancer follow-up in primary and secondary care - a systematic review

BACKGROUND

Both incidence of breast cancer and survival have increased in recent years and there is a need to review follow up strategies. This study aims to assess the evidence for benefits of follow-up in different settings for women who have had treatment for early breast cancer.

METHOD

A systematic review to identify key criteria for follow up and then address research questions. Key criteria were: 1) Risk of second breast cancer over time - incidence compared to general population. 2) Incidence and method of detection of local recurrence and second ipsi and contra-lateral breast cancer. 3) Level 1-4 evidence of the benefits of hospital or alternative setting follow-up for survival and well-being. Data sources to identify criteria were MEDLINE, EMBASE, AMED, CINAHL, PSYCHINFO, ZETOC, Health Management Information Consortium, Science Direct. For the systematic review to address research questions searches were performed using MEDLINE (2011). Studies included were population studies using cancer registry data for incidence of new cancers, cohort studies with long term follow up for recurrence and detection of new primaries and RCTs not restricted to special populations for trials of alternative follow up and lifestyle interventions.

RESULTS

Women who have had breast cancer have an increased risk of a second primary breast cancer for at least 20 years compared to the general population. Mammographically detected local recurrences or those detected by women themselves gave better survival than those detected by clinical examination. Follow up in alternative settings to the specialist clinic is acceptable to women but trials are underpowered for survival.

CONCLUSIONS

Long term support, surveillance mammography and fast access to medical treatment at point of need may be better than hospital based surveillance limited to five years but further large, randomised controlled trials are needed.

Prospective study of factors predicting adherence to surveillance mammography in women treated for breast cancer

PURPOSE

This prospective study examined the factors that predicted sustained adherence to surveillance mammography in women treated for breast cancer.

METHODS

Breast cancer survivors (N = 204) who were undergoing surveillance mammography completed questionnaires assessing mammography-related anticipatory anxiety, persistent breast pain, mammography pain, and catastrophic thoughts about mammography pain. Adherence to mammography in the following year was assessed.

RESULTS

In the year after study entry, 84.8% of women (n = 173) returned for a subsequent mammogram. Unadjusted associations showed that younger age, shorter period of time since surgery, and having upper extremity lymphedema were associated with lower mammography adherence. Forty percent of women reported moderate to high levels of mammography pain (score of ≥ 5 on a 0 to 10 scale). Although mammography pain was not associated with adherence, higher levels of mammography-related anxiety and pain catastrophizing were associated with not returning for a mammogram (P < .05). The impact of anxiety on mammography use was mediated by pain catastrophizing (indirect effect, P < .05).

CONCLUSION

Findings suggest that women who are younger, closer to the time of surgery, or have upper extremity lymphedema may be less likely to undergo repeated mammograms. It may be important for health professionals to remind selected patients directly that some women avoid repeat mammography and to re-emphasize the value of mammography for women with a history of breast cancer. Teaching women behavioral techniques (eg, redirecting attention) or providing medication for reducing anxiety could be considered for women with high levels of anxiety or catastrophic thoughts related to mammography.

Factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer

BACKGROUND

Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II-IV non-small cell lung cancer (NSCLC). Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use.

PATIENTS AND METHODS

Insured patients, ages 50+, with stages II-IV NSCLC between 2000 and 2007 were identified via tumor registry (n=406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0-2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided.

RESULTS

Overall compliance with first line chemotherapy guidelines was 71%. Significant (p<0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient's neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient's neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit. Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers.

Professionals' opinion on follow-up in breast cancer patients; perceived purpose and influence of patients' risk factors

AIM

To provide insight into professionals' opinions on breast cancer follow-up to facilitate implementation of new follow-up strategies. The study focuses on current practice, purpose and perceived effects, and preferred frequency and duration of follow-up.

DESIGN

A 29-item questionnaire on professionals' demographics, current practice, opinion on the current guideline, preferences in frequency and duration of tailored follow-up, and the purpose and perceived effects of follow-up was sent to 633 Dutch professionals.

RESULTS

The current national guideline is followed by 81% of respondents. All different specialists are involved in follow-up. Sixty-nine percent of respondents' report nurse practitioners to be involved in follow-up. When asked for tailored follow-up, professionals indicate more factors for increased follow-up (age<40 years, pT3-4 tumour, pN2-3, treatment related morbidity, and psychosocial support), than for reduced schedules (age >70 years and DCIS histology). Alternative forms of follow-up are not endorsed by >90% of respondents. Detection of a new primary tumour of the breast is considered the most important purpose of follow-up (98%), 57% still indicates detecting metastases as a goal.

CONCLUSIONS

Professionals tend towards longer and more intensive follow-up than the current guideline for a large group of patients. Limitations and developments in follow-up need to be considered to facilitate alternative follow-up strategies.

Outcomes of surveillance mammography after treatment of primary breast cancer: a population-based case series

GOAL

To ascertain outcomes of surveillance mammography (SM) following treatment of early stage unilateral primary breast cancer (PBC) in a population based case series.

METHODS

Random samples from all 12,279 women having breast surgery within 4 months after diagnosis of PBC, between July 1991 and December 1993 in Ontario, were drawn from a database created by deterministic linkage of PBC files from the Ontario Cancer Registry (OCR) with episodes of breast surgery extracted from the hospital Discharge Abstract Database (DAD), and mammography from the Ontario physician billings database (OHIP). Among women having >or=1 episode(s) of breast surgery subsequent (SBS) to the date of diagnosis up to December 2000, a sample of 1,200/5,064 (23.7%) was drawn, and among women with no SBS, a sample of 400/7,215 (5.5%). Among these two samples, operative, pathology, and mammography reports were abstracted from original charts. Treatments were abstracted and categorized. Women with complete data for Stages 1 and 2 unilateral PBC were included. From the subsequent surgery sample, 609/1,200 (50.8%) were excluded because of simultaneous or sequential bilateral breast cancers or mastectomies within 6 months, missing stage information, Stage 3 or 4 PBC, or missing primary charts. From the no subsequent surgery sample, 90/400 (22.5%) were excluded by the same criteria. Episodes of bilateral 2-view X-ray mammography, beginning >or=6 months after the diagnosis of unilateral PBC, and if multiple, at least 11 months apart, and not prompted by a clinical concern or symptom, were classified as SM. We confirmed episodes of cancer recurrence within the ipsilateral conserved breast (CRICB) and metachronous contralateral primary breast cancer (CPBC) >or=6 months after the diagnosis of the unilateral PBC from original operative and pathology reports. We used Cox models to describe the association of exposure to >or=1 episode(s) of SM with the risk of death from breast cancer among the study population, and separately among women experiencing CRICB or CPBC.

RESULTS

Eligible women comprising 591/1,200 and 310/400 produced a combined case series of 901/1,600 (56.3%). Women with >or=1 episode(s) of SM numbered 721/901 (80.0%). We confirmed 84 CRICB events among 584 women initially treated by lumpectomy (14.4%), and 49 CPBC events among all 901 women in the study population (5.4%). Among women having >or=1 episode(s), the 25th percentile of observed follow up was 1,631 days, the 50th, 4,287 days, and the 75th 5,011 days. Among women without any SM, the 25th percentile of observed follow-up was 440 days, the 50th, 891 days, and the 75th, 1,849 days. Hazard ratio (HR) for death due to breast cancer associated with >or=1 episode of SM was 0.28 (95% CI 0.22-0.37), adjusted for age, stage, type of surgery, adjuvant chemotherapy, and tamoxifen. Among 84/584 women with CRICB, unadjusted HR = 0.36 (95%CI 0.13, 1.00) and among 49/901 women with CPBC, unadjusted HR = 0.86 (0.20-3.77).

CONCLUSION

SM was associated with a significant reduction in the hazard for breast cancer death. Among women who experienced CRICB, the reduction was of borderline significance, and the reduction was not significant among women who experienced CPBC.

Under utilization of surveillance mammography among older breast cancer survivors

BACKGROUND

Annual surveillance mammography is recommended for follow-up of women with a history of breast cancer. We examined surveillance mammography among breast cancer survivors who were enrolled in integrated healthcare systems.

METHODS

Women in this study were 65 or older when diagnosed with early stage invasive breast cancer (N = 1,762). We assessed mammography use during 4 years of follow-up, using generalized estimating equations to account for repeated measurements.

RESULTS

Eighty-two percent had mammograms during the first year after treatment; the percentage declined to 68.5% in the fourth year of follow-up. Controlling for age and comorbidity, women who were at higher risk of recurrence by being diagnosed at stage II or receiving breast-conserving surgery (BCS) without radiation therapy were less likely to have yearly mammograms (compared to stage I, odds ratio [OR] for stage IIA 0.72, confidence interval [CI] 0.59, 0.87, OR for stage IIB 0.75, CI 0.57, 1.0; compared to BCS with radiation, OR 0.58, CI 0.43, 0.77). Women with visits to a breast cancer surgeon or oncologist were more likely to receive mammograms (OR for breast cancer surgeon 6.0, CI 4.9, 7.4, OR for oncologist 7.4, CI 6.1, 9.0).

CONCLUSIONS

Breast cancer survivors who are at greater risk of recurrence are less likely to receive surveillance mammograms. Women without a visit to an oncologist or breast cancer surgeon during a year have particularly low rates of mammography. Improvements to surveillance care for breast cancer survivors may require active participation by primary care physicians and improvements in cancer survivorship programs by healthcare systems.

Surveillance mammography and the risk of death among elderly breast cancer patients

PURPOSE

To examine the benefits of mammography for elderly breast cancer survivors in community settings.

METHODS

Using the 1991-1999 linked SEER-Medicare data, we examined if mammography reduced the risk of breast-cancer-specific and all-cause mortality among women age 66 or older who were diagnosed with first primary breast cancer (FPBC) at stages 0-III and survived at least 30 months. To analyze the influence of mammography (both within one year and within two years prior to death/censoring) on the risk of breast-cancer-specific mortality, we compared women who died of breast cancer (cases) with women who died of other causes or were censored (controls). For an analysis of all-cause mortality, we compared women who died from any cause (cases) with women who were censored (controls). Propensity scores were used to adjust for tumor-related, treatment-related, and sociodemographic confounders.

RESULTS

Among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period in propensity-score-adjusted analysis (within one year odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.72-0.95; within two years OR: 0.80, 95% CI: 0.70-0.92). Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals.

CONCLUSIONS

In community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.

Social and Racial Differences in Selection of Breast Cancer Adjuvant Chemotherapy Regimens

Purpose

Breast cancer outcomes are worse among black women and women of lower socioeconomic status. The purpose of this study was to investigate racial and social differences in selection of breast cancer adjuvant chemotherapy regimens.

Methods

Detailed information on patient, disease, and treatment factors was collected prospectively on 957 patients who were receiving breast cancer adjuvant chemotherapy in 101 oncology practices throughout the United States. Adjuvant chemotherapy regimens included in any of several published guidelines were considered standard. Receipt of nonstandard regimens was examined according to clinical and nonclinical factors. Differences between groups were assessed using χ2 tests. Multivariate logistic regression was used to identify factors associated with use of nonstandard regimens.

Results

Black race (P = .008), lower educational attainment (P = .003), age ≥ 70 years (P = .001), higher stage (P < .0001), insurance type (P = .048), employment status (P = .045), employment type (P = .025), and geographic location (P = .021) were associated with the use of nonstandard regimens in univariate analyses. In multivariate analysis, black race (P = .020), lower educational attainment (P = .024), age ≥ 70 years (P = .032), and higher stage (P < .0001) were associated with receipt of nonstandard regimens.

Conclusion

The more frequent use of non–guideline-concordant adjuvant chemotherapy regimens in black women and women with lower educational attainment may contribute to less favorable outcomes in these populations. Addressing such differences in care may improve cancer outcomes in vulnerable populations.

Mammography surveillance and mortality in older breast cancer survivors

PURPOSE

There are more than 2,000,000 breast cancer survivors in the United States today. While surveillance for asymptomatic recurrence and second primary is included in consensus recommendations, the effectiveness of this surveillance has not been well characterized. Our purpose is to estimate the effectiveness of surveillance mammography in a cohort of breast cancer survivors with complete ascertainment of surveillance mammograms and negligible losses to follow-up.

PATIENTS AND METHODS

We enrolled 1,846 stage I and II breast cancer patients who were at least 65 years old at six integrated health care delivery systems. We used medical record review and existing databases to ascertain patient, tumor, and therapy characteristics, as well as receipt of surveillance mammograms. We linked personal identifiers to the National Death Index to ascertain date and cause of death. We matched four controls to each breast cancer decedent to estimate the association between receipt of surveillance mammogram and breast cancer mortality.

RESULTS

One hundred seventy-eight women died of breast cancer during 5 years of follow-up. Each additional surveillance mammogram was associated with a 0.69-fold decrease in the odds of breast cancer mortality (95% CI, 0.52 to 0.92). The protective association was strongest among women with stage I disease, those who received mastectomy, and those in the oldest age group.

CONCLUSION

Given existing recommendations for post-therapy surveillance, trials to compare surveillance with no surveillance are unlikely. This large observational study provides support for the recommendations, suggesting that receipt of surveillance mammograms reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.

Reduced mortality rate associated with annual mammograms after breast cancer therapy

Guidelines have been developed for appropriate posttherapy surveillance for breast cancer recurrence. One purpose of posttherapy surveillance is to detect potentially curable local recurrences and new cancers in the opposite breast. The objective of this investigation was to assess the impact of annual mammography on all-cause mortality in breast cancer survivors. We conducted a case-control analysis nested in a cohort of 865 stage I or II breast cancer patients diagnosed from 1996 to 1999. The exposure variable was the number of mammograms received after completing primary therapy. Cases were decedents and we used risk-set sampling to match eight controls to each case on follow-up time. The mortality rate declined with an increasing number of mammograms (p for trend=0.007). The age- and therapy-adjusted odds ratio associating receipt of an additional mammogram, compared with receipt of no mammogram, equaled 0.77 (95% confidence interval [CI] 0.53-1.1). These results are consistent with a protective effect of regular surveillance mammography after completing therapy for early stage breast cancer.