Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening

Association of DCIS size and margin status with risk of developing breast cancer post-treatment: multinational, pooled cohort study

OBJECTIVE

To examine the association between size and margin status of ductal carcinoma in situ (DCIS) and risk of developing ipsilateral invasive breast cancer and ipsilateral DCIS after treatment, and stage and subtype of ipsilateral invasive breast cancer.

DESIGN

Multinational, pooled cohort study.

SETTING

Four large international cohorts.

PARTICIPANTS

Patient level data on 47 695 women with a diagnosis of pure, primary DCIS between 1999 and 2017 in the Netherlands, UK, and US who underwent surgery, either breast conserving or mastectomy, often followed by radiotherapy or endocrine treatment, or both.

MAIN OUTCOME MEASURES

The main outcomes were 10 year cumulative incidence of ipsilateral invasive breast cancer and ipsilateral DCIS estimated in relation to DCIS size and margin status, and adjusted hazard ratios and 95% confidence intervals, estimated using multivariable Cox proportional hazards analyses with multiple imputed data RESULTS: The 10 year cumulative incidence of ipsilateral invasive breast cancer was 3.2%. In women who underwent breast conserving surgery with or without radiotherapy, only adjusted risks for ipsilateral DCIS were significantly increased for larger DCIS (20-49 mm) compared with DCIS <20 mm (hazard ratio 1.38, 95% confidence interval 1.11 to 1.72). Risks for both ipsilateral invasive breast cancer and ipsilateral DCIS were significantly higher with involved compared with clear margins (invasive breast cancer 1.40, 1.07 to 1.83; DCIS 1.39, 1.04 to 1.87). Use of adjuvant endocrine treatment was not significantly associated with a lower risk of ipsilateral invasive breast cancer compared to treatment with breast conserving surgery only (0.86, 0.62 to 1.21). In women who received breast conserving treatment with or without radiotherapy, higher DCIS grade was not significantly associated with ipsilateral invasive breast cancer, only with a higher risk of ipsilateral DCIS (grade 1: 1.42, 1.08 to 1.87; grade 3: 2.17, 1.66 to 2.83). Higher age at diagnosis was associated with lower risk (per year) of ipsilateral DCIS (0.98, 0.97 to 0.99) but not ipsilateral invasive breast cancer (1.00, 0.99 to 1.00). Women with large DCIS (≥50 mm) more often developed stage III and IV ipsilateral invasive breast cancer compared to women with DCIS <20 mm. No such association was found between involved margins and higher stage of ipsilateral invasive breast cancer. Associations between larger DCIS and hormone receptor negative and human epidermal growth factor receptor 2 positive ipsilateral invasive breast cancer and involved margins and hormone receptor negative ipsilateral invasive breast cancer were found.

CONCLUSIONS

The association of DCIS size and margin status with ipsilateral invasive breast cancer and ipsilateral DCIS was small. When these two factors were added to other known risk factors in multivariable models, clinicopathological risk factors alone were found to be limited in discriminating between low and high risk DCIS.

Active surveillance versus treatment in low-risk DCIS: Women's preferences in the LORD-trial

BACKGROUND

Ductal carcinoma in situ (DCIS) can progress to invasive breast cancer (IBC), but most DCIS lesions remain indolent. However, guidelines recommend surgery, often supplemented by radiotherapy. This implies overtreatment of indolent DCIS. The non-randomised patient preference LORD-trial tests whether active surveillance (AS) for low-risk DCIS is safe, by giving women with low-risk DCIS a choice between AS and conventional treatment (CT). Here, we aim to describe how participants are distributed among both trial arms, identify their motives for their preference, and assess factors associated with their choice.

METHODS

Data were extracted from baseline questionnaires. Descriptive statistics were used to assess the distribution and characteristics of participants; thematic analyses to extract self-reported reasons for the choice of trial arm, and multivariable logistic regression analyses to investigate associations between patient characteristics and chosen trial arm.

RESULTS

Of 377 women included, 76% chose AS and 24% CT. Most frequently cited reasons for AS were "treatment is not (yet) necessary" (59%) and trust in the AS-plan (39%). Reasons for CT were cancer worry (51%) and perceived certainty (29%). Women opting for AS more often had lower educational levels (OR 0.45; 95% confidence interval [CI], 0.22-0.93) and more often reported experiencing shared decision making (OR 2.71; 95% CI, 1.37-5.37) than women choosing CT.

CONCLUSION

The LORD-trial is the first to offer women with low-risk DCIS a choice between CT and AS. Most women opted for AS and reported high levels of trust in the safety of AS. Their preferences highlight the necessity to establish the safety of AS for low-risk DCIS.

Artificial intelligence to support person-centred care in breast imaging - A scoping review

AIM

To overview Artificial Intelligence (AI) developments and applications in breast imaging (BI) focused on providing person-centred care in diagnosis and treatment for breast pathologies.

METHODS

The scoping review was conducted in accordance with the Joanna Briggs Institute methodology. The search was conducted on MEDLINE, Embase, CINAHL, Web of science, IEEE explore and arxiv during July 2022 and included only studies published after 2016, in French and English. Combination of keywords and Medical Subject Headings terms (MeSH) related to breast imaging and AI were used. No keywords or MeSH terms related to patients, or the person-centred care (PCC) concept were included. Three independent reviewers screened all abstracts and titles, and all eligible full-text publications during a second stage.

RESULTS

3417 results were identified by the search and 106 studies were included for meeting all criteria. Six themes relating to the AI-enabled PCC in BI were identified: individualised risk prediction/growth and prediction/false negative reduction (44.3%), treatment assessment (32.1%), tumour type prediction (11.3%), unnecessary biopsies reduction (5.7%), patients' preferences (2.8%) and other issues (3.8%). The main BI modalities explored in the included studies were magnetic resonance imaging (MRI) (31.1%), mammography (27.4%) and ultrasound (23.6%). The studies were predominantly retrospective, and some variations (age range, data source, race, medical imaging) were present in the datasets used.

CONCLUSIONS

The AI tools for person-centred care are mainly designed for risk and cancer prediction and disease management to identify the most suitable treatment. However, further studies are needed for image acquisition optimisation for different patient groups, improvement and customisation of patient experience and for communicating to patients the options and pathways of disease management.

Characteristics of breast cancers detected by screening mammography in Taiwan: a single institute's experience

BACKGROUND/AIM

Breast cancer is the most common female malignancy in the world. Nearly ninety percent of screening-detected breast cancers were diagnosed with earlier stages of 0 to II in Taiwan. It's widely acknowledged that mammography screening of breast cancer can achieve the goal of early diagnosis and treatment in terms of preventive task while neglected interval cancers are associated with unfavorable tumor characteristics and worse outcomes. The purpose of this study was to explore the characteristics of screening-detected breast cancers in Taiwan.

MATERIALS AND METHODS

Both screening and diagnostic mammography examinations with accompanied BI-RADS (breast imaging-reporting and data system) classification were extracted from the health information system and linked to cancer registry in Taiwan. Enrolled population included those attending their first mammography between 2012 and 2016, excluding subjects with previous breast cancer, or with missing or incomplete data. We compared treatment outcomes between breast cancers with either initial screening or diagnostic mammography (control group), and investigated the compositions of breast cancers detected by screening mammography through direct chart reviews.

RESULTS

A total of 84,246 screening and 61,230 diagnostic mammography sessions were performed from 2010 to 2020. More positive results (BI-RADS 0, 3, 4 and 5) were observed for those attending the first diagnostic than the first screening mammography (43.58% versus 16.12%, p < 0.001). Earlier stages (0 and I) distribution (92% versus 81%, p < 0.0001), better survivorship (overall survival: 96.91% versus 92.17%, p = 0.007) and a lower HER2 (human epidermal growth factor receptor II) positive status and lower tumor grade were noted in breast cancers with initial screening rather than diagnostic mammography. Among 26,103 mammography screening invitees between 2012 and 2016, 325 breast cancers were ascertained from cancer registry. Of these, 234 had one, 72 had two and 19 had three episodes of mammography before cancer diagnosis. Extensive chart reviews revealed that women with and without breast symptoms constituted 29.9 and 70.1% of the 325 screening-detected breast cancers, with the latter further divided into false negative results (interval cancer), diagnosed at the first mammography, diagnostic at the secondary or subsequent mammography and those with a delayed biopsy or confirmatory imaging constituted (5.2, 47, 10.5 and 7.4%).

CONCLUSION

Screening-detected breast cancers were a mixture of women with and without symptoms, those with a false negative result, true negative results with cancer detected at subsequent mammography and non-adherers. Despite this, efficacy of mammography screening was ascertained in Taiwan from this study. To further enhance earlier detection and decrease false negativity, the impact of repeated mammography, and additional sonography for symptomatic women, compliance following a positive screening mammography should not be overemphasized.

Modern Diagnostic Imaging Technique Applications and Risk Factors in the Medical Field: A Review

Medical imaging is the process of visual representation of different tissues and organs of the human body to monitor the normal and abnormal anatomy and physiology of the body. There are many medical imaging techniques used for this purpose such as X-ray, computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT), digital mammography, and diagnostic sonography. These advanced medical imaging techniques have many applications in the diagnosis of myocardial diseases, cancer of different tissues, neurological disorders, congenital heart disease, abdominal illnesses, complex bone fractures, and other serious medical conditions. There are benefits as well as some risks to every imaging technique. There are some steps for minimizing the radiation exposure risks from imaging techniques. Advance medical imaging modalities such as PET/CT hybrid, three-dimensional ultrasound computed tomography (3D USCT), and simultaneous PET/MRI give high resolution, better reliability, and safety to diagnose, treat, and manage complex patient abnormalities. These techniques ensure the production of new accurate imaging tools with improving resolution, sensitivity, and specificity. In the future, with mounting innovations and advancements in technology systems, the medical diagnostic field will become a field of regular measurement of various complex diseases and will provide healthcare solutions.

Leveraging Multi-Task Learning to Cope With Poor and Missing Labels of Mammograms

In breast cancer screening, binary classification of mammograms is a common task aiming to determine whether a case is malignant or benign. A Computer-Aided Diagnosis (CADx) system based on a trainable classifier requires clean data and labels coming from a confirmed diagnosis. Unfortunately, such labels are not easy to obtain in clinical practice, since the histopathological reports of biopsy may not be available alongside mammograms, while normal cases may not have an explicit follow-up confirmation. Such ambiguities result either in reducing the number of samples eligible for training or in a label uncertainty that may decrease the performances. In this work, we maximize the number of samples for training relying on multi-task learning. We design a deep-neural-network-based classifier yielding multiple outputs in one forward pass. The predicted classes include binary malignancy, cancer probability estimation, breast density, and image laterality. Since few samples have all classes available and confirmed, we propose to introduce the uncertainty related to the classes as a per-sample weight during training. Such weighting prevents updating the network's parameters when training on uncertain or missing labels. We evaluate our approach on the public INBreast and private datasets, showing statistically significant improvements compared to baseline and independent state-of-the-art approaches. Moreover, we use mammograms from Susan G. Komen Tissue Bank for fine-tuning, further demonstrating the ability to improve the performances in our multi-task learning setup from raw clinical data. We achieved the binary classification performance of AUC = 80.46 on our private dataset and AUC = 85.23 on the INBreast dataset.

A systematic review of decision aids for mammography screening: Focus on outcomes and characteristics

PURPOSE

Decision Aid systems (DAs) provide information on the pros and cons of mammography. This study aimed to review the research on mammography DAs, synthesize the findings related to their outcomes and characteristics, and address the existed research gap.

METHODS

Relevant studies were identified through a comprehensive search on some e-databases, including PubMed, EMBASE, Scopus, and Web of Science in August 2020; by searching the keywords of "Breast cancer", "Screening", and "Decision aid systems" as well as their synonyms in the titles and abstracts of the papers with no time limits. Among the selected English journal papers with the interventional study design, those measuring outcome values of using mammography DAs were recognized as eligible for being included in this review.

RESULTS

The systematic search results in 16 DAs regarding mammography that were designed and then evaluated from 18 selected studies. The results showed that DAs provide improvements in knowledge and informed choice, the decreased decisional conflicts and decisional confidence, almost without changing any attitude towards mammography, mammography participation rates, psychological issues, anticipated regret, and perceived risk of breast cancer. The DAs' effects on women's inclination to screening were divergent. In other words, the DAs affect individuals' inclination in rare cases; however, on occasion, they could affect women's decision to undergo screening.

CONCLUSION

DAs could correct the bias attached to the existing knowledge on mammography and breast cancer in women so that they are more likely to make a precise decision. Additionally, it might be of central importance in shared decision-making and assisting health providers, in order to promote the quality of care. Accordingly, performing more studies is needed to develop more professional DAs in various countries with different facilities, cultures, and languages.

Facilitating Factors and Barriers of Women's Cancer Screening in Iran: A Systematic Review

Low uptake of women's cancer screening and its facilitating factors and barriers in Iran has been studied so far but no consensus on factors affecting this low uptake has been stated previously. Nevertheless, facilitating factors and barriers of breast cancer and cervical cancer have been reviewed. In this systematic review, Web of Science, PubMed, EMBASE, Scopus, and Google Scholar were the preferred search engines. In addition, the Persian database of Magiran and SIDs and ISC indexed journals were searched with different combinations of Persian keywords compatible with English search. A hand search of key Iranian journals was also accomplished. Through 964 primarily searched articles, finally, after duplicates being removed, the screen of records, and full-text articles assessed for eligibility, only 12 articles were included in the review. Barriers observed mostly were screening not advised by a physician, having no relevant problems or disease, having no knowledge about the procedure, fear from pain or cancer detection, shame from the procedure, and forget to have screening. Facilitators were less focused than barriers and frequently were identified as advised by healthcare professionals, the perceived necessity for screening, and the important identified risk of cancer acquire. Almost all studies focused on individual and interpersonal barriers and facilitators for screening instead of a holistic view on the utilization of screening programs. In future studies on women's cancer screening, facilitating factors and barriers of both supply (health system provision and policy implications) and demand-side (individual and interpersonal factors) of healthcare provision has been strongly recommended.

Impact of Educational Level and Family income on Breast Cancer Awareness among College-Going Girls in Shillong (Meghalaya), India

Background:

Breast cancer (BC) is the most common cancer among women in India and shows an increasing trend. The mammography screening seems unfeasible as a public health service in India. Thus, breast self-examination (BSE), followed by clinical breast examination (CBE), is the affordable method to downstage BC. A cross-sectional study was conducted with senior school and college-going girls in Shillong (Meghalaya) to study the impact of girls’ academic level and family income on breast cancer knowledge and the prevalence of BC’s known risk factors in girls.

Methods:

A self-administered questionnaire was employed to collect relevant information. The data were analysed using statistical software SPSS version 22. The categorical data presented as frequency (%) and the comparison made using Chi-square or Fisher exact test.

Results:

(i) 78.2% girls knew about breast cancer, 19.2% of these were aware of BSE, and 22.9% of BSE knowing ever performed it (ii) Awareness of breast cancer and BSE, and its practice is significantly associated with their academic level and family income (iii) The consumption of alcohol beverages and physical activity of girls was positively associated with educational level and family income (iv) Body mass index (BMI) was weakly associated with family income with an insignificant relationship with academic level (v) oily food consumption related inversely with the level of education irrespective of family income (vi) there was a positive correlation between parents education and family income.

Conclusions:

The results show a severe lack of breast cancer knowledge in senior school and college-going girls under the survey. To spread community awareness, we suggest a public health policy-driven educational intervention through culturally relevant mass/social media on the risk factors of breast cancer and practice of BSE. It is also recommended that dedicated facilities be created for breast cancer early diagnosis in the public health system.

Machine learning-based lifetime breast cancer risk reclassification compared with the BOADICEA model: impact on screening recommendations

Background

The clinical utility of machine-learning (ML) algorithms for breast cancer risk prediction and screening practices is unknown. We compared classification of lifetime breast cancer risk based on ML and the BOADICEA model. We explored the differences in risk classification and their clinical impact on screening practices.

Methods

We used three different ML algorithms and the BOADICEA model to estimate lifetime breast cancer risk in a sample of 112,587 individuals from 2481 families from the Oncogenetic Unit, Geneva University Hospitals. Performance of algorithms was evaluated using the area under the receiver operating characteristic (AU-ROC) curve. Risk reclassification was compared for 36,146 breast cancer-free women of ages 20–80. The impact on recommendations for mammography surveillance was based on the Swiss Surveillance Protocol.

Results

The predictive accuracy of ML-based algorithms (0.843 ≤ AU-ROC ≤ 0.889) was superior to BOADICEA (AU-ROC = 0.639) and reclassified 35.3% of women in different risk categories. The largest reclassification (20.8%) was observed in women characterised as ‘near population’ risk by BOADICEA. Reclassification had the largest impact on screening practices of women younger than 50.

Conclusion

ML-based reclassification of lifetime breast cancer risk occurred in approximately one in three women. Reclassification is important for younger women because it impacts clinical decision- making for the initiation of screening.

Inter- and intra-provincial variation in screen-detected breast cancer across five Canadian provinces: a CanIMPACT study

OBJECTIVE

Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces.

METHODS

Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer.

RESULTS

There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50-69 but women aged 50-59 had approximately 4-8% lower screen detection than those aged 60-69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62-0.89 relative to highest income quintile/urban patients aged 50-69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37-0.76).

CONCLUSION

Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

The Structure and Parameterization of the Breast Cancer Transition Model Among Chinese Women

OBJECTIVES

Markov model simulation based on the natural history of disease is commonly employed for the comparative research of health interventions. The present study aims to simulate the natural progression of breast cancer and parameterize the initial and transition probabilities of multiple states of breast cancer development among Chinese women.

METHODS

The age-specific incidence, mortality, and clinical stage distribution of breast cancer; and relapse rate of each clinical stage were collected from China's cancer registry yearbooks and clinical epidemiological studies to simulate the process from full health to breast cancer to death among Chinese women aged 30 to 80 through a Markov cohort study. The validity analysis was conducted to evaluate the accuracy of the model estimation.

RESULTS

A Markov transition model with 7 states (no breast cancer, clinical stages 0-IV breast cancer, and death) was constructed for Chinese women. The age-specific incidence, mortality, and clinical stage distribution of breast cancer estimated by the initial and transition probabilities among different Markov states were highly consistent with the registered data and observed studies.

CONCLUSION

A breast cancer transition model for Chinese women has been established with validity. It could be a point of reference for further economic evaluations and breast cancer screening policy formulation.

How scientific mobility can help current and future radiology research: a radiology trainee's perspective

One of the ways in which modern radiology is manifesting itself in higher education and research is through the increasing importance of scientific mobility. This article seeks to provide an overview and a prospective of radiology fellows in their last year of training about the current trends and policy tools for promoting mobility among young radiologists, especially inside the European Union. Nowadays, the need to promote international cooperation is even greater to ensure that the best evidence-based medical practices become a common background of a next cross-border generation of radiologists. Organisations such as the European Society of Radiology (ESR) and the Radiological Society of North America (RSNA) are called upon to play as guarantors of the training of young radiologists building know-how and world-class excellence. Today, it is not just being certified radiologist that matters, the place where the training was done plays an important role in enhancing chances when applying for a high-level job or fellowship. The article argues that the mobility of radiology trainees is an indispensable prerequisite to face new challenges, including the application of artificial intelligence to medical imaging, which will require a large multicentre collaboration.

How Many of the Biopsy Decisions Taken at Inexperienced Breast Radiology Units Were Correct?

OBJECTIVE

In this study, we aimed to determine the need for biopsy in patients referred from other clinics for the performance of biopsy with the suspicion of breast cancer.

MATERIALS AND METHODS

112 patients were included in the study. It was decided that their biopsies be performed following examinations in other clinics and they presented to the breast radiology unit of our hospital for a second opinion. The demographic characteristics, diagnostic studies completed in the other centers, properties of lesions, decision made as a result of examinations and BI-RADS (Breast Imaging Reporting and Data Systems) categorizations were recorded on the registration forms of the study patients. In addition, the quality of examinations, reasons of repeat tests, additional tests features and the last decision of our clinic were documented. The obtained data were analyzed in terms of re-examination, additional tests and change in the biopsy decision. Changes in the biopsy decisions for patients were specifically inquired.

RESULTS

The biopsy decisions were cancelled in our breast radiology unit for 63 out of 112 patients (56.3%) whose biopsy decisions were made at an external institute. For 42 patients, examinations made by the other clinics were deemed adequate, yet there was no need for biopsy in 22 of them. The biopsy decisions were cancelled for 27 out of 47 patients (57.4%) with repeat examination and 18 out of 28 patients (64.3%) with additional tests because of the insufficient test quality.

CONCLUSION

Incorrect, inadequate breast screening and false positivity were higher at inexperienced institutes.

Determinants of Awareness and Practice of Breast Self Examination Among Rural Women in Trichy, Tamil Nadu

Introduction:

Breast cancer is the most common cancer among women worldwide, and it can be detected at an early stage through self-examination which increases the chance of survival. This study aimed to assess knowledge and practice of breast self-examination (BSE) among females in a rural area of Trichy district.

Methodology:

This community-based, cross-sectional study was carried out among a total sample of 200 women in rural area of Trichy. The participants were interviewed using a structured interviewer-administered questionnaire to obtain information on their sociodemographic characteristics, awareness on breast cancer, and knowledge, attitude, practice of BSE. Data were entered into MS Excel and analyzed using SPSS version 20.0. Spearman correlation and Chi-square test were used to analyze the association between the variables.

Results:

The mean age of the study group was 36.9 ± 8.8 years. Eighty percent were literates. Most of the women 178 (89%) were aware of breast cancer. Only 26% of the women were aware of BSE. Only 18% of the females had ever checked their breast and 5% practiced it regularly. Awareness of BSE was found to be significantly associated with age and educational attainment.

Conclusion:

The level of knowledge and practice of BSE among females are unacceptably low. Efforts should be made to increase level of knowledge and practice of BSE through health education programs.

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

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

Distant metastasis detected by routine staging in breast cancer patients participating in the national German screening programme: consequences for clinical practice

PURPOSE

To determine frequency of routine radiological staging of breast cancer patients diagnosed in a German Breast Cancer Screening Center from 2007 to 2014, the incidence and consequences of distant metastases detected and the resulting implications for clinical routine.

METHODS

Records of 896 patients with primary breast cancer diagnosed in the Screening Centre and treated in five participating hospitals were analyzed retrospectively. Evaluation included frequency and type of staging procedures and results with respect to distant metastasis and their consequences on clinical management.

RESULTS

894/896 Patients (99.8 %) received staging for distant metastases by bone scintigraphy, chest X-ray and liver sonography and/or CT/MRT diagnostics. Distant metastasis was suggested In 6/894 patients but excluded in 3 by further diagnostics or clinical course. Thus, 3 (0.3 %) were clinically verified to have metastatic disease in bone (n = 2; both pT2) or in bone and lung (n = 1; cT4, cN3).

CONCLUSION

Due to the low incidence of verified metastatic disease, the high false positive rate of staging procedures and the unfavorable cost/benefit ratio routine radiological staging should be completely omitted in asymptomatic breast cancer patients diagnosed in a breast cancer screening programme.

Health workforce planning and service expansion during an economic crisis: A case study of the national breast screening programme in Ireland

This article aims to estimate the workforce and resource implications of the proposed age extension of the national breast screening programme, under the economic constraints of reduced health budgets and staffing levels in the Irish health system. Using a mixed method design, a purposive sample of 20 participants were interviewed and data were analysed thematically (June-September 2012). Quantitative data (programme-level activity data, screening activity, staffing levels and screening plans) were used to model potential workload and resource requirements. The analysis indicates that over 90% operational efficiency was achieved throughout the first six months of 2012. Accounting for maternity leave (10%) and sick leave (3.5%), 16.1 additional radiographers (whole time equivalent) would be required for the workload created by the age extension of the screening programme, at 90% operational efficiency. The results suggest that service expansion is possible with relatively minimal additional radiography resources if the efficiency of the skill mix and the use of equipment are improved. Investing in the appropriate skill mix should not be limited to clinical groups but should also include administrative staff to manage and support the service. Workload modelling may contribute to improved health workforce planning and service efficiency.

A cross-national comparative study on the influence of individual life course factors on mammography screening

OBJECTIVES

Drawing on insights from the life course perspective, the aim of this paper is to gain a better understanding of persistent socioeconomic inequalities related to the uptake of mammography screening in 13 European countries. We examine whether these inequalities originate in childhood and relate them to the history and progression of each country's screening programs.

METHODS

Retrospective data from the third wave of the Survey of Health, Ageing and Retirement (SHARELIFE) is analyzed by means of event-history analyses to examine the role of childhood preventive health behavior on mammography screening initiation. The results are framed within the context of policy developments concerning mammography screening in each of the separate European countries.

RESULTS

Childhood preventive health care behavior predicts mammography screening in 9 of the 13 countries after conventional measurements of socioeconomic position in childhood and adulthood are accounted for. Net effects of education and income are still found for respectively 6 and 7 countries, but in about half of these countries national screening programs are able to reduce the social gradient. Very strong cohort and period effects are found for every country.

CONCLUSIONS

In a substantial number of the European countries, socioeconomic inequalities in preventive health behavior originate in childhood, which point to the deeply rooted nature of these inequalities. A long-term perspective is essential to further unravel how health policies can reduce or eliminate these persistent inequalities.

Willingness to participate in mammography screening: a randomized controlled questionnaire study of responses to two patient information leaflets with different factual content

BACKGROUND

From 2010 onward, a new leaflet about mammography screening for breast cancer, more informative than the preceding version, has been sent to women in Germany aged 50 to 69 with the invitation to undergo screening. The purpose of this study was to determine the effect of different informational content on the decision whether or not to be screened.

METHODS

In a randomized and blinded design, 792 women aged 48 to 49 were sent either the old or the new leaflet. Questionnaires were sent together with the leaflets in order to assess the following: willingness to undergo mammography screening, knowledge, decisional confidence, personal experiences of breast cancer, and demographic data.

RESULTS

370 (46.7%) of the questionnaires were returned, and 353 were evaluable. The two groups did not differ significantly in their willingness to be screened: 81.5% (95% confidence interval [CI] 75.8%-87.2%) versus 88.6% (95% CI 83.9%-91.3%, p = 0.060). A post-hoc analysis showed that women who reported having had personal experience of breast cancer (18.7%) were more willing to be screened if they were given the new leaflet, rather than the old one (interaction p = 0.014). The two groups did not differ in their knowledge about screening (p = 0.260). Women who received the old leaflet reported a higher decisional confidence (p = 0.017). The most commonly mentioned factors affecting the decision were experience of breast cancer in relatives and close acquaintances (26.5% of mentions) and a doctor's recommendation (48.2%). Leaflets (3.6%) and all other factors played only a secondary role.

CONCLUSION

The greater or lesser informativeness of the leaflet affected neither the participants' knowledge of mammography screening nor their willingness to undergo it. The leaflet was not seen as an aid to decision-making. The best way to assure an informed decision about screening may be for the patient to discuss the matter personally with a qualified professional.

Epidemiological correlates of breast cancer in South India

BACKGROUND

Breast cancer is the most frequent cancer in women globally and represents the second leading cause of cancer death among women (after lung cancer). India is going through epidemiologic transition. It is reported that the incidence of breast cancer is rising rapidly as a result of changes in reproductive risk factors, dietary habits and increasing life expectancy, acting in concert with genetic factors.

MATERIALS AND METHODS

In order to understand the existing epidemiological correlates of breast cancer in South India, a systematic review of evidence available on epidemiologic correlates of breast cancer addressing incidence, prevalence, and associated factors like age, reproductive factors, cultural and religious factors was performed with specific focus on screening procedures in southern India.

RESULTS

An increase in breast cancer incidence due to various modifiable risk factors was noted, especially in women over 40 years of age, with late stage of presentation, lack of awareness about screening, costs, fear and stigma associated with the disease serving as major barriers for early presentation.

CONCLUSIONS

Educational strategies should be aimed at modifying the life style, early planning of pregnancy, promoting breast feeding and physical activity. It is very important to obtain reliable data for planning policies, decision-making and setting up the priorities.

Is mammography for breast cancer screening cost-effective in both Western and asian countries?: results of a systematic review

BACKGROUND

Mammography is considered the gold standard of breast cancer mass screening and many countries have implemented this as an established breast cancer screening strategy. However, although the incidence of breast cancer and racial characteristics are different between Western and Asian countries, many Asian countries adopted mammography for mass screening. Therefore, the objective of this research was to determine whether mammography mass screening is cost-effective for both Western and Asian countries.

MATERIALS AND METHODS

A systematic review was performed of 17 national mammography cost-effectiveness data sets. Per capita gross domestic product (GDP), breast cancer incidence rate, and the most optimal cost- effectiveness results [cost per life year saved (LYS)] of a mammography screening strategy for each data set were extracted. The CE/per capita GDP ratio is used to compare the cost-effectiveness of mammography by countries. Non-parametric regression was used to find a cut-off point which indicated the breast cancer incidence rate boundary line determining whether mammography screening is cost-effective or not.

RESULTS

We found that the cost-effective cut-off point of breast cancer incidence rate was 45.04; it exactly divided countries into Western and Asian countries (p<0.0014).

CONCLUSIONS

Mammography screening is cost-effective in most of Western countries, but not in Asian countries. The reason for this result may be the issues of incidence rate or racial characteristics, such as dense breast tissue. The results indicate that mammography screening should be adopted prudently in Asian countries and other countries with low incidence rates.

Variations in screening outcome among pairs of screening radiologists at non-blinded double reading of screening mammograms: a population-based study

OBJECTIVES

Substantial inter-observer variability in screening mammography interpretation has been reported at single reading. However, screening results of pairs of screening radiologists have not yet been published. We determined variations in screening performances among pairs of screening radiologists at non-blinded double reading.

METHODS

We included pairs of screening radiologists with at least 7,500 screening examinations per pair, obtained between 1997 and 2011. During 2-year follow-up, breast imaging reports, surgical reports and pathology results were collected of all referred women and interval cancers. Referral rate, cancer detection rate, positive predictive value and sensitivity were calculated for each pair.

RESULTS

A total of 310,906 screening mammograms, read by 26 pairs of screening radiologists, were included for analysis. The referral rate ranged from 1.0 % (95 % CI 0.8 %-1.2 %) to 1.5 % (95 % CI 1.3 %-1.8 %), the cancer detection rate from 4.0 (95 % CI 2.8-5.2) to 6.3 (95 % CI 4.5-8.0) per 1,000 screens. The programme sensitivity and positive predictive value of referral ranged from 55.1 % (95 % CI 45.1 %-65.1 %) to 81.5 % (95 % CI 73.4 %-89.6 %) and from 28.7 % (95 % CI 20.8 %-36.6 %) to 49.5 % (95 % CI 39.7 %-59.3 %), respectively.

CONCLUSION

We found significant variations in screening outcomes among pairs of screening radiologists at non-blinded double reading. This stresses the importance of monitoring screening results on a local scale.

KEY POINTS

• Substantial inter-observer variability in screening mammography interpretation is known at single reading • Population-based study showed significant variations in outcomes among pairs of screening radiologists • Local monitoring and regular feedback are important to optimise screening outcome.

Mortality characteristics and prediction of female breast cancer in China from 1991 to 2011

AIMS

To analyze time-dependent changes in female breast cancer (BC) mortality in China, forecast the trend in the ensuing 5 years, and provide recommendations for prevention and management.

MATERIALS AND METHODS

Mortality data of breast cancer in China from 1991 to 2011 was used to describe characteristics and distribution, such as the changes of the standardized mortality rate, urban-rural differences and age differences. Trend-surface analysis was used to study the geographical distribution of mortality. In addition, curve estimation, time series modeling, Gray modeling (GM) and joinpoint regression were performed to estimate and predict future trends.

RESULTS

In China, the mortality rate of breast cancer has increased yearly since 1991. In addition, our data predicted that the trend will continue to increase in the ensuing 5 years. Rates in urban areas are higher than those in rural areas. Over the past decade, all peak ages for death by breast cancer have been delayed, with the first death peak occurring at 55 to 65 years of age in urban and rural areas. Geographical analysis indicated that mortality rates increased from Southwest to Northeast and from West to East.

CONCLUSIONS

The standardized mortality rate of breast cancer in China is rising and the upward trend is predicted to continue for the next 5 years. Since this can cause an enormous health impact in China, much better prevention and management of breast cancer is needed. Consequently, disease control centers in China should place more focus on the northeastern, eastern and southeastern parts of China for breast cancer prevention and management, and the key population should be among women between ages 55 to 65, especially those in urban communities.

Trends in incidence of breast cancer among women under 40 in seven European countries: a GRELL cooperative study

Young women are not usually screened for breast cancer (BC). The trends in incidence in this population may better reflect changes in risk factors. However, studies on this subject are scarce and heterogeneous. The aim of this study was to describe the trends in incidence of BC in women under 40 from 1990 to 2008, using pooled European data. Thirty-seven European population-based cancer registries from Belgium, Bulgaria, France, Italy, Portugal, Spain and Switzerland participated in this study. World age-standardized incidence rates were first analyzed graphically and then using a Poisson regression model, in order to estimate average annual percent changes (AAPCs). The overall incidence rate of BC in the area covered increased linearly during the study period by 1.19% (0.93; 1.46) on average per year. This increase varied between countries from 0.20% (-0.53; 0.64) in Bulgaria to 2.68% (1.97; 3.40) in Portugal. In Italy, after a significant rise of 2.33% (1.14; 3.54) per year, BC incidence began decreasing in 2002 by -2.30% (-4.07; -0.50) yearly. The rise in incidence was greater for women under 35 and for ductal carcinomas. This increase can be due to a rise in risk factors and/or changes in diagnosis and surveillance practices, but we could not clearly distinguish between these two non-exclusive explanations.

Combined performance of physical examination, mammography, and ultrasonography for breast cancer screening among Chinese women: a follow-up study

OBJECTIVE

We aimed to determine which combination of physical examination (pe), mammography (mam), and ultrasonography (us) would optimize breast cancer detection in China.

METHODS

We conducted a trial of screening with pe, mam, and us among Chinese women 25 years of age and older. All initial screenings using the three modalities were completed within 30 days of each other, and subjects were followed approximately 1 year later. The performances of the three screening methods used alone, in parallel, or in series were compared. Data were analyzed using exact confidence intervals (cis) and the McNemar test.

RESULTS

Between March 2009 and July 2011, 3028 eligible women completed all study examinations. At a mean follow-up of 1.3 years, 33 breast cancers were identified in the study population. Mammography detected 28 cancers; us, 24 cancers; and pe, 22 cancers. During the follow-up period, 2 false-negative cases occurred clinically. The highest sensitivity for breast cancer screening (93.9%) was achieved by paralleling mam with us, but came at the cost of a higher recall rate (12.15%). Using us alone at the first stage, followed by mam when indicated, offered high specificity (99.4%) and the lowest recall rate (1.82%), which were not reached at the expense of sensitivity (84.8%). Used in series, us and mam achieved a sensitivity similar to that for the same modalities used in parallel (McNemar p > 0.05).

CONCLUSIONS

Taking limited health resources into consideration, the strategy of screening with us alone at the first stage, followed by mam when indicated, may optimize breast cancer detection in most regions of China.

Trends of population-based breast cancer survival in Germany and the US: decreasing discrepancies, but persistent survival gap of elderly patients in Germany

Background

Studies have revealed both higher cancer survival in the US than in Germany and substantial improvement of cancer survival in the past in these countries. This population-based study aims at comparing most recent 5-year relative survival of breast cancer patients and preceding trends in both countries.

Methods

Women with a first invasive breast cancer diagnosed and followed up between 1988 and 2008 from Germany and the US (utilizing data from the Saarland Cancer Registry and the Surveillance, Epidemiology, and End Results Program, respectively) were included. Period analysis was used to derive most up-to-date 5-year relative survival and preceding survival trends according to age and stage.

Results

Since 1993, age standardized relative survival has steadily improved in Germany and the US to 83% and 88%, respectively. In the period 2005–08, relative survival of localized cancer was above 97% in both countries, and 79% and 83% for locally/regionally spread breast cancer, respectively. Prognosis of metastasized disease has remained very poor overall, with improvement essentially being restricted to younger patients. The proportion of patients diagnosed with localized breast cancer was consistently higher in the US. If adjusted for stage, the differences in relative survival between both countries diminished over time and eventually disappeared.

Conclusions

Similar survival is now observed in both countries for patients below the age of 70 years, but in Germany survival is still much lower for elderly patients. The observed trends point to treatment advances as a major cause for improved survival. However, substantial differences in mammography usage existed between both countries and might probably also account for the observed differences (to a lesser extent, also differences in health care systems, and delivery of cancer care). Encouraging, survival of breast cancer patients has improved in Germany to a much greater extent than in the US, albeit the persisting survival gap for elderly patients in Germany requires particular attention by researchers, public health authorities, and clinicians.

The descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality

BACKGROUND

This paper presents the latest international descriptive epidemiological data for invasive breast cancer amongst women, including incidence, survival and mortality, as well as information on mammographic screening programmes.

RESULTS

Almost 1.4 million women were diagnosed with breast cancer worldwide in 2008 and approximately 459,000 deaths were recorded. Incidence rates were much higher in more developed countries compared to less developed countries (71.7/100,000 and 29.3/100,000 respectively, adjusted to the World 2000 Standard Population) whereas the corresponding mortality rates were 17.1/100,000 and 11.8/100,000. Five-year relative survival estimates range from 12% in parts of Africa to almost 90% in the United States, Australia and Canada, with the differential linked to a combination of early detection, access to treatment services and cultural barriers. Observed improvements in breast cancer survival in more developed parts of the world over recent decades have been attributed to the introduction of population-based screening using mammography and the systemic use of adjuvant therapies.

CONCLUSION

The future worldwide breast cancer burden will be strongly influenced by large predicted rises in incidence throughout parts of Asia due to an increasingly "westernised" lifestyle. Efforts are underway to reduce the global disparities in survival for women with breast cancer using cost-effective interventions.

Mammography Screening: Keeping Women Alive

Evaluation of: Tabár L, Vitak B, Chen TH et al. Swedish Two-County Trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 260(3), 658–663 (2011). In the 1980s, the periodic invitation of women aged 40–69 years for mammographic screening in the Swedish Two-County Trial showed a strong 30% reduction in breast cancer mortality. The result of 2–3-yearly mammographic examinations has persisted throughout the long follow-up of three decades. Through the richness of the collected and verified data, the trial has also demonstrated a substantial and absolute reduction in mortality risk. For each 414 women screened for 7 years (approximately four screening examinations), one breast cancer death was prevented. Transferring these outcomes to, for example, the national program of the UK, for every 1000 women aged 47–73 years attending the 3-yearly screenings (nine screening examinations) at least five to seven breast cancer deaths would be prevented. In recent follow-up papers by the Swedish trial group, the major human cost of screening (false-positive outcome, occurrence of interval cancer, overdiagnosis and radiation exposure) were judged to be in balance with the accurately demonstrated mortality benefit.

Approaches to breast cancer screening among primary care physicians in rural areas of crete, Greece

The aim of this study was to assess levels of knowledge regarding breast cancer screening among primary care physicians in rural areas of Crete. A cross-sectional survey of 106 general practitioners and internists and 83 trainee general practitioners (GPs) employed as of October 2004 and practicing at 14 primary health centers in Crete was performed. It was a self-administered survey with 27 items exploring knowledge, attitudes, and behaviors concerning delivery of general preventive and cancer screening services. The main outcome measures were responses to four items on approaches to breast cancer screening practices. Overall response rate was 55% (primary care physicians (PCPs) = 53%; trainee GPs = 60%). Respondents demonstrated a limited awareness of international recommendations for breast cancer screening and exhibited marked variation in their responses to survey items. Agreement with current international guidelines ranged from 31% to 58% for the individual survey items. This survey revealed limited knowledge among PCPs to well-publicized breast cancer screening guidelines and variations in approaches to breast cancer early detection.

The association between socio-demographic characteristics and adherence to breast and colorectal cancer screening: analysis of large sub populations

BACKGROUND

Populations having lower socioeconomic status, as well as ethnic minorities, have demonstrated lower utilization of preventive screening, including tests for early detection of breast and colorectal cancer.

THE OBJECTIVE

To explore socio-demographic disparities in adherence to screening recommendations for early detection of cancer.

METHODS

The study was conducted by Maccabi Healthcare Services, an Israeli HMO (health plan) providing healthcare services to 1.9 million members. Utilization of breast cancer (BC) and colorectal cancer (CC) screening were analyzed by socio-economic ranks (SERs), ethnicity (Arab vs non-Arab), immigration status and ownership of voluntarily supplemental health insurance (VSHI).

RESULTS

Data on 157,928 and 303,330 adults, eligible for BC and CC screening, respectively, were analyzed. Those having lower SER, Arabs, immigrants from Former Soviet Union countries and non-owners of VSHI performed fewer cancer screening examinations compared with those having higher SER, non-Arabs, veterans and owners of VSHI (p < 0.001). Logistic regression model for BC Screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab and having a lower SER. The model for CC screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. The model estimated for BC and CC screening among females revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant.

CONCLUSION

Patients from low socio-economic backgrounds, Arabs, immigrants and those who do not own supplemental insurance do fewer tests for early detection of cancer. These sub-populations should be considered priority populations for targeted intervention programs and improved resource allocation.

A nation-wide multicenter 10-year (1999-2008) retrospective clinical epidemiological study of female breast cancer in China

BACKGROUND

According to the very limited cancer registry, incidence and mortality rates for female breast cancer in China are regarded to be increasing especially in the metropolitan areas. Representative data on the breast cancer profile of Chinese women and its time trend over years are relatively rare. The aims of the current study are to illustrate the breast cancer profile of Chinese women in time span and to explore the current treatment approaches to female breast cancer.

METHODS

This was a hospital-based nation-wide and multi-center retrospective study of female primary breast cancer cases. China was divided into 7 regions according to the geographic distribution; from each region, one tertiary hospital was selected. With the exception of January and February, one month was randomly selected to represent each year from year 1999 to 2008 at every hospital. All inpatient cases within the selected month were reviewed and related information was collected based on the designed case report form (CRF). The Cancer Hospital/Institute, Chinese Academy of Medical Sciences (CICAMS) was the leading hospital in this study.

RESULTS

Four-thousand two-hundred and eleven cases were randomly selected from the total pool of 45,200 patients and were included in the analysis. The mean age at diagnosis was 48.7 years (s.d. = 10.5 yrs) and breast cancer peaked in age group 40-49 yrs (38.6%). The most common subtype was infiltrating ductal carcinoma (86.5%). Clinical stage I & II accounted for 60.6% of 4,211 patients. Three-thousand five-hundred and thirty-four cases had estrogen receptor (ER) and progestin receptor (PR) tests, among them, 47.9% were positive for both. Two-thousand eight-hundred and forty-nine cases had human epidermal growth factor receptor 2(HER-2) tests, 25.8% of them were HER-2 positive. Among all treatment options, surgery (96.9% (4,078/4,211)) was predominant, followed by chemotherapy (81.4% (3,428/4,211). Much less patients underwent radiotherapy (22.6% (952/4,211)) and endocrine therapy (38.0% (1,599/4,211)).

CONCLUSIONS

The younger age of breast cancer onset among Chinese women and more advanced tumor stages pose a great challenge. Adjuvant therapy, especially radiotherapy and endocrine therapy are of great unmet needs.

Narrowing the Equity Gap: The Impact of Organized versus Opportunistic Cancer Screening in Catalonia (Spain)

Objectives

To assess the impact on equity of access of an organized breast cancer screening programme, compared with opportunistic breast and cervical cancer screening activities.

Methods

Two cross-sectional health interview surveys conducted in 1994 and 2006 in Catalonia (Spain), with 6382 and 7653 women participating in both surveys. The main outcome measures were having undergone regular mammography, and regular cytology. Age-standardized prevalence rates for both screening tests were computed using the direct method. The relative inequality index was computed to measure changes over time in inequality on screening utilization.

Results

Participation among women aged 50-69 has increased after the introduction of the organized breast screening programme; the greatest impact has been observed among those women with lower educational levels (from 17% in 1994 to 79% in 2006). Equity of access by education was particularly increased in the target group for breast cancer screening.

Conclusion

This study indicates that an organized screening programme could improve participation and equity of access.

First report of introducing population-based breast cancer screening in Poland: experience of the 3-million population region of Lower Silesia

BACKGROUND

To achieve a reduction in breast cancer mortality in Poland a nation-wide population-based screening was introduced in 2007.

AIM

To assess the quality of breast cancer screening programme during the first round of operation in Lower Silesia-a region of over 3 million inhabitants.

METHODS

Women aged 50-69 are invited for screening, with the exception of those undergoing treatment or being followed up after treatment for breast cancer. Biennial two-view screen-film mammography is used as the standard screening test. Quality evaluation was carried out via early performance indicators. These parameters were calculated according to European Guidelines and compared with recommended levels.

RESULTS

Only 40% of women from the eligible population were screened. Among programme attendees the technical recall rate (a repeat mammogram because of technical inadequacy of the screening mammogram) was 0.27%. Further assessment rate (additional diagnostic techniques, either non-invasive or invasive, performed for medical reasons in order to clarify the nature of a perceived abnormality detected at the screening mammography) was 6.2%, while the short-term recall rate (early re-screen mammography at an interval less than the routine round length of the programme) was 2.4%. Cancer detection rate was 6.6/1000 while cancer detection rate expressed as a multiple of the expected breast cancer incidence rate was 3.8. Positive predictive values of the screening test and the further assessment were 11% and 77%, respectively.

CONCLUSION

The general assessment using early indicators reveals that diagnostic service conforms to the European standards on an acceptable or even desirable level. The only exception among these parameters is a too high short-term recall rate, which should be drastically decreased during the next rounds to improve the cost-effectiveness. The main disadvantage of the screening programme at its start is a dramatically poor coverage of the eligible population. If the invitation policy is not significantly intensified the breast cancer mortality rate will not be reduced, despite the good quality of diagnostic service.

Trends in breast, ovarian and cervical cancer incidence in Mumbai, India over a 30-year period, 1976-2005: an age-period-cohort analysis

Background:

Demographic, socioeconomic and cultural changes in India have increased longevity, delayed childbearing, decreased parity and resulted in a more westernised lifestyle, contributing to the increasing burden of cancer, especially among women.

Methods:

We evaluated secular changes in the incidence of breast, cervical and ovarian cancer in Mumbai women aged 30–64 between 1976 and 2005. Age-standardised incidence rates were calculated and presented by site and calendar period. An age–period–cohort (APC) analysis quantified recent time trends and the significance of birth cohort and calendar period effects. The estimated annual percent change (EAPC) was obtained from the drift parameter, expressing the linear time trend common to both calendar period and birth cohort.

Results:

Over the 30-year study period, the age-standardised rates significantly increased for breast cancer (EAPC: 1.1% (95% confidence interval (CI): 1.0, 1.3)), significantly decreased for cervical cancer (EAPC: −1.8% (95% CI: −2.0, −1.6)) and there was no statistically significant change for ovarian cancer (EAPC: 0.3% (95% CI: −0.1, 0.6)). For breast and cervical cancer, the best-fitting model was the APC model.

Conclusions:

The rates of breast, cervical and ovarian cancer remain low in comparison with western countries, and the divergent trends of breast (increasing) and cervical cancer (decreasing) in Mumbai were similar to those observed in several other Asian countries. The changing risk profile in successive generations – improved education, higher socioeconomic status, later age at marriage and at first child, and lower parity – may in combination partially explain the diverging generational changes in breast and cervical cancer in Mumbai in the last decades.

Breast cancer screening in the Czech Republic: time trends in performance indicators during the first seven years of the organised programme

Background

The Czech Breast Cancer Screening Programme (CBCSP) was initiated in September 2002 by establishing a network of accredited centres. The aim of this article is to describe progress in the programme quality over time after the inception of the organised programme.

Methods

The CBCSP is monitored using an information system consisting of three principal components: 1) the national cancer registry, 2) a screening registry collecting data on all screening examinations, further assessments and final diagnoses at accredited programme centres, and 3) administrative databases of healthcare payers. Key performance indicators from the European Guidelines have been adopted for continuous monitoring.

Results

Breast cancer incidence in the Czech Republic has steadily been increasing, however with a growing proportion of less advanced stages. The mortality rate has recently stabilised. The screening registry includes 2,083,285 records on screening episodes between 2002 and 2008. In 2007-2008, 51% of eligible women aged 45-69 were screened. In 2008, the detection rates were 6.1 and 3.7 per 1,000 women in initial and subsequent screening respectively. Corresponding recall rates are 3.9% and 2.2%, however, it is necessary to pay attention to further assessment performed during the screening visits. Benign to malignant open biopsy ratio was 0.1. Of invasive cases detected in screening, 35.6% was less than 10 mm in diameter. Values of early performance indicators, as measured by both crude and standardized estimates, are generally improving and fulfil desirable targets set by European Guidelines.

Conclusions

Mammography screening in the Czech Republic underwent successful transformation from opportunistic prevention to an organised programme. Values of early indicators confirm continuous improvement in different aspects of process quality. Further stimulation of participation through invitation system is necessary to exploit the full potential of screening mammography at the population level.

Residual confounding after adjustment for age: a minor issue in breast cancer screening effectiveness

Residual confounding, after adjustment for age, is the major criticism of observational studies on breast cancer screening effectiveness. We developed realistic scenarios for the prevalence and strength of risk factors on screened and not screened groups, and explored the impact of residual confounding bias. Our results demonstrate that residual confounding bias is a minor issue in screening programme evaluations.

Increasingly strong reduction in breast cancer mortality due to screening

BACKGROUND

Favourable outcomes of breast cancer screening trials in the 1970s and 1980s resulted in the launch of population-based service screening programmes in many Western countries. We investigated whether improvements in mammography and treatment modalities have had an influence on the effectiveness of breast cancer screening from 1975 to 2008.

METHODS

In Nijmegen, the Netherlands, 55,529 women received an invitation for screening between 1975 and 2008. We designed a case-referent study to evaluate the impact of mammographic screening on breast cancer mortality over time from 1975 to 2008. A total number of 282 breast cancer deaths were identified, and 1410 referents aged 50-69 were sampled from the population invited for screening. We estimated the effectiveness by calculating the odds ratio (OR) indicating the breast cancer death rate for screened vs unscreened women.

RESULTS

The breast cancer death rate in the screened group over the complete period was 35% lower than in the unscreened group (OR=0.65; 95% CI=0.49-0.87). Analysis by calendar year showed an increasing effectiveness from a 28% reduction in breast cancer mortality in the period 1975-1991 (OR=0.72; 95% CI=0.47-1.09) to 65% in the period 1992-2008 (OR=0.35; 95% CI=0.19-0.64).

CONCLUSION

Our results show an increasingly strong reduction in breast cancer mortality over time because of mammographic screening.