First Results of a Mammographic Screening Program in Two Municipalities of Massa-Carrara Province (Italy)

The First Breast Cancer Screening Program in Southern Italy: Preliminary Results from Three Municipalities of the Naples Province

Aims and Background

It has been demonstrated that breast cancer screening induces a 30% reduction of specific mortality. In May 1990, we started a pilot screening program to assess the feasibility of carrying out such a program in Campania (southern Italy). Herein we report the results of the first round of the program from three municipalities (Giugliano, Mugnano and Qualiano) that lie within the local health district no. 23, close to the city of Naples.

Methods

Women between the ages of 50 and 69 years were sent a personalized letter inviting them to attend the screening test; those not responding were sent a second invitation. The screening test consisted of clinical examination followed by two-view mammography. Second–level diagnostic tools were sonography, fine needle aspiration (manual, echo-guided and stereotaxic) and surgical biopsy.

Results

Out of 5,732 women invited for the first round, 1,813 (31.6%) attended the screening. Attendance rate was higher among younger women. Ninety-one women were positive at the screening test and underwent further examination (recall rate, 5.0%). Among them, 19 had surgical biopsy (biopsy rate, 1.0%) that led to breast cancer diagnosis in 11 cases. The benign/malignant biopsy rate was 0.73. Detection rate was 6.07 × 1,000 screened women and varied among age categories, increasing within the 60–69 subgroup; detection rate/expected incidence ratio in the overall group was 4.5 and also increased within the older age category. Seven out of 11 cancers were at UICC stage 0-I. Among 327 self-referring women, 38 were positive (recall rate, 11.6%), and 14 underwent biopsy (biopsy rate, 4.3%), which showed cancer in 7 cases (benign/malignant biopsy rate, 1.0). In addition, 2 inflammatory cancers were diagnosed without surgical biopsy. Thus 9 cancer cases were detected in this group. Self-referring women differed from responding women in that they had a higher frequency of symptoms or familiar history of cancer, and a higher educational level and awareness of preventive medicine. Clinical examination added no diagnostic advantage in the responding group but did not significantly worsen the recall rate. In the self-referring group, one case of inflammatory cancer was missed by mammography and diagnosed by clinical examination.

Conclusion

The early results (recall rate = 5%, detection rate/expected incidence ratio = 4.5, benign/malignant biopsy rate = 0.73, advanced cancers = 36.4%) are encouraging and indicate the validity of the program. Strategies to improve attendance rate are planned.

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.

Endoscopic surveillance of Barrett's esophagus: a cost-effectiveness comparison with mammographic surveillance for breast cancer

OBJECTIVE

Endoscopic surveillance of Barrett's esophagus is commonly practiced to detect malignancy in an early and curable stage. However, the cost-effectiveness of this practice has been questioned. To clarify this issue, we undertook a cost analysis of endoscopic surveillance to detect adenocarcinoma in Barrett's esophagus compared with mammography used to detect occult carcinoma of the breast, a widely accepted cancer surveillance technique.

METHODS

The rate of esophageal adenocarcinoma detected by endoscopic surveillance was calculated for Duluth Clinic patients with Barrett's esophagus seen from 1980 to 1995 and compared with published rates. The rate of occult breast cancer detection was calculated for all women undergoing surveillance mammography at the Duluth Clinic for the year 1994 and compared with published rates. Costs for screening studies and therapy for cancer treatment for both cancers were calculated based on clinical results and assumptions regarding outcomes derived from published reports, and the costs were compared.

RESULTS

Endoscopic surveillance of 149 patients with benign Barrett's esophagus was performed for a total of 510 patient-yr, during which time seven patients developed adenocarcinoma, an incidence of one case per 73 patient-yr of follow-up. Occult breast cancer was detected in 50 of 12,537 mammograms, a detection rate of 0.4%. The incidences in both cases were comparable to published figures. The costs of detecting a case of adenocarcinoma in Barrett's esophagus and occult breast cancer were $37,928 and $54,513, respectively, and those for treatment resulting in cure were $83,340 and $83,292. Cost per life-yr saved was $4,151 for adenocarcinoma in Barrett's esophagus and $57,926 for breast cancer.

CONCLUSION

Endoscopic surveillance of patients with Barrett's esophagus compares favorably with the common practice of surveillance mammography to detect early breast cancer, and should therefore be considered to be as cost-effective as surveillance mammography.

Sociodemographic factors associated with the diagnostic staging of breast cancer in southern Italy

BACKGROUND

There are marked regional differences in breast cancer mortality rates in Italy, probably linked to factors such as diagnostic delay, therapeutic strategies, and biologic and sociodemographic differences. To investigate a possible link between sociodemographic factors (e.g. age, education, and residence) and delay in the diagnosis of breast cancer, data were evaluated from all such patients from our Institute living in the Campania Region of Southern Italy for 1991-1993.

METHODS

Patients were grouped into Tis-T1/N0-N+ versus T2-4/N0-N+ and the variables examined were age (< 40, 41-50, 51-60, > 60 years), education (< or = 5 vs. > 5 school years) and residence (urban vs. rural). An analysis was made using the Pearson's Chi-square test and the multiple logistic regression.

RESULTS

Statistically significant differences were found for both residence (P = 0.04) and education level (P = 0.03) in the older than 60 years age group, but only for residence (P = 0.03) in the 51-60 years age group. The risks according to Mantel-Haenszel were 1.28 for education (P = 0.08) and 1.32 for residence in rural municipalities (P = 0.05). The odds ratio for residence in rural municipalities, adjusted by education and by the education-residence interaction, was 2.26 (95% confidence interval [CI], 1.12-4.54) in the 51-60 years age group and 1.74 (95% CI, 1.01-3.00) in the older than 60 years age group.

CONCLUSIONS

These data clearly indicate that residents of rural municipalities, as well as poorly educated subjects, are more likely than their respective counter-parts to have a delayed diagnosis of breast cancer.