Quantifying independent risk factors for failing to rescreen in a breast cancer screening program in Flanders, Belgium

The state of health in Belgium, 1990-2019: a benchmarking analysis based on the Global Burden of Disease 2019 study

BACKGROUND

In a context of decreasing resources and growing health needs, evidence-based health and care policies are essential. This study aims to assess the health trends in Belgium between 1990 and 2019, to compare the Belgian health status to that of the EU-15 countries, and to identify the main drivers in trends over time and country differences within the EU-15.

METHODS

We extracted estimates from the GBD 2019 study via the GBD results tool and visualization tools. We compared the Belgian health status with 14 European Union comparator countries between 1990 and 2019, and decomposed the time trends and country differences into the unique contributions of the different underlying causes of death and disability.

RESULTS

Life expectancy (LE) in Belgium improved significantly between 1990 and 2019 for both men and women. Belgium age-standardised mortality rates dropped significantly for men (-40%) and women (-33%) between 1990 and 2019. Overall, Belgium age-standardised disability-adjusted life year (DALY) rates dropped by 23%. This decrease is mainly due to decreasing trends in age-standardised years of life lost (YLL) rates while age-standardised years lived with disability (YLD) rates remained stable. Compared to EU-15, Belgium's ranking in terms of age-standardised DALY rates worsened for both men and women in 2019. Self-harm and falls are major causes of disease burden, with DALY rates that are higher than in many other EU-15 countries, indicating a realistic potential for improvement. Lung cancer DALY rates remain worrisome for men, and even show an increasing trend for women. Increasing trends of headache disorders, drug use disorders, and diabetes, require further attention.

CONCLUSION

Non-communicable diseases remain the main contributors for health burden in Belgium, with disability accounting for an increasingly larger share of the disease burden. Despite considerable improvements, Belgium's ranking for DALYs decreased between 1990 and 2019 compared to the EU-15. This study identified priority causes of disease burden based on their contributions to current evolutions and EU-15 differences. Since many of these causes are considered to be avoidable, primary and secondary prevention are crucial elements for reducing the burden of disease on the healthcare system.

Overdiagnosis of invasive breast cancer in population-based breast cancer screening: A short- and long-term perspective

BACKGROUND

Overdiagnosis of invasive breast cancer (BC) is a contentious issue.

OBJECTIVE

The aim of this paper is to estimate the overdiagnosis rate of invasive BC in an organised BC screening program and to evaluate the impact of age and follow-up time.

METHODS

The micro-simulation model SiMRiSc was calibrated and validated for BC screening in Flanders, where women are screened biennially from age 50 to 69. Overdiagnosis rate was defined as the number of invasive BC that would not have been diagnosed in the absence of screening per 100,000 screened women during the screening period plus follow-up time (which was set at 5 years and varied from 2 to 15 years). Overdiagnosis rate was calculated overall and stratified by age.

RESULTS

The overall overdiagnosis rate for women screened biennially from 50 to 69 was 20.1 (95%CI: 16.9-23.2) per 100,000 women screened at 5-year follow-up from stopping screening. Overdiagnosis at 5-year follow-up time was 12.9 (95%CI: 4.6-21.1) and 74.2 (95%CI: 50.9-97.5) per 100,000 women screened for women who started screening at age 50 and 68, respectively. At 2- and 15-year follow-up time, overdiagnosis rate was 98.5 (95%CI: 75.8-121.3) and 13.4 (95%CI: 4.9-21.9), respectively, for women starting at age 50, and 297.0 (95%CI: 264.5-329.4) and 34.2 (95%CI: 17.5-50.8), respectively, for those starting at age 68.

CONCLUSIONS

Sufficient follow-up time (≥10 years) after screening stops is key to obtaining unbiased estimates of overdiagnosis. Overdiagnosis of invasive BC is a larger problem in older compared to younger women.

Differences and Similarities in Breast and Colorectal Cancer Screening Uptake among Municipalities in Flanders, Belgium

Despite the recognized benefits of fecal occult blood test (FOBT) and mammography screenings, participation in breast (BC) and colorectal cancer (CRC) screening programs is still suboptimal. This study investigates municipal characteristics associated with their BC/CRC screening uptake profiles among women aged 55–69 years. Using data from 308 municipalities of Flanders from 2014 to 2017, a profile for each municipality based on its BC/CRC screening uptake compared with the median screening uptake was created. Logistic regression with generalized estimating equations was used to assess the associations between municipal characteristics and BC/CRC screening uptake profiles. The overall median uptake of cancer screening was higher for CRC (57.4%) than for BC (54.6%). The following municipal characteristics were associated with worse performance in terms of only CRC, only BC, or both CRC and BC screening uptake, respectively: foreign nationality, self-employment rate, (early) retirement rate, diabetes, disabilities; (early) retirement rate; age group 65–69, foreign nationality, self-employment rate, (early) retirement rate, wage-earners, diabetes. The following municipal characteristics were associated with better performance in terms of only CRC, only BC, or both CRC and BC screening uptake respectively: residential stability, having a partner, having children, jobseeker rate, GP visits, preventive dental visits; having children, GP visits; age group 55–59, residential stability, having a partner, having children, jobseeker rate, higher education, GP visits, preventive dental visits. This study’s results regarding the interrelation between the BC and CRC screening could be used to tailor interventions to improve the participation of the target population in both programs.

Subsequent attendance in a breast cancer screening program after a false-positive result in the Local Health Authority of Bologna (Italy)

We conducted a cross-sectional study to assess the likelihood of returning for routine breast cancer screening among women who have experienced a false-positive result (FPR) and to describe the possible individual and organizational factors that could influence subsequent attendance to the screening program. Several information were collected on demographic and clinical characteristics data. Electronic data from 2014 to 2016 related to breast screening program of the Local Health Authority (LHA) of Bologna (Italy) of women between 45 and 74 years old were reviewed. A total of 4847 women experienced an FPR during mammographic screening and were recalled to subsequent round; 80.2% adhered to the screening. Mean age was 54.2 ± 8.4 years old. Women resulted to be less likely to adhere to screening if they were not-Italian (p = 0.001), if they lived in the Bologna district (p < 0.001), if they had to wait more than 5 days from II level test to end of diagnostic procedures (p = 0.001), if the diagnostic tests were performed in a hospital with the less volume of activity and higher recall rate (RR) (p < 0.001) and if they had no previous participation to screening tests (p < 0.001). Our results are consistent with previous studies, and encourages the implementation and innovation of the organizational characteristics for breast cancer screening. The success of screening programs requires an efficient indicators monitoring strategy to develop and evaluate continuous improvement processes.

The Role of Socio-Demographic Factors in the Coverage of Breast Cancer Screening: Insights From a Quantile Regression Analysis

Background: In Flanders, breast cancer (BC) screening is performed in a population-based breast cancer screening program (BCSP), as well as in an opportunistic setting. Women with different socio-demographic characteristics are not equally covered by BC screening.

Objective: To evaluate the role of socio-demographic characteristics on the lowest 10th and highest 90th quantile levels of BC screening coverage.

Methods: The 2017 neighborhood-level coverage rates of 8,690 neighborhoods with women aged 50–69 and eligible for BCSP and opportunistic screening were linked to socio-demographic data. The association between socio-demographic characteristics and the coverage rates of BCSP and opportunistic screening was evaluated per quantile of coverage using multivariable quantile regression models, with specific attention to the lowest 10th and highest 90th quantiles.

Results: The median coverage in the BCSP was 50%, 33.5% in the 10th quantile, and 64.5% in the 90th quantile. The median coverage of the opportunistic screening was 12, 4.2, and 24.8% in the 10th and 90th quantile, respectively. A lower coverage of BCSP was found in neighborhoods with more foreign residents and larger average household size, which were considered indicators for a lower socioeconomic status (SES). However, a higher average personal annual income, which was considered an indicator for a higher SES, was also found in neighborhoods with lower coverage of BCSP. For these neighborhoods, that have a relatively low and high SES, the negative association between the percentage of foreign residents, average household size, and average personal annual income and the coverage in the BCSP had the smallest regression coefficient and 95% confidence interval (CI) values were −0.75 (95% CI: −0.85, −0.65), −13.59 (95% CI: −15.81, −11.37), and −1.05 (95% CI: −1.18, −0.92), respectively, for the 10th quantile. The neighborhoods with higher coverage of opportunistic screening had a relatively higher average personal annual income, with the largest regression coefficient of 1.72 (95% CI: 1.59, 1.85) for the 90th quantile.

Conclusions: Women from relatively low and high SES neighborhoods tend to participate less in the BCSP, whereas women with a relatively high SES tend to participate more in opportunistic screening. For women from low SES neighborhoods, tailored interventions are needed to improve the coverage of BCSP.

Coverage determinants of breast cancer screening in Flanders: an evaluation of the past decade

Background

Breast cancer (BC) is the most common cancer in women in the developed world. In order to find developing cancers in an early stage, BC screening is commonly used. In Flanders, screening is performed in and outside an organized breast cancer screening program (BCSP). However, the determinants of BC screening coverage for both screening strategies are yet unknown.

Objective

To assess the determinants of BC screening coverage in Flanders.

Methods

Reimbursement data were used to attribute a screening status to each woman in the target population for the years 2008–2016. Yearly coverage data were categorized as screening inside or outside BCSP or no screening. Data were clustered by municipality level. A generalized linear equation model was used to assess the determinants of screening type.

Results

Over all years and municipalities, the median screening coverage rate inside and outside BCSP was 48.40% (IQR: 41.50–54.40%) and 14.10% (IQR: 9.80–19.80%) respectively. A higher coverage rate outside BSCP was statistically significantly (P < 0.001) associated with more crowded households (OR: 3.797, 95% CI: 3.199–4.508), younger age, higher population densities (OR: 2.528, 95% CI: 2.455–2.606), a lower proportion of unemployed job seekers (OR: 0.641, 95% CI: 0.624–0.658) and lower use of dental care (OR: 0.969, 95% CI: 0.967–0.972).

Conclusion

Coverage rate of BC screening is not optimal in Flanders. Women with low SES that are characterized by younger age, living in a high population density area, living in crowded households, or having low dental care are less likely to be screened for BC in Flanders. If screened, they are more likely to be screened outside the BCSP.

Flemish breast cancer screening programme: 15 years of key performance indicators (2002-2016)

Background

We examined 15 years of key performance indicators (KPIs) of the population-based mammography screening programme (PMSP) in Flanders, Belgium.

Methods

Individual screening data were linked to the national cancer registry to obtain oncological follow-up. We benchmarked crude KPI results against KPI-targets set by the European guidelines and KPI results of other national screening programmes. Temporal trends were examined by plotting age-standardised KPIs against the year of screening and estimating the Average Annual Percentage Change (AAPC).

Results

PMSP coverage increased significantly over the period of 15 years (+ 7.5% AAPC), but the increase fell to + 1.6% after invitation coverage was maximised. In 2016, PMSP coverage was at 50.0% and opportunistic coverage was at 14.1%, resulting in a total coverage by screening of 64.2%. The response to the invitations was 49.8% in 2016, without a trend. Recall rate decreased significantly (AAPC -1.5% & -5.0% in initial and subsequent regular screenings respectively) while cancer detection remained stable (AAPC 0.0%). The result was an increased positive predictive value (AAPC + 3.8%). Overall programme sensitivity was stable and was at 65.1% in 2014.

In initial screens of 2015, the proportion of DCIS, tumours stage II+, and node negative invasive cancers was 18.2, 31.2, and 61.6% respectively. In subsequent regular screens of 2015, those proportions were 14.0, 24.8, and 65.4% respectively. Trends were not significant.

Conclusion

Besides a suboptimal attendance rate, most KPIs in the Flemish PMSP meet EU benchmark targets. Nonetheless, there are several priorities for further investigation such as a critical evaluation of strategies to increase screening participation, organising a biennial radiological review of interval cancers, analysing the effect that preceding opportunistic screening has on the KPI for initial screenings, and efforts to estimate the impact on breast cancer mortality.

The impact of regional screening policies on the diffusion of cancer screening participation in Belgium: time trends in educational inequalities in Flanders and Wallonia

BACKGROUND

We investigate whether the extent of educational inequalities in the use of Pap smears (cervical cancer screening) and mammograms (breast cancer screening) in Belgium has changed over time in accordance with the pattern predicted by diffusion of innovation theory, as well as how the regional cancer screening policies of Flanders and Wallonia influence this pattern.

METHODS

Data were obtained from five successive cross-sectional waves (1997-2001-2004-2008-2013) of the Belgian Health Interview Survey. Final sample sizes consisted of 8988 women aged 25-64 years for cervical cancer screening and 4194 women aged 50-69 years for breast cancer screening. We calculated absolute and relative measures of inequality, more specifically, the slope index of inequality (SII) and the relative index of inequality (RII), and their development over time.

RESULTS

In both Flanders and Wallonia, mammogram use increased greatly between 1997 and 2013, while Pap smear use has remained quite stable over time. Educational inequalities in cervical-cancer screening have been largely persistent over time in both regions. In contrast, educational inequalities in breast cancer screening fluctuated more between 1997 and 2013. Between 1997 and 2001, when the breast cancer screening programme was implemented in Flanders, RII reduced significantly by 45%. Inequality measures did not change significantly in Wallonia, where it is known that most women are screened opportunistically outside the programme.

CONCLUSIONS

By focussing on Belgium, this study demonstrates that regional variations in the support of a national screening programme can result in regional variations in the pattern of diffusion for cancer screening, as well as to the development of inequalities in cancer screening participation. Moreover, the findings demonstrate that high visibility and awareness of the screening programme, as was more the case in Flanders than it was in Wallonia, are required in order to reduce or eliminate educational inequalities in cancer screening participation over time. General practitioners and gynaecologists can play a decisive role in this regard.

Breast cancer risk is increased in the years following false-positive breast cancer screening

Supplemental Digital Content is available in the text.

A small number of studies have investigated breast cancer (BC) risk among women with a history of false-positive recall (FPR) in BC screening, but none of them has used time-to-event analysis while at the same time quantifying the effect of false-negative diagnostic assessment (FNDA). FNDA occurs when screening detects BC, but this BC is missed on diagnostic assessment (DA). As a result of FNDA, screenings that detected cancer are incorrectly classified as FPR. Our study linked data recorded in the Flemish BC screening program (women aged 50–69 years) to data from the national cancer registry. We used Cox proportional hazards models on a retrospective cohort of 298 738 women to assess the association between FPR and subsequent BC, while adjusting for potential confounders. The mean follow-up was 6.9 years. Compared with women without recall, women with a history of FPR were at an increased risk of developing BC [hazard ratio=2.10 (95% confidence interval: 1.92–2.31)]. However, 22% of BC after FPR was due to FNDA. The hazard ratio dropped to 1.69 (95% confidence interval: 1.52–1.87) when FNDA was excluded. Women with FPR have a subsequently increased BC risk compared with women without recall. The risk is higher for women who have a FPR BI-RADS 4 or 5 compared with FPR BI-RADS 3. There is room for improvement of diagnostic assessment: 41% of the excess risk is explained by FNDA after baseline screening.

Patterns of participation over four rounds of annual fecal immunochemical test-based screening for colorectal cancer: what predicts rescreening?

BACKGROUND

Participation at the recommended intervals is critical for screening to be effective in reducing colorectal cancer (CRC) incidence. This study describes patterns of screening participation over four rounds of fecal immunochemical testing (FIT) to identify whether demographic variables and prior screening satisfaction are significantly associated with patterns of re-participation.

METHODS

Baseline surveys were mailed to 4000 South Australians randomly selected from the electoral-roll. Respondents (n = 1928/48.2%) were offered four annual FIT rounds. Screening participation and satisfaction at each round were recorded.

RESULTS

Study participation was 58.5, 66.9, 73.1 and 71.4% respectively over four rounds. Three participation patterns were described: consistent participation (43.1%), consistent non-participation (26.4%) and inconsistent participation (changeable; 30.5%), including intermittent and sustained change patterns. Sustained change described those who changed participatory behavior and then maintained for at least two rounds (n = 375/19.5%). Older people, and those not working were most likely to sustain participation. Younger invitees, especially men, were more likely to change participatory behavior and sustain the change. People with higher disadvantage, less education, not working and with no prior (pre-trial) screening experience were more likely to start participating and drop out. People dissatisfied with a prior screening test, including finding aspects embarrassing or unpleasant, were also more likely not to participate in annual screening or to drop out.

CONCLUSIONS

The findings identify those at risk of non- or inconsistent participation in rescreening. They should aid targeting of interventions for demographic groups at risk and ensuring screening experiences are not perceived as unpleasant or difficult.

Effect of second timed appointments for non-attenders of breast cancer screening in England: a randomised controlled trial

BACKGROUND

In England, participation in breast cancer screening has been decreasing in the past 10 years, approaching the national minimum standard of 70%. Interventions aimed at improving participation need to be investigated and put into practice to stop this downward trend. We assessed the effect on participation of sending invitations for breast screening with a timed appointment to women who did not attend their first offered appointment within the NHS Breast Screening Programme (NHSBSP).

METHODS

In this open, randomised controlled trial, women in six centres in the NHSBSP in England who were invited for routine breast cancer screening were randomly assigned (1:1) to receive an invitation to a second appointment with fixed date and time (intervention) or an invitation letter with a telephone number to call to book their new screening appointment (control) in the event of non-attendance at the first offered appointment. Randomisation was by SX number, a sequential unique identifier of each woman within the NHSBSP, and at the beginning of the study a coin toss decided whether women with odd or even SX numbers would be allocated to the intervention group. Women aged 50-70 years who did not attend their first offered appointment were eligible for the analysis. The primary endpoint was participation (ie, attendance at breast cancer screening) within 90 days of the date of the first offered appointment; we used Poisson regression to compare the proportion of women who participated in screening in the study groups. All analyses were by intention to treat. This trial is registered with Barts Health, number 009304QM.

FINDINGS

We obtained 33 146 records of women invited for breast cancer screening at the six centres between June 2, 2014, and Sept 30, 2015, who did not attend their first offered appointment. 26 054 women were eligible for this analysis (12 807 in the intervention group and 13 247 in the control group). Participation within 90 days of the first offered appointment was significantly higher in the intervention group (2861 [22%] of 12 807) than in the control group (1632 [12%] of 13 247); relative risk of participation 1·81 (95% CI 1·70-1·93; p<0·0001).

INTERPRETATION

These findings show that a policy of second appointments with fixed date and time for non-attenders of breast screening is effective in improving participation. This strategy can be easily implemented by the screening sites and, if combined with simple interventions, could further increase participation and ensure an upward shift in the participation trend nationally. Whether the policy should vary by time since last attended screen will have to be considered.

FUNDING

National Health Service Cancer Screening Programmes and Department of Health Policy Research Programme.

Breast cancer screening in England and the United States: a comparison of provision and utilisation

OBJECTIVES

Comparing breast cancer screening across countries within the context of some of the benefits and harms offers the opportunity to improve effectiveness through mutual learning.

METHODS

This paper describes the provision of breast cancer screening in England and the United States. The various recommendations for accessing breast cancer screening in the two countries are set out and the organisation of services including quality assurance, incentives and performance mechanisms considered.

RESULTS

In the United States, younger women are routinely screened; they are less likely to benefit and more likely to be harmed. The utilisation of breast cancer screening amongst eligible women is broadly comparable in the two countries. However, there are differences in technical performance; the reasons for these including radiological reading procedures and cultural factors are explored.

CONCLUSIONS

Despite a well-functioning screening programme, breast cancer mortality and survival in England are poor relative to other countries. Emphasis for American improvement should be on reducing false-positive recall rates, while the English NHS could supplement existing efforts to understand and improve comparatively poor survival and mortality.