Comparisons of assessment pathways after abnormal mammography screening in Denmark, Norway, and Spain

PURPOSE

To ensure high-quality screening programmes and effective utilization of resources, it is important to monitor how cancer detection is affected by different strategies performed at recall assessment. This study aimed to describe procedures performed at recall assessment and compare and evaluate the performance of the assessment in Denmark, Norway, and Spain in terms of screen-detected cancer (SDC) and interval cancer (IC) rates.

METHODS

We included women aged 50-69 years from Denmark, Norway, and Spain, who were recalled for assessment after screening mammography, and recorded all procedures performed during six months after diagnosis, and the timing of the procedures. Women were followed for two years and screen-detected and interval cancer, and sensitivity of recall was calculated and compared.

RESULTS

In total, data from 24,645 Danish, 30,050 Norwegian, and 41,809 Spanish women were included in the study. Most of the women had some assessment within 2 months in all three countries. SDC rates were higher in Denmark (0.57) and Norway (0.60) compared to Spain (0.38), as were the IC rates, i.e. 0.25 and 0.18 vs. 0.12, respectively. The sensitivity of the diagnostic follow-up was somewhat higher in Denmark (98.3%) and Norway (98.2%), compared to Spain (95.4%), but when excluding non-invasive assessment pathways, the sensitivities were comparable.

CONCLUSION

This comparison study showed variation in the assessment procedures used in the three countries as well as the SDC and IC rates and the sensitivity of recall.

Adherence to follow-up and resource use after abnormal FIT-screening: Evaluation of the Danish colorectal cancer screening program

Background and study aims The effectiveness of colorectal cancer screening programs depends on adherence to surveillance protocols for screening-positive individuals. We evaluated adherence in the Danish population-based screening program and estimated the volume of diagnostic resources required to achieve this adherence. Patients and methods In this register- and population-based study, we included individuals with a positive fecal immunochemical test (FIT) screening from 2014 to 2017 and followed them until mid-2022. All endoscopic, imaging, and surgical procedures performed at public and private hospitals were identified. Adherence to national protocols was reported in terms of proportions and timeliness. Use of diagnostic and surveillance procedures was estimated during a 4-year post-screening period. Results Among 82,221 individuals with a positive FIT test, 84% had a baseline colonoscopy within 1 month. After removal of intermediate or high-risk adenomas, 12% and 6%, respectively, did not have any follow-up. Only ~50% had timely surveillance. Approximately 10% to 20%, depending on their referral diagnosis, did not have a second surveillance colonoscopy. In addition, 12% with a negative colonoscopy had a second colonoscopy within 4 years. Conclusions High adherence to baseline colonoscopy after positive FIT-screening is followed by lower adherence throughout the adenoma surveillance program. Better adherence to the guidelines could potentially improve the effectiveness and efficiency of the screening program.

How follow-up rates in cervical cancer screening depend on organizational factors: A comparison of two population-based organized screening programmes

OBJECTIVES

This study compares the follow-up rates of non-normal cervical screening samples between Denmark and Flanders (Belgium) to illuminate whether organizational differences between the health systems might affect the follow-up rates, e.g. sending of reminders in Denmark since 2012 compared to Flanders with no such system in place.

METHODS

The study population included 48,082 Danish women and 22,271 Flemish women who received abnormal or inadequate primary screening results from 2014 to 2016. The participants were followed for 24 months, and the timeliness and appropriateness of the recommended follow-up, according to national guidelines, were evaluated.

RESULTS

After 18 months over 90% of the Danish women had received some form of follow-up, while in Flanders, this level is achieved only for those who test positive for human papillomavirus. The analysis also revealed that 10-28% of follow-ups were performed too early, with Danish women showing the highest proportions. In both regions, general practitioners (GPs) exhibited better follow-up rates compared to gynaecologists, with gynaecologists displaying a tendency towards earlier re-testing than recommended.

CONCLUSIONS

An important factor influencing the follow-up rate may be the sending of reminders in Denmark since 2012, as the follow-up rates in general were higher in this period. It is noteworthy that a reminder system is currently being implemented in Flanders and further studies on the potential effects should be studied. Additionally, the organization of the health system might influence the follow-up rate, as engaging the GP for screening in Denmark may have had a positive effect.

Value of a catch-up HPV test in women aged 65 and above: A Danish population-based nonrandomized intervention study

BACKGROUND

High-risk human papillomavirus (HPV) test is replacing cytology as the primary cervical cancer screening test due to superior sensitivity, but in most countries women ≥65 years have never had an HPV test despite they account for around 50% of cervical cancer deaths. We explored the effect of a catch-up HPV test among 65- to 69-year-old women without previous record of HPV-based screening.

METHODS AND FINDINGS

This population-based nonrandomized intervention study (quasi-experimental design) included Danish women aged 65 to 69 with no record of cervical cancer screening in the last ≥5.5 years and no HPV-exit test at age 60 to 64 at the time of study inclusion. Eligible women residing in the Central Denmark Region were invited for HPV screening either by attending clinician-based sampling or requesting a vaginal self-sampling kit (intervention group, n = 11,192). Women residing in the remaining four Danish regions received standard care which was the opportunity to have a cervical cytology collected for whatever reason (reference group, n = 33,387). Main outcome measures were detection of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) per 1,000 women eligible for the screening offer and the benefit-harm ratio of the intervention and standard practice measured as the number of colposcopies needed to detect one CIN2+ case. The minimum follow-up time was 13 months for all tested women (range: 13 to 25 months). In the intervention group, 6,965 (62.2%) were screened within 12 months from the date of study inclusion and 743 (2.2%) women had a cervical cytology collected in the reference group. The CIN2+ detection was significantly higher in the intervention group (3.9, 95% confidence interval (CI): [2.9, 5.3]; p < 0.001; n = 44/11,192) as compared to the reference group (0.3, 95% CI: [0.2, 0.6]; n = 11/33,387). For the benefit-harm ratio, 11.6 (95% CI: [8.5, 15.8]; p = 0.69; n = 511/44) colposcopies were performed to detect one CIN2+ in the intervention group as compared to 10.1 (95% CI: [5.4, 18.8]; n = 111/11) colposcopies in the reference group. The study design entails a risk of confounding due to the lack of randomization.

CONCLUSIONS

The higher CIN2+ detection per 1,000 eligible women in the intervention group supports that a catch-up HPV test could potentially improve cervical cancer prevention in older women. This study informs the current scientific debate as to whether women aged 65 and above should be offered a catch-up HPV test if they never had an HPV test.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04114968.

Choice of Assessment and Subsequent Risk of Breast Cancer among Women with False-Positive Mammography Screening

Women with false-positive mammography screening results have a two- to four-fold higher risk of breast cancer. This study aimed to investigate if the subsequent risk of breast cancer after a false-positive mammography screening is associated with the received diagnostic assessment. The study population consisted of women who underwent false-positive mammography screening from January 2010 to June 2019. They were categorised into seven groups depending on the elements in the assessment (standard care: additional mammography, ultrasound, and if they had a relevant biopsy). Risks of interval cancer, next-round screen-detected cancer, and long-term breast cancer for non-standard care assessments were compared to standard care assessments using Binomial and Cox regression models. We included 44,279 women with a false-positive result. Invasive assessments that lacked an ultrasound or additional mammography were not more associated with an increased risk of subsequent cancers compared to that of 'all three elements'. The few assessments that included 'only ultrasound' or 'only mammography' resulted in higher relative risks of next-round screen-detected cancer of 1.52 (95% CI: 0.93-2.47) and 1.67 (95% CI: 0.54-5.16), respectively, compared to that of standard care. The increased subsequent risk of breast cancer among women with a previous false-positive result was not found to be correlated with the choice of elements in the assessment process.

Colorectal cancer screening participation among citizens not recommended to be screened: a cohort study

BACKGROUND

Guidelines on colorectal cancer (CRC) screening recommend screening of average-risk adults only. In addition, screening of individuals with active inflammatory bowel disease (IBD) might result in too many false-positive cases. However, the organisers of CRC screening programmes are often uninformed of whom to exclude due to an elevated CRC risk or active IBD. It is therefore unknown how often high-risk individuals (i.e. individuals with a previous diagnosis of CRC or polyps associated with hereditary CRC syndromes and certain patient groups with a diagnosis of inflammatory bowel disease (IBD) or multiple polyps) and individuals with active IBD participate in CRC screening following invitation.

MATERIALS AND METHODS

We used data from the first two years of the Danish CRC screening programme (2014-2015). Information on invitations, participations and FIT test results were obtained from the national screening database, while information on previous CRC, hereditary CRC syndromes, IBD or multiple polyps diagnoses were obtained from the Danish Cancer Registry and the Danish Patient Register. Screening participation rates and FIT-positive rates were calculated and compared for high-risk invitees, invitees having IBD and an average risk group of remaining invitees not diagnosed with colorectal polyps in 10 years preceding the invitation.

RESULTS

When invited to CRC screening, 28-48% of high-risk residents (N: 29; 316; 5584) and 55% of residents with IBD (N: 2217; 6927) chose to participate. The participation rate was significantly higher (67%) among residents without previous colorectal disease, i.e. the average risk group (N = 585,624). In this average group 6.7% of the participants had a positive FIT test. The proportion of positive FIT results was higher among all disease groups (7.7-14.8%), though not statistically significant for participants with prior CRC diagnosis and participants with high-risk IBD.

CONCLUSION

When high-risk residents and residents with IBD receive an invitation to CRC screening, many participate despite being recommended not to. The screening program was not intended for these groups and further research is needed as several of these groups have a higher rate of positive screening result than the average risk population.

Gut inflammation in CVID: causes and consequences

INTRODUCTION

There is a wide spectrum of noninfectious gastrointestinal pathology, causing considerable morbidity and mortality in CVID, where both etiology and effective therapy are under debate.

AREAS COVERED

This review will focus on the noninfectious inflammation in the GI tract in CVID patients, covering the both the upper and lower GI tract inflammation, including the liver. The controversy of the CVID enteropathy definition and that of gluten-free diet for celiac-like disease in CVID will be discussed. Furthermore, the review will cover the link between GI inflammation and GI cancer. Finally, the role of gut microbiota, IgA, and genetics and its relationship with CVID enteropathy is scrutinized. The authors reviewed literature from PubMed.

EXPERT OPINION

The heterogeneity and the unknown mechanism behind CVID enteropathy, and thereby the lack of effective treatment, is one of the key challenges in the field of CVID. Celiac-like disease in CVID is due to immune dysregulation, and a gluten-free diet is therefore not indicated. Gut microbial dysbiosis and mucosal IgA can initiate systemic and local inflammation and is involved in the immune dysregulation in CVID. Considering the heterogeneity of CVID enteropathy, personalized medicine is probably the future for these patients.

Variations in pathways and resource use in follow-up after abnormal mammography screening: a nationwide register-based study

PURPOSE

Mammography screening reduces breast cancer mortality, but a successful screening programme depends on both high participation and a sufficient follow-up of abnormalities. This study investigated patterns of follow-up after abnormal screening mammography in Denmark, and whether the variation was associated with health care resource use.

METHODS

We included 19,458 women aged 50-69 years with an abnormal screening mammography during a 3-year period of 2014-2016. Women were followed until the end of 2018. Their follow-up pathway was categorized in terms of the timeliness, appropriateness (i.e. whether all recommended diagnostic tests were utilized), and the ratio of benign vs. malignant surgeries. Further, we estimated health care resource use including post-diagnostic imaging and surgery procedures.

RESULTS

Ninety-seven percent of women had a diagnostic follow-up test within 6 months and 94% of those had diagnostic procedures in accordance with the recommendations. The proportion with timely follow-up (i.e. within 1 month) was 83%, but varied significantly between administrative regions (p < 0.001), and also between women with a screen-detected cancer and those with a false-positive mammogram (87% vs. 81%, p < 0.001). The ratio between having a benign versus a malignant surgery was 1:8, but it varied depending on which tests were used for diagnosis. The average number of procedures was, generally, in accordance with the recommendations.

CONCLUSION

In most cases, follow-up after abnormal screening mammography followed national recommendations. We nevertheless found that this was not always the case in certain subgroups and administrative regions.

Gaps between recommendations and their implementation: A register-based study of follow-up after abnormalities in cervical cancer screening

Follow-up after screen-detected abnormalities is crucial for the success of cervical cancer screening programs but is usually not closely monitored in official screening statistics. We determined how the follow-up deviated from the recommendations in the Danish organized program. Using Danish nationwide population-based registers, the follow-up pathways of 60,199 women aged 23-59 with non-negative screening samples from 2012 to 2014 were mapped until end of 2018. We studied the timeliness and appropriateness of follow-up tests after cervical cytology screening and the total resource use in accordance with the national recommendations. Regression analyses were used to determine variations in adherence according to age, provider type, region, and history of abnormalities. Among women referred for immediate colposcopy, 91.3% (95% CI: 90.9%-91.6%) attended within four months as recommended, whereas up to about half of the women with a recommendation for a repeat test received this test either too early or very late. Overall, only 43% (95% CI: 42.9%-43.7%) of women with non-negative screening tests received the recommended follow-up, whereas 18% (95% CI: 17.6%-18.2%) received more than was recommended, 35% (95% CI: 34.4%-35.1%) received some follow-up but less than recommended and 4% (95% CI: 3.9%-4.2%) were not followed up at all. These proportions varied by screening diagnosis, woman's age, type of health care provider, region, and history of abnormalities. On average, women underwent more tests of each type than recommended by the guidelines. Deviations from follow-up recommendations are very frequent even in organized cervical screening programs and should be routinely monitored by screening program statistics.

Rifaximin alters gut microbiota profile, but does not affect systemic inflammation - a randomized controlled trial in common variable immunodeficiency

Common variable immunodeficiency (CVID) patients have reduced gut microbial diversity compared to healthy controls. The reduced diversity is associated with gut leakage, increased systemic inflammation and ten "key" bacteria that capture the gut dysbiosis (dysbiosis index) in CVID. Rifaximin is a broad-spectrum non-absorbable antibiotic known to reduce gut leakage (lipopolysaccharides, LPS) in liver disease. In this study, we explored as a 'proof of concept' that altering gut microbial composition could reduce systemic inflammation, using CVID as a disease model. Forty adult CVID patients were randomized, (1:1) to twice-daily oral rifaximin 550 mg versus no treatment for 2 weeks in an open-label, single-centre study. Primary endpoints were reduction in plasma/serum levels of soluble (s) CD14, sCD25, sCD163, neopterin, CRP, TNF, LPS and selected cytokines measured at 0, 2 and 8 weeks. Secondary endpoint was changes in intra-individual bacterial diversity in stool samples. Rifaximin-use did not significantly change any of the inflammation or gut leakage markers, but decreased gut microbial diversity compared with no treatment (p = 0.002). Importantly, the gut bacteria in the CVID dysbiosis index were not changed by rifaximin. The results suggest that modulating gut microbiota by rifaximin is not the chosen intervention to affect systemic inflammation, at least not in CVID.

Altered gut microbiota profile in common variable immunodeficiency associates with levels of lipopolysaccharide and markers of systemic immune activation

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by low immunoglobulin (Ig)G and IgA, and/or IgM. In addition to bacterial infections, a large subgroup has noninfectious inflammatory and autoimmune complications. We performed 16S ribosomal RNA-based profiling of stool samples in 44 CVID patients, 45 patients with inflammatory bowel disease (disease controls), and 263 healthy controls. We measured plasma lipopolysaccharide (LPS) and markers of immune cell activation (i.e., soluble (s) CD14 and sCD25) in an expanded cohort of 104 patients with CVID and in 30 healthy controls. We found a large shift in the microbiota of CVID patients characterized by a reduced within-individual bacterial diversity (alpha diversity, P<0.001) without obvious associations to antibiotics use. Plasma levels of both LPS (P=0.001) and sCD25 (P<0.0001) were elevated in CVID, correlating negatively with alpha diversity and positively with a dysbiosis index calculated from the taxonomic profile. Low alpha diversity and high dysbiosis index, LPS, and immune markers were most pronounced in the subgroup with inflammatory and autoimmune complications. Low level of IgA was associated with decreased alpha diversity, but not independently from sCD25 and LPS. Our findings suggest a link between immunodeficiency, systemic immune activation, LPS, and altered gut microbiota.

Meeting the challenges of wound care in Danish home care

OBJECTIVE

To evaluate a community-based educational intervention to improve wound-care practice, and thereby reduce the costs of care, in four communities in Denmark.

METHOD

Annual wound care audits recorded patients' ages, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and nurse time per dressing change. Data were available at year 1 and year 3 post-intervention. A statistical analysis was performed, testing for changes in a range of variables between these years.

RESULTS

In the post-intervention period, significant reductions were found in the proportion of chronic wounds, the proportion of wounds requiring a daily dressing change, mean frequency of dressing change, mean nurse time spent in wound care per week, and the total cost of wound care per week.

CONCLUSION

These results suggest that it is possible to improve wound-care practice and reduce the resource costs of wound care through a systematic programme of education and training, tailored to suit the needs of local communities.

Activating PI3Kδ mutations in a cohort of 669 patients with primary immunodeficiency

The gene PIK3CD codes for the catalytic subunit of phosphoinositide 3-kinase δ (PI3Kδ), and is expressed solely in leucocytes. Activating mutations of PIK3CD have been described to cause an autosomal dominant immunodeficiency that shares clinical features with common variable immunodeficiency (CVID). We screened a cohort of 669 molecularly undefined primary immunodeficiency patients for five reported mutations (four gain-of-function mutations in PIK3CD and a loss of function mutation in PIK3R1) using pyrosequencing. PIK3CD mutations were identified in three siblings diagnosed with CVID and two sporadic cases with a combined immunodeficiency (CID). The PIK3R1 mutation was not identified in the cohort. Our patients with activated PI3Kδ syndrome (APDS) showed a range of clinical and immunological findings, even within a single family, but shared a reduction in naive T cells. PIK3CD gain of function mutations are more likely to occur in patients with defective B and T cell responses and should be screened for in CVID and CID, but are less likely in patients with a pure B cell/hypogammaglobulinaemia phenotype.