Ensuring Epidemiological Consistency in Risk-Stratified Cancer Screening Models: A Novel Approach Based on Flemish Breast Cancer Screening.

Risk-stratified breast cancer screening has been proposed as an alternative to age-based screening programs, though its implementation may face challenges and requires support from stakeholders, particularly women. This study used structural equation modeling (SEM) to identify personal factors influencing women's attitudes, comfort level, and willingness towards risk-stratified screening. Factors analyzed included sociodemographic variables, general health, breast cancer risk perception, screening, and genetic testing history. Three models were tested to assess the direct and indirect effects of statistically significant factors. None of the outcomes were significantly associated with women's perceived health or history of genetic testing (all p > 0.05). A history of mammography was found to mediate the relationships between age, perceived risk, and personal breast cancer history with the outcomes. Income also mediated the relationships between education, employment, marital status, and the outcomes. A history of mammography and higher income were significantly associated with more favorable attitudes (β_mammo = 0.157; β_income = 0.098), greater comfort (β_mammo = 0.425; β_income = 0.134), and higher willingness (β_mammo = 0.471; β_income = 0.198) towards risk-stratified screening. In contrast, non-white ethnicity and older age were linked to less favorable attitudes (β_ethnicity = - 0.117; β_age = - 0.071), lower comfort (β_ethnicity = - 0.104; β_age = - 0.269), and decreased willingness (β_ethnicity = - 0.142; β_age = - 0.295). This study identified key factors influencing the acceptability of risk-stratified breast cancer screening that could be targeted to facilitate its implementation.

Given the controversy over the effectiveness of age-based breast cancer (BC) screening, offering risk-stratified screening to women may be a way to improve patient outcomes with detection of earlier-stage disease. While this approach seems promising, its integration requires the buy-in of many stakeholders. In this cross-sectional study, we surveyed Canadian healthcare professionals about their views and attitudes toward a risk-stratified BC screening approach. An anonymous online questionnaire was disseminated through Canadian healthcare professional associations between November 2020 and May 2021. Information collected included attitudes toward BC screening recommendations based on individual risk, comfort and perceived readiness related to the possible implementation of this approach. Close to 90% of the 593 respondents agreed with increased frequency and earlier initiation of BC screening for women at high risk. However, only 9% agreed with the idea of not offering BC screening to women at very low risk. Respondents indicated that primary care physicians and nurse practitioners should play a leading role in the risk-stratified BC screening approach. This survey identifies health services and policy enhancements that would be needed to support future implementation of a risk-stratified BC screening approach in healthcare systems in Canada and other countries.

BackgroundAdvances in genetic technologies are expected to make population-wide genetic testing feasible. This could provide a basis for risk stratified cancer screening; but acceptability in the target populations has not been explored.MethodsWe assessed attitudes to risk-stratified ovarian cancer (OC) screening based on prior genetic risk assessment using a survey design. Home-based interviews were carried out by the UK Office of National Statistics in a population-based sample of 1095 women aged 18–74. Demographic and personal correlates of attitudes to risk-stratified OC screening based on prior genetic risk assessment were determined using univariate analyses and adjusted logistic regression models.ResultsFull data on the key analytic questions were available for 829 respondents (mean age 46 years; 27 % ‘university educated’; 93 % ‘White’). Relatively few respondents felt they were at ‘higher’ or ‘much higher’ risk of OC than other women of their age group (7.4 %, n = 61). Most women (85 %) said they would ‘probably’ or ‘definitely’ take up OC genetic testing; which increased to 88 % if the test also informed about breast cancer risk. Almost all women (92 %) thought they would ‘probably’ or ‘definitely’ participate in risk-stratified OC screening. In multivariate logistic regression models, university level education was associated with lower anticipated uptake of genetic testing (p = 0.009), but with more positive attitudes toward risk-stratified screening (p <0.001). Perceived risk was not significantly associated with any of the outcome variables.ConclusionsThese findings give confidence in taking forward research on integration of novel genomic technologies into mainstream healthcare.

Breast cancer is the commonest cancer among Malaysian women. Current clinical practice guidelines (CPG) by the Ministry of Health, Malaysia comprise recommendations based on a risk stratification approach. This paper reviewed and reflected on the challenges and uncertainties that needed to be considered regarding the implementation and delivery of risk-stratified breast cancer screening in Malaysia. Our iterative writing, discussions and reflections revolved around the results of key relevant literature search from the Ministry of Health Malaysia website, PubMed, and Google Scholar, and on feedback from local clinical experts in the field of breast cancer screening practice. The articles related to risk-stratified breast cancer screening, genetic testing, screening guidelines for the Malaysia population, and articles published in English were included in this narrative review. Further infrastructure and workforce capacity building is needed in order to achieve successful wider implementation e.g.; genetic counselling and testing services are limited in Malaysia. Furthermore, there is a need to elicit Malaysian women's views and evaluate their acceptance of risk-stratified breast cancer screening. The primary healthcare setting is an obvious potential avenue to introduce and deliver initial risk assessment and stratification. However, the workload and willingness of Malaysian primary healthcare doctors to practice risk-stratified screening is yet to be explored to have a better understanding on their perspective. Identifying a valid and appropriate risk model tailored to the population profile and needs of Malaysian women and conducting a pilot project of risk-stratified screening, guided by implementation science would provide lessons and insights for policymakers, health service managers, and public and primary health care professionals. The results of these activities would increase the likelihood that decisions and plans would lead to the successful implementation in Malaysia of a sustainable and effective breast cancer screening strategy that incorporates a patient-sensitive, risk-stratified approach.

The age-based or "one-size-fits-all" breast screening approach does not take into account the individual variation in risk. Mammography screening reduces death from breast cancer at the cost of overdiagnosis. Identifying risk-stratified screening strategies with a more favorable ratio of overdiagnoses to breast cancer deaths prevented would improve the quality of life of women and save resources. To assess the benefit-to-harm ratio and the cost-effectiveness of risk-stratified breast screening programs compared with a standard age-based screening program and no screening. A life-table model was created of a hypothetical cohort of 364 500 women in the United Kingdom, aged 50 years, with follow-up to age 85 years, using (1) findings of the Independent UK Panel on Breast Cancer Screening and (2) risk distribution based on polygenic risk profile. The analysis was undertaken from the National Health Service perspective. The modeled interventions were (1) no screening, (2) age-based screening (mammography screening every 3 years from age 50 to 69 years), and (3) risk-stratified screening (a proportion of women aged 50 years with a risk score greater than a threshold risk were offered screening every 3 years until age 69 years) considering each percentile of the risk distribution. All analyses took place between July 2016 and September 2017. Overdiagnoses, breast cancer deaths averted, quality-adjusted life-years (QALYs) gained, costs in British pounds, and net monetary benefit (NMB). Probabilistic sensitivity analyses were used to assess uncertainty around parameter estimates. Future costs and benefits were discounted at 3.5% per year. The risk-stratified analysis of this life-table model included a hypothetical cohort of 364 500 women followed up from age 50 to 85 years. As the risk threshold was lowered, the incremental cost of the program increased linearly, compared with no screening, with no additional QALYs gained below 35th percentile risk threshold. Of the 3 screening scenarios, the risk-stratified scenario with risk threshold at the 70th percentile had the highest NMB, at a willingness to pay of £20 000 (US $26 800) per QALY gained, with a 72% probability of being cost-effective. Compared with age-based screening, risk-stratified screening at the 32nd percentile vs 70th percentile risk threshold would cost £20 066 (US $26 888) vs £537 985 (US $720 900) less, would have 26.7% vs 71.4% fewer overdiagnoses, and would avert 2.9% vs 9.6% fewer breast cancer deaths, respectively. Not offering breast cancer screening to women at lower risk could improve the cost-effectiveness of the screening program, reduce overdiagnosis, and maintain the benefits of screening.

BackgroundRisk-stratified breast screening has gained international attention, as individualized risk assessments can inform screening initiation, frequency, and whether to screen. In this study, we evaluated the cost-effectiveness of risk-stratified screening based on genetic testing for breast cancer-associated single nucleotide polymorphisms (SNPs) compared to the current age-based screening program in Taiwan.MethodsA Markov model was used to estimate lifetime health outcomes and costs for 35-year-old Taiwanese women without a family history of breast cancer. The model adopted the healthcare payer's perspective, applied a 3 % annual discount rate, and utilized epidemiological and cost data primarily derived from Taiwanese sources whenever possible. Scenario analyses included various percentile thresholds used to define polygenic risk groups in the risk-stratified screening strategy. Within this strategy, no screening was modeled for women in the low-risk group, while those in the intermediate- and high-risk groups were offered standard biennial mammography, beginning at ages 40 and 35, respectively, and continuing until 69.ResultsCompared to the current age-based mammogram-only screening, polygenic risk scores (PRS)-informed risk-stratified breast cancer screening generated additional costs and quality-adjusted life years (QALYs), with an incremental cost-effectiveness ratio (ICER) of US$75.71/QALY. Scenario analyses using different PRS cutoffs consistently yielded ICERs well below one time Taiwan's gross domestic product per capita per QALY, suggesting cost-effectiveness of genetic risk-stratified screening.ConclusionIncorporating polygenic risk into the current breast cancer screening program may improve health outcomes at an acceptable cost. These findings support implementing risk-stratified screening in future policy.

Objectives:To reveal the number of cancer screenings in primary care during the pandemic period and whether there is a change in screening compared to the pre-pandemic period.Methods:This record-based descriptive study was carried out by evaluating the number of people who applied to family health centers or cancer early diagnosis, screening, and education center (KETEM) units for cancer screening (breast, cervical, and colorectal) for any reason. The study data were scanned between January 2017 and December 2020 and were obtained from the Gaziantep Provincial Health Directorate Cancer Branch.Results:Breast cancer screening was the highest in December 2019 (n=2971), cervical cancer screening was the highest in October 2019 (n=4693), and colon cancer screening was the highest in September 2019 (n=2464). Breast cancer screening was the lowest in August 2020 (n=0), cervical cancer screening was the lowest in May 2020 (n=6), and colon cancer screening was the lowest in February and March 2018. Although the target populations and percentages in breast cancer, cervical cancer and colon cancer screenings increased with the following years, the screening populations and percentages decreased in 2020 compared to other years (percentages, 4.4%, 6.2%, 1.9%).Conclusion:For cancers that can be prevented by early diagnosis, it is of great importance to increase cancer screenings, which have decreased with the pandemic, to the required level.

What effect does mammographic breast density have on lesion detection in digital mammography?

Cancer Screening During the Coronavirus Disease-2019 Pandemic: A Perspective From the National Cancer Institute’s PROSPR Consortium

Socioeconomic inequalities in breast and thyroid cancer screening in Korea: A nationwide cross-sectional study

A polygenic risk score (PRS) quantifies the aggregated effects of common genetic variants in an individual. A 'personalised breast cancer risk assessment' combines PRS with other genetic and non-genetic risk factors to offer risk-stratified screening and interventions. Large-scale studies are evaluating the clinical utility and feasibility of implementing risk-stratified screening; however, GPs' views remain largely unknown. To explore GPs' knowledge of PRS and risk-stratified screening, attitudes towards risk-stratified screening, and preferences for continuing professional development. Cross-sectional online survey of UK GPs, July-August 2022, distributed by the Royal College of General Practitioners and via other mailing lists and social media. In total, 109 GPs completed the survey; 49% were not familiar with the concept of PRS. Regarding risk-stratified screening pathways, 75% agreed with earlier and more frequent screening for women at high risk; 43% neither agreed nor disagreed with later and less screening for women at lower-than-average risk; and 55% disagreed with completely removing screening for women at much lower risk. Eighty-one percent felt positive about the potential impact of risk-stratified screening towards patients; 62% felt positive about the potential impact on their practice. GPs selected training of healthcare professionals as the priority for future risk-stratified screening implementation, preferring online formats for learning. The results suggest limited knowledge of PRS and risk-stratified screening among GPs. Training - preferably using online learning formats - was identified as the top priority for future implementation. GPs felt positive about the potential impact of risk-stratified screening; however, there was hesitance and disagreement towards a low-risk screening pathway.

Mammography for Older Women?

A polygenic risk score (PRS) quantifies the aggregated effects of common genetic variants in an individual. A ‘personalised breast cancer risk assessment’ combines PRS with other genetic and nongenetic risk factors to offer risk-stratified screening and interventions. Large-scale studies are evaluating the clinical utility and feasibility of implementing risk-stratified screening; however, General Practitioners’ (GPs) views remain largely unknown. This study aimed to explore GPs’: (i) knowledge of risk-stratified screening; (ii) attitudes towards risk-stratified screening; and (iii) preferences for continuing professional development. A cross-sectional online survey of UK GPs was conducted between July–August 2022. The survey was distributed by the Royal College of General Practitioners and via other mailing lists and social media. In total, 109 GPs completed the survey; 49% were not familiar with the concept of PRS. Regarding risk-stratified screening pathways, 75% agreed with earlier and more frequent screening for women at high risk, 43% neither agreed nor disagreed with later and less screening for women at lower-than-average risk, and 55% disagreed with completely removing screening for women at much lower risk. In total, 81% felt positive about the potential impact of risk-stratified screening towards patients and 62% felt positive about the potential impact on their practice. GPs selected training of healthcare professionals as the priority for future risk-stratified screening implementation, preferring online formats for learning. The results suggest limited knowledge of PRS and risk-stratified screening amongst GPs. Training—preferably using online learning formats—was identified as the top priority for future implementation. GPs felt positive about the potential impact of risk-stratified screening; however, there was hesitance and disagreement towards a low-risk screening pathway.

BackgroundInequalities in uptake of cancer screening by ethnic minority populations are well documented in a number of international studies. However, most studies to date have explored screening uptake for a single cancer only. This paper compares breast and bowel cancer screening uptake for a cohort of South Asian women invited to undertake both, and similarly investigates these women's breast cancer screening behaviour over a period of fifteen years.MethodsScreening data for rounds 1, 2 and 5 (1989-2004) of the NHS breast cancer screening programme and for round 1 of the NHS bowel screening pilot (2000-2002) were obtained for women aged 50-69 resident in the English bowel screening pilot site, Coventry and Warwickshire, who had been invited to undertake breast and bowel cancer screening in the period 2000-2002. Breast and bowel cancer screening uptake levels were calculated and compared using the chi-squared test.Results72,566 women were invited to breast and bowel cancer screening after exclusions. Of these, 3,539 were South Asian and 69,027 non-Asian; 18,730 had been invited to mammography over the previous fifteen years (rounds 1 to 5). South Asian women were significantly less likely to undertake both breast and bowel cancer screening; 29.9% (n = 1,057) compared to 59.4% (n = 40,969) for non-Asians (p < 0.001). Women in both groups who consistently chose to undertake breast cancer screening in rounds 1, 2 and 5 were more likely to complete round 1 bowel cancer screening. However, the likelihood of completion of bowel cancer screening was still significantly lower for South Asians; 49.5% vs. 82.3% for non-Asians, p < 0.001. South Asian women who undertook breast cancer screening in only one round were no more likely to complete bowel cancer screening than those who decided against breast cancer screening in all three rounds. In contrast, similar women in the non-Asian population had an increased likelihood of completing the new bowel cancer screening test. The likelihood of continued uptake of mammography after undertaking screening in round 1 differed between South Asian religio-linguistic groups. Noticeably, women in the Muslim population were less likely to continue to participate in mammography than those in other South Asian groups.ConclusionsCulturally appropriate targeted interventions are required to reduce observed disparities in cancer screening uptakes.

The total coverage of both the Flemish breast cancer and cervical screening program remain suboptimal, with approximately 63% for both. Of all the women invited to the breast cancer screening program, 14.1% never underwent any type of breast cancer screening (any type of mammogram, ultrasound, or clinical breast examination). For the cervical cancer screening, this proportion of 'never-screeners' is 12.1%. We conducted two randomized controlled trials to assess whether various communication and presentation styles in the invitation package, were effective at motivating women who had never participated to attend. The study population was limited to never-screeners (women who had never participated in the screening program). The RCT embedded in the breast cancer screening consisted of seven intervention arms and one control arm (all of them included a fixed appointment by letter). The RCT embedded in the cervical cancer screening consisted of three intervention arms and two control arms. In both RCTs, several content and style adaptations were made to the invitation letter, information leaflet, and envelope. None of the intervention arms in either the breast cancer screening or the cervical cancer screening had a statistically significant impact on the participation rate compared to 'usual care' (the regular invitation package used in the screening program). Sending adapted invitation packages to never-screeners, from the Flemish breast and cervical cancer screening program, does not seem to be effective in increasing the proportion of women screened. Innovative methods are needed to motivate never-screeners to be screened.