Organized Mammography Screening Research Articles

The “gray zone” in fine-needle aspiration cytology of the organized mammography screening. Cytohistological correlation

The National Public Health Program has established the organized mammography screening in Hungary. The aim of this study was to conduct an audit of “gray zone” smears of the organized mammography screening in comparison with histopathological diagnoses. Methods: Cytology results were rated to C3 atypia probably benign and C4 suspicious of malignancy. Results: 1361 women had aspiration cytology performed from a total of 47,718 mammography non-negative lesions. 105 (7.8%) were diagnosed as C3, whereas 78 (5.7) as C4. Of the 105 patients with C3 diagnosis 61 (58%) patients underwent surgical biopsy. Histology proved malignancy in 20 (32.8%) cases, and benign lesion in 41 (67.2%) cases. All (100%) of the 78 patients with C4 diagnosis had open biopsies; 69 (88.4%) cases were histologically malignant and 9 (11.6%) cases were benign lesions. Conclusion: The auditing results of fine needle aspiration cytology of “gray zone” in organized mammography screening meet the proposed threshold values. Authors conclude that the “gray zone” category in breast cytology is useful and of value if used judiciously. Orv. Hetil., 2011, 152, 292–295.

Das populationsbezogene Mammografie-Screening-Programm in Deutschland: Inanspruchnahme und erste Erfahrungen von Frauen in 10 Bundesländern

Within the statutory health insurance (SHI) cancer early detection programme (KFU) an organised, population-based, quality-assured mammographic screening programme in Germany was initiated for women aged 50-69 years in 2004. The aim of the study was to evaluate uptake and first experiences of participants with this new screening approach and to evaluate the background of knowledge, attitudes and intention to address a needs-assessed communication strategy. A representative, explorative survey within the female population was conducted in 10 federal states. A telephone survey of randomly selected 68,188 contacts was performed, 9,004 women gave informed consent to evaluate rates of invitation and uptake followed by a mailed questionnaire. Of these, 3,469 were returned and 3,226 were analysed. The invitation rate of the programme was 56.6%, the uptake of mammographic screening was 66%, and the screening coverage rate was 37.3%. 90% of the participants were insured by SHI, women with lower socio-economic strata were attracted in accordance with the data of the general population. 61% of all women did not know that the risk of breast cancer increases with age and 56% believed that screening prevents breast cancer. 62.1% judged their own risk to be low. A physician's recommendation to participate was significantly associated with attendance (p<0.05). 90% of the participants would follow the next invitation. The KFU targeted group of women was reached and the organised mammography screening programme was well perceived by invited women. For developing a lasting communication strategy information deficits have to be considered along with beliefs and attitudes of elegible women.

Quality assurance of fine-needle aspiration cytology of the organized mammography screening

The National Public Health Program has established the organized mammography screening in Hungary. The aim of our study was to determine the quality assurance of breast aspiration cytology. Cytology results were rated to 5 categories (C1, C2, C3, C4 and C5). All cytology reports were compared with the final histology diagnosis. 1361 women had aspiration cytology diagnosis performed from a total of 47718 mammography non-negative lesions. There were 805 (59.1%) benign and 187 (13.7%) malignant alterations. Sensitivity was 91%, specificity 88%, positive predictive value 96.6% and negative predictive value turned to be 71% (p<0.001). The auditing values of fine needle aspiration cytology in our laboratory meet, or in certain aspects exceed the proposed minimum threshold values.

The Background Review for the USPSTF Recommendation on Screening for Breast Cancer

Letters20 April 2010The Background Review for the USPSTF Recommendation on Screening for Breast CancerFREEKarsten J. Jørgensen, MD and Peter C. Gøtzsche, DrMedSciKarsten J. Jørgensen, MDFrom The Nordic Cochrane Centre, 2100 Copenhagen, Denmark.Search for more papers by this author and Peter C. Gøtzsche, DrMedSciFrom The Nordic Cochrane Centre, 2100 Copenhagen, Denmark.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-8-201004200-00198 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Nelson and colleagues calculate the reduction in breast cancer mortality on the basis of randomized trials (1) but present no calculations for the most important harm: overdiagnosis. They quote a mixture of observational studies and results from statistical models with unverifiable and doubtful assumptions. Only for the Malmö trial do they quote real data, but these data were obtained 15 years after the trial ended, when many additional cases of cancer had occurred in both groups. When we corrected for this dilution and for the 24% of the women in the control group who were also screened during the trial, we found a 25% overdiagnosis rate (2), rather than the 10% reported by the authors.It is indefensible that Nelson and colleagues base their estimate of overdiagnosis on flawed studies when data from about 600 000 randomly assigned women are available, which we pooled in our Cochrane systematic review in 2009 (3) and before that in 2006 and 2001. We found 31% more lumpectomies and mastectomies. In July, we reported an overdiagnosis rate of 52% in a systematic review of publicly organized mammography screening programs, without using assumptions or statistical modeling (4). It is also curious that Nelson and colleagues do not quote our Cochrane review, as they searched the Cochrane Library.Nelson and colleagues reported that most studies found an overdiagnosis rate between 1% and 10%. However, systematic reviewing is not a consensus conference—it is a scientific discipline—and Nelson and colleagues overlook that the small estimates of overdiagnosis are based on poor science, mostly produced by researchers with vested interests in screening. If one opens one's eyes, unaided by any statistical tricks, one cannot escape seeing a huge amount of overdiagnosis, such as in the United Kingdom (4, 5).The Task Force now recommends against breast screening in women aged 40 to 49 years, but the harms may outweigh the benefits in all age groups. An effect of 15% and an overdiagnosis rate of 30% mean that for every 2000 women invited for screening throughout 10 years, 1 woman will have her life prolonged and 10 healthy women, who would not have breast cancer diagnosed if there had not been screening, will be treated unnecessarily (3). Furthermore, about 1000 women in the United States will have had a false-positive diagnosis (3). The psychological strain until one knows whether it was cancer can be severe. The harms caused by overdiagnosis are lifelong.Karsten J. Jørgensen, MDPeter C. Gøtzsche, DrMedSciThe Nordic Cochrane Centre2100 Copenhagen, Denmark

Breast cancer mortality in organised mammography screening in Denmark: comparative study

Objective To determine whether the previously observed 25% reduction in breast cancer mortality in Copenhagen following the introduction of mammography screening was indeed due to screening, by using an additional...

Trends in the survival of patients diagnosed with breast cancer in the Nordic countries 1964–2003 followed up to the end of 2006

Background. Breast cancer is the leading cancer among women worldwide in terms of both incidence and mortality. European patients have generally high 5-year relative survival ratios, and the Nordic countries, except for Denmark, have ratios among the highest. Material and methods. Based on the NORDCAN database we present trends in age-standardised incidence and mortality rates of invasive breast cancer in the Nordic countries, alongside 5- and 10-year relative survival for the period of diagnosis 1964–2003 followed up to the end of 2006. Excess mortality rates are also provided for varying follow-up intervals after diagnosis. The analysis is confined to invasive breast cancer in Nordic women. Results. Incidence increased rapidly in all five countries, whereas mortality remained almost unchanged. Both incidence and mortality rates were highest in Denmark. Between 1964 and 2003 both 5- and 10-year relative survival increased by 20–30 percentage points in all countries, and 10-year survival remained around 10 percentage points lower than 5-year survival. Relative survival was lowest in Denmark throughout the period, with a 5-year survival of 79% for years 1999–2003, but 83–87% in the other countries. From 1964 the youngest women had the highest survival ratios up until the introduction of screening, when a shift occurred towards higher survival among age groups 50–59 and 60–69 in each country, except for Denmark. Excess death rates during the first months after diagnosis were highest in Denmark. Conclusion. Breast cancer survival is high and rising in the Nordic countries, and probably relates to the early implementation of organised mammography screening in each country except Denmark and a high and relatively uniform standard of living, diagnosis and treatment. Denmark stands out with higher mortality and poorer survival. The major determinants may include a failure to instigate national breast screening and a greater co-morbidity resulting from a higher prevalence of both tobacco smoking and alcohol consumption.

Overdiagnosis in organised mammography screening in Denmark. A comparative study

BackgroundOverdiagnosis in cancer screening is the detection of cancer lesions that would otherwise not have been detected. It is arguably the most important harm. We quantified overdiagnosis in the Danish mammography screening programme, which is uniquely suited for this purpose, as only 20% of the Danish population has been offered organised mammography screening over a long time-period.MethodsWe collected incidence rates of carcinoma in situ and invasive breast cancer in areas with and without screening over 13 years with screening (1991-2003), and 20 years before its introduction (1971-1990). We explored the incidence increase comparing unadjusted incidence rates and used Poisson regression analysis to compensate for the background incidence trend, variation in age distribution and geographical variation in incidence.ResultsFor the screened age group, 50 to 69 years, we found an overdiagnosis of 35% when we compared unadjusted incidence rates for the screened and non-screened areas, but after compensating for a small decline in incidence in older, previously screened women. Our adjusted Poisson regression analysis indicated a relative risk of 1.40 (95% CI: 1.35-1.45) for the whole screening period, and a potential compensatory drop in older women of 0.90 (95% CI: 0.88-0.96), yielding an overdiagnosis of 33%, which we consider the most reliable estimate. The drop in previously screened women was only present in one of the two screened regions and was small in absolute numbers.DiscussionOne in four breast cancers diagnosed in the screened age group in the Danish screening programme is overdiagnosed. Our estimate for Denmark is lower than that for comparable countries, likely because of lower uptake, lower recall rates and lower detection rates of carcinoma in situ.

Is breast cancer overdiagnosed?

Jørgensen and Gøtzsche quantified the degree of overdiagnosis of breast cancer in five publicly organized mammography screening programs in different parts of the world. overall, they estimated a total degree of breast cancer (including carcinoma in situ) overdiagnosis of 52%, while overdiagnosis for invasive breast cancer was 35%, a finding with potential implications for both clinical practice and public health.

Overuse of mammography during the first round of an organized breast cancer screening programme

We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination. A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals. The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0-26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7-5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6-12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months. Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.

Improved breast cancer survival following introduction of an organized mammography screening program among both screened and unscreened women: a population-based cohort study

IntroductionMammography screening reduces breast cancer mortality through earlier diagnosis but may convey further benefit if screening is associated with optimized treatment through multidisciplinary medical care. In Norway, a national mammography screening program was introduced among women aged 50 to 69 years during 1995/6 to 2004. Also during this time, multidisciplinary breast cancer care units were implemented.MethodsWe constructed three cohorts of breast cancer patients: 1) the pre-program group comprising women diagnosed and treated before mammography screening began in their county of residence, 2) the post-program group comprising women diagnosed and treated through multidisciplinary breast cancer care units in their county but before they had been invited to mammography screening; and 3) the screening group comprising women diagnosed and treated after invitation to screening. We calculated Kaplan-Meier plots and multivariable Cox proportional hazard models.ResultsWe studied 41,833 women with breast cancer. The nine-year breast cancer-specific survival rate was 0.66 (95%CI: 0.65 to 0.67) in the pre-program group; 0.72 (95%CI: 0.70 to 0.74) in the post-program group; and 0.84 (95%CI: 0.80 to 0.88) in the screening group. In multivariable analyses, the risk of death from breast cancer was 14% lower in the post-program group than in the pre-program group (hazard ratio 0.86; (95%CI: 0.78 to 0.95, P = 0.003)).ConclusionsAfter nine years follow-up, at least 33% of the improved survival is attributable to improved breast cancer management through multidisciplinary medical care.

Effectiveness of organised versus opportunistic mammography screening

Background: Detailed comparison of effectiveness between organised and opportunistic mammography screening operating in the same country has seldom been carried out.Patients and methods: Prognostic indicators, as defined in the European Guidelines, were used to evaluate screening effectiveness in Switzerland. Matching of screening programmes’ records with population-based cancer registries enabled to compare indicators of effectiveness by screening and detection modality (organised versus opportunistic screening, unscreened, interval cancers). Comparisons of prognostic profile were also drawn with two Swiss regions uncovered by service screening of low and high prevalence of opportunistic screening, respectively.Results: Opportunistic and organised screening yielded overall little difference in prognostic profile. Both screening types led to substantial stage shifting. Breast cancer prognostic indicators were systematically more favourable in Swiss regions covered by a programme. In regions without a screening programme, the higher the prevalence of opportunistic screening, the better was the prognostic profile.Conclusions: Organised screening appeared as effective as opportunistic screening. Mammography screening has strongly influenced the stage distribution of breast cancer in Switzerland, and a favourable impact on mortality is anticipated. Extension of organised mammography screening to the whole of Switzerland can be expected to further improve breast cancer prognosis in a cost-effective way.

Estimation of lead time and overdiagnosis in breast cancer screening

Sir, It is reported that 7 years after the start of screening in Sweden, the incidence of invasive breast cancer in the screened age group was 69% higher than expected (Duffy et al, 2008). After adjustment for a lead time of 2.4 years and for the increased use of hormone replacement therapy, they found 39% excess. We have reservations about adjustments for lead time (Zahl et al, 2008). Correction for lead time should only be done for those cancers that would have been diagnosed at a later time in the absence of screening. But many screen-detected cancers would not have come to the women’s attention in their remaining lifetime, if they had not attended screening and are by definition overdiagnosed. If these cancers are not excluded from the calculation of lead time, the lead-time distribution will be artificially rightskewed, and the average lead time will appear to be much longer than it really is. Duffy et al, (2008) did not exclude such cancers from the calculation of lead time, but counted all excess cancers detected in a randomised trial as advanced diagnoses, when some of them were in fact overdiagnosed cases. They have therefore overestimated the lead-time effect. Duffy et al (2008) recognise that the detection of non-overdiagnosed cancers should give rise to a drop in incidence when the women leave the screening programme. Quantifying such a compensatory drop is a less bias-prone method for adjusting the incidence increase for leadtime effects, as it makes no assumption about the average lead time. It is also very simple to use (see, e.g., Zahl et al, 2004). We have done a systematic review of incidence trends in countries with organised mammography screening that presented data on breast cancer incidence for both screened and nonscreened age groups for at least 7 years before screening and 7 years after screening had been fully implemented (Jorgensen and Gotzsche, 2008). We were able to include data from United Kingdom, Canada, Australia, Sweden and Norway. We found that compensatory drops in the older age groups were small or absent, although major drops would have been expected if the lead time of 2.4 years were true. When we adjusted for these drops, we found 36% overdiagnosis of invasive breast cancer, in good agreement with the results of Duffy et al (2008), and 51% when we included carcinoma in situ. Duffy et al (2008) mention that after prolonged follow-up of the Malmo randomised screening trial, an overdiagnosis of 7–8% was reported and they find this estimate considerably more plausible than their own estimate of 39%. However, they have overlooked that the former estimate is seriously flawed (Zahl et al, 2008). There was substantial opportunistic screening in the control group and after adjustment for this, the overdiagnosis estimate in the Malmo trial is 24% (Gotzsche and Jorgensen, 2006). It is asserted that after adjustments, overdiagnosis estimates will be smaller than many rates quoted in the past (Duffy et al, 2008). We disagree, as most ‘rates quoted in the past’ have been too small (Gotzsche and Nielsen, 2006). On the basis of randomised trials, the overdiagnosis is 30% (Gotzsche and Nielsen, 2006), and it becomes 44% if adjusted for opportunistic screening in the control groups (Jorgensen and Gotzsche, 2008). The low rates in the past have been too low for the very reason that they have been based on flawed lead-time models (Jorgensen and Gotzsche, 2008; Zahl et al, 2008). We believe the most reliable estimate for organised mammography screening is 51% (Jorgensen and Gotzsche, 2008). This means that one in three breast cancers detected in a population offered organised mammography screening are overdiagnosed. Many women are therefore harmed substantially by screening, as practically all detected carcinoma in situ cases and invasive cancers are treated, at great physical and psychological costs.

Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends

Objective To estimate the extent of overdiagnosis (the detection of cancers that will not cause death or symptoms) in publicly organised screening programmes.Design Systematic review of published trends in incidence...

Cost-effectiveness of opportunistic versus organised mammography screening in Switzerland

Background Various centralised mammography screening programmes have shown to reduce breast cancer mortality at reasonable costs. However, mammography screening is not necessarily cost-effective in every situation. Opportunistic screening, the predominant screening modality in several European countries, may under certain circumstances be a cost-effective alternative. In this study, we compared the cost-effectiveness of both screening modalities in Switzerland. Methods Using micro-simulation modelling, we predicted the effects and costs of biennial mammography screening for 50–69 years old women between 1999 and 2020, in the Swiss female population aged 30–70 in 1999. A sensitivity analysis on the test sensitivity of opportunistic screening was performed. Results Organised mammography screening with an 80% participation rate yielded a breast cancer mortality reduction of 13%. Twenty years after the start of screening, the predicted annual breast cancer mortality was 25% lower than in a situation without screening. The 3% discounted cost-effectiveness ratio of organised mammography screening was €11,512 per life year gained. Opportunistic screening with a similar participation rate was comparably effective, but at twice the costs: €22,671–24,707 per life year gained. This was mainly related to the high costs of opportunistic mammography and frequent use of imaging diagnostics in combination with an opportunistic mammogram. Conclusion Although data on the performance of opportunistic screening are limited, both opportunistic and organised mammography screening seem effective in reducing breast cancer mortality in Switzerland. However, for opportunistic screening to become equally cost-effective as organised screening, costs and use of additional diagnostics should be reduced.

The Science Is Needed

HomeRadiologyVol. 249, No. 2 PreviousNext CommunicationsLetters to the EditorThe Science Is NeededDaniel B. KopansDaniel B. KopansAuthor AffiliationsDepartment of Radiology, Massachusetts General Hospital, Ambulatory Care Building, Suite 219, 15 Parkman St, Boston, MA 02114e-mail: [email protected]Daniel B. KopansPublished Online:Nov 1 2008https://doi.org/10.1148/radiol.2492080904MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Hall FM. The rise and impending decline of screening mammography. Radiology 2008;247(3):597–601. Link, Google Scholar2 Kopans DB, Monsees B, Feig SA. Screening for cancer: when is it valid? lessons from the mammography experience. Radiology 2003;229:319–327. Google Scholar3 Duffy SW, Tabar L, Chen H, et al. The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties. Cancer 2002;95:458–469. Crossref, Medline, Google Scholar4 Otto SJ, Fracheboud J, Looman CW, et al. Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet 2003;361:1411–1417. Crossref, Medline, Google Scholar5 Kopans DB. Beyond randomized, controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2002;94:580–581. Crossref, Medline, Google Scholar6 Tabar L, Vitak B, Tony HH, Yen MF, Duffy SW, Smith RA. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality. Cancer 2001;91:1724–1731. Crossref, Medline, Google Scholar7 Slanetz PJ, Edminster WB, Yeh ED, Talele AC, Kopans DB. Occult contralateral breast carcinoma incidentally detected by breast magnetic resonance imaging. Breast J 2002;8:145–148. Crossref, Medline, Google Scholar8 Kopans DB. Beyond routine screening: the elephants in the closet. Presented at the seventh postgraduate course of the Society of Breast Imaging, Vancouver, British Columbia, May 25, 2005. Google Scholar9 Kopans DB, Rafferty E, Georgian-Smith D, et al. A simple model of breast cancer growth may provide explanations for observations of apparently complex phenomena. Cancer 2003;97:2951–2959. Crossref, Medline, Google ScholarArticle HistoryPublished in print: 2008 FiguresReferencesRelatedDetailsRecommended Articles Comparative Benefit-to–Radiation Risk Ratio of Molecular Breast Imaging, Two-Dimensional Full-Field Digital Mammography with and without Tomosynthesis, and Synthetic Mammography with TomosynthesisRadiology: Imaging Cancer2019Volume: 1Issue: 1Tomosynthesis Is Taking Small Steps to Become the Standard for Breast Cancer ScreeningRadiology2021Volume: 299Issue: 3pp. 568-570Robert McLelland, MDRadiology2017Volume: 285Issue: 3pp. 1066MRI to Detect Contralateral Breast Cancer in Patients with Newly Diagnosed Breast Cancer: An Increase in Overall Survival to Be ConfirmedRadiology2022Volume: 304Issue: 2pp. 308-309Background Parenchymal Enhancement at Postoperative Surveillance Breast MRI: Association with Future Second Breast Cancer RiskRadiology2022Volume: 0Issue: 0See More RSNA Education Exhibits Breast Density Issues and Impacts on Mammography ScreeningDigital Posters2018Let’s Talk about Next-Generation Breast Cancer Screening Programs: How Should We Do? What Should We Use?Digital Posters2020Non-Contrast-Enhanced Breast MR Screening for Women with Dense BreastsDigital Posters2019 RSNA Case Collection Malignancy on abbreviated screening breast MRIRSNA Case Collection2020Asymmetric lactational change RSNA Case Collection2021Locally Advanced Breast CancerRSNA Case Collection2021 Vol. 249, No. 2 Metrics Downloaded 64 times Altmetric Score PDF download

Molecular Subtypes of Breast Cancers Detected in Mammography Screening and Outside of Screening

The frequency and significance of gene expression profile-derived molecular subtypes of breast cancers found in mammography screening are unknown. We identified breast cancers diagnosed in women of any age living in defined geographic regions in Finland in 1991 to 1992 and collected clinical and pathologic data. Surrogates for the molecular subtypes were determined for 247 cancers found in organized mammography screening and 989 cancers detected outside of screening using immunohistochemistry or in situ hybridization. Molecular subtypes were defined as luminal A [estrogen receptor (ER) positive and/or progesterone receptor (PR) positive, HER2-], luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-, cytokeratin 5+, and/or HER1+), HER2+/ER- (ER-, PR-, and HER2+), and unclassified. The median follow-up time was 9.4 years. The luminal type A was common (73.7%) and the HER2+/ER- type is rare (5.7%) in screen-detected cancer, and only 16% were HER2 positive. Women with cancer diagnosed in screening at ages 50 to 69 years had similar molecular subtype distribution as women whose cancer was found outside of screening at age >69 years. In a multivariate model, cancer detection at screening independently predicted favorable distant disease-free survival when the molecular subtype was included as a covariate in addition to age, histologic grade, and cancer size. Women with small (pT(1)N(0)M(0)) HER2-positive cancer had similar outcome regardless of the method of detection. Molecular subtype distribution of screen-detected breast cancer differs from that of cancers found outside of screening and accounts in part for the better outcome of screen-detected cancer.

Does educational level determine screening participation?

The objective of this study was to test the hypothesis that nonparticipation in organized mammography screening is due to insufficient understanding of the information in the invitation letter by relating educational level to user pattern. Data from two Danish mammography screening programmes in Copenhagen, 1991-1999, and Funen, 1993-2001 were taken for this study. The Danish Central Population Register was used to define target groups; screened participation data were provided by the health authority, and data on highest obtained education came from Statistics Denmark. Data on all breast imaging in 2000 outside organized screening were provided by radiology clinics. Included were all women eligible for at least three screens, and participation was classified into four mutually exclusive user groups. Organized mammography screening programmes in Copenhagen and Funen, Denmark were used as field of this study. Main outcome measures were age-adjusted relative risks (RR) and 95% confidence intervals (CI) of 'never use' versus 'always use' of screening by educational level, using women with secretarial/sales education as baseline. The RR of 'never use' was 1.65 (95% CI: 1.37-1.99) in Copenhagen and 1.93 (95% CI: 1.42-2.62) in Funen for academics, 1.60 (95% CI: 1.48-1.73) in Copenhagen and 1.26 (95% CI: 1.14-1.39) Funen for women with lower primary educational level. Taking other breast imaging into account, the RR was 1.60 (95% CI: 1.32-1.95) for academics in Copenhagen, and 1.90 (95% CI: 1.75-2.07) for women with lower primary education. In conclusion, our results did not support the hypothesis that lack of understanding the information in the invitation letter explains nonparticipation. 'Never use' was not inversely associated with the level of education, but showed a U-shaped association, even when use of breast imaging outside organized screening was taken into account.

Workflow in der digitalen Screeningmammographie

The overriding goal of an organized mammography screening program is to offer high level medical care to everyone at a justifiable cost. The following overview will demonstrate how both aspects of screening, quality and cost efficiency, are supported by a fully digital workflow. Digital mammography systems allow for a constant high image quality and repeat examinations due to overexposure or underexposure can be avoided. Dedicated mammography screening workstations with integration of image viewing and reporting enable efficient softcopy reading. Many aspects of the screening workflow, such as double reading, archiving and retrieval of stored films, as well as information exchange between members of the certified team of the screening unit and other physicians involved in the further treatment, are made significantly easier by the presence of image data in digital form.

Benefit and risk of mammography screening: considerations from an epidemiological viewpoint.

An organized mammography screening program is being implemented in Germany since the end of 2005. Even before its inception, a heated debate surrounded the question of how to communicate its rationale appropriately. Selective literature review identifying facts relevant to informing decision making about mammography attendance. Decision making about individual attendance for mammography screening is crucially dependent on the reduction of risk of death from breast cancer for a diseased woman. This can be communicated in the following way: out of 100 women with a diagnosis of breast cancer 31 will die within the following 10 years without screening and 20 with screening (35% fewer). The actuarial concept of risk is defined by the probability of the undesired event multiplied by the expected magnitude of loss. This approach appears more appropriate for the appraisal of risk in the context of mammography screening than a pure event probability. It could help understand why women attend screening even if they perceive the risk of getting breast cancer as low--namely, that they rank the consequences of getting the disease as highly significant for themselves and others in their social environment.

Organised mammography screening reduces breast cancer mortality: A cohort study from Finland

We evaluated the effectiveness and the efficacy of population-based mammography programme in Finland, and explored associations between the screening performance and the screening efficacy. The main outcome, incidence-based mortality from breast cancer, was estimated by invitation, participation, age at death, and screening centres categorised by recall rates. The study was based on an individual followup of screening invitees and participants from 1992 to 2003. The coverage of screening invitations was 95% among 50-59 years old women, and 20-40% among women aged 60-69 years. We compared observed deaths from breast cancer to expected breast cancer deaths without screening in ages 50-69 at death. The observed deaths were obtained from a cohort of individual invitees (n = 361,848). The expected deaths were defined by modelling breast cancer mortality from 1974 to 1985 and 1992 to 2003 at population level. The population data were derived from the same municipalities (n = 260) that were incorporated into the cohort. The breast cancer mortality among the invited women was reduced by 22% (relative risk 0.78, 95% confidence interval 0.70-0.87). After adjusting for the self-selection, the efficacy among the participants was 28% (0.72,0.56-0.88). No clear association between the recall rates and the screening efficacy was observed. The organised mammography screening in Finland is effective. The relationship between the estimates of process and outcome of mammography is not yet straightforward: effectiveness and efficacy remain the best estimates for evaluating the success of mammography screening.