Population-based Breast Cancer Screening Program Research Articles

Differences in breast cancer risk after benign breast disease by type of screening diagnosis

IntroductionWe aimed to assess differences in breast cancer risk across benign breast disease diagnosed at prevalent or incident screens. Materials and methodsWe conducted a retrospective cohort study with data from 629,087 women participating in a long-standing population-based breast cancer screening program in Spain. Each benign breast disease was classified as non-proliferative, proliferative without atypia, or proliferative with atypia, and whether it was diagnosed in a prevalent or incident screen. We used partly conditional Cox hazard regression to estimate the adjusted hazard ratios of the risk of breast cancer. ResultsCompared with women without benign breast disease, the risk of breast cancer was significantly higher (p-value = 0.005) in women with benign breast disease diagnosed in an incident screen (aHR, 2.67; 95%CI: 2.24–3.19) than in those with benign breast disease diagnosed in a prevalent screen (aHR, 1.87; 95%CI: 1.57–2.24). The highest risk was found in women with a proliferative benign breast disease with atypia (aHR, 4.35; 95%CI: 2.09–9.08, and 3.35; 95%CI: 1.51–7.40 for those diagnosed at incident and prevalent screens, respectively), while the lowest was found in women with non-proliferative benign breast disease (aHR, 2.39; 95%CI: 1.95–2.93, and 1.63; 95%CI: 1.32–2.02 for those diagnosed at incident and prevalent screens, respectively). ConclusionOur study showed that the risk of breast cancer conferred by a benign breast disease differed according to type of screen (prevalent or incident). To our knowledge, this is the first study to analyse the impact of the screening type on benign breast disease prognosis.

Time of day and mammographic reader performance in a population-based breast cancer screening programme.

To analyse how reader performance varied by time during the day in a population-based breast cancer screening programme. A total of 2,937,312 readings from 148 radiologists and 1,468,656 women were included in this study from Norway. Number and percentages of mammographic readings, positive scores, true and false positive readings, true and false negative readings, sensitivity and specificity were presented for categories of time of day and for each day of the week. Multilevel mixed effect logistic regression models with restricted cubic splines were fitted to the data, and used to predict the odds ratio of the different performance measures. The following distribution was found for the performance measures during the study period: true positive: 12,463 (0.4%); false positive: 128,419 (4.4%); true negative: 2,794,636 (95.1%); and false negative: 1794 (0.06%). The percentage of positive readings (true positive and false positive) was highest before lunch and in the early afternoon (4.9%): false positive was highest in both periods (4.5%) and true positive was highest in the early afternoon (0.5%). The percentage of true negative was highest in the evening (95.6%), and of false negative was highest at lunchtime (0.07%). This corresponds to a gradually decreasing predicted sensitivity throughout the day. The opposite was observed for specificity. Screen-reading early versus late during the day resulted in higher sensitivity, although at the cost of specificity. Despite small differences in the performance measures during the day, the results may be important in the discussion of optimal management of screening programmes.

Estimation of the risk of lung cancer in women participating in a population-based breast cancer screening program

IntroductionLung cancer mortality is increasing in women. In Spain, estimates suggest that lung cancer mortality may soon surpass breast cancer mortality, the main cause of cancer mortality among women. The aim of this study was to estimate the proportion of women at high risk of developing lung cancer in a group of participants in a population-based breast cancer screening program. MethodsCross-sectional study in a sample of women who participated in a population-based breast cancer screening program in 2016 in Hospitalet de Llobregat n = 1,601. High risk of lung cancer was defined according to the inclusion criteria of the National Lung Screening Trial (NLST) and the Dutch-Belgian randomized lung cancer screening trial (NELSON). ResultsAround 20% of smokers according to NLST and 40% of smokers according to NELSON criteria, and around 20% of former smokers according to both criteria, are at high risk of developing lung cancer. A positive and statistically significant trend is observed between the proportion of women at high risk and nicotine dependence measured with the brief Fagerström Test. ConclusionsA high proportion of participants in this breast cancer screening program have a high risk of developing lung cancer and would be eligible to participate in a lung cancer screening program. Population-based breast cancer screening programs may be useful to implement lung cancer primary prevention activities.

Readmissions and complications in breast ductal carcinoma in situ: A retrospective study comparing screen- and non-screen-detected patients.

Objective:Population-wide mammographic screening programs aim to reduce breast cancer mortality. However, a broad view of the harms and benefits of these programs is necessary to favor informed decisions, especially in the earliest stages of the disease. Here, we compare the outcomes of patients diagnosed with breast ductal carcinoma in situ in participants and non-participants of a population-based mammographic screening program.Methods:A retrospective cohort study of all patients diagnosed with breast ductal carcinoma in situ between 2000 and 2010 within a single hospital. A total of 211 patients were included, and the median follow-up was 8.4 years. The effect of detection mode (screen-detected and non-screen-detected) on breast cancer recurrences, readmissions, and complications was evaluated through multivariate logistic regression analysis.Results:In the majority of women, breast ductal carcinoma in situ was screen-detected (63.5%). Screen-detected breast ductal carcinoma in situ was smaller in size compared to those non-screen-detected (57.53% < 20 mm versus 78.03%, p = 0.002). Overall, breast-conserving surgery was the most frequent surgery (86.26%); however, mastectomy was higher in non-screen-detected breast ductal carcinoma in situ (20.78% versus 9.7%, p = 0.024). Readmissions for mastectomy were more frequent in non-screen-detected breast ductal carcinoma in situ. Psychological complications, such as fatigue, anxiety, and depression, had a prevalence of 15% within our cohort. Risk of readmissions and complications was higher within the non-screen-detected group, as evidenced by an odds ratio = 6.25 (95% confidence interval = 1.95–19.99) for readmissions and an odds ratio = 2.41 (95% confidence interval = 1.95–4.86) for complications.Conclusions:Our findings indicate that women with breast ductal carcinoma in situ breast cancer diagnosed through population-based breast cancer screening program experience a lower risk of readmissions and complications than those diagnosed outside these programs. These findings can help aid women and health professionals make informed decisions regarding screening.

Estimación del riesgo de cáncer de pulmón en mujeres que participan en un programa de cribado poblacional de cáncer de mama

IntroductionLung cancer mortality is increasing in women. In Spain, estimates suggest that lung cancer mortality may soon surpass breast cancer mortality, the main cause of cancer mortality among women. The aim of this study was to estimate the proportion of women at high risk of developing lung cancer in a group of participants in a population-based breast cancer screening program. MethodsCross-sectional study in a sample of women who participated in a population-based breast cancer screening program in 2016 in Hospitalet de Llobregat (n=1,601). High risk of lung cancer was defined according to the criteria of the National Lung Screening Trial (NLST) and the Dutch-Belgian randomized lung cancer screening trial (NELSON). ResultsAround 20% of smokers according to NLST criteria and 40% of smokers according to NELSON criteria, and around 20% of former smokers according to both criteria, are at high risk of developing lung cancer. A positive and statistically significant trend is observed between the proportion of women at high risk and nicotine dependence measured with the brief Fagerström test. ConclusionsA high proportion of participants in this breast cancer screening program have a high risk of developing lung cancer and would be eligible to participate in a lung cancer screening program. Population-based breast cancer screening programs may be useful to implement lung cancer primary prevention activities.

Communication Channels Used by Women to Contact a Population-Based Breast Cancer Screening Program in Catalonia, Spain.

Communication is a corner stone of population-based breast cancer screening programs that need to invite all the women from their target population and provide them with balanced information on screening to guaranty informed participation. Invited women also need to be able to contact screening programs to get further information on screening procedures and/or cancel and reschedule appointments. This study describes the communication channels used by women invited for breast cancer screening to contact the program. The study population consisted of 141,684 women, aged 50-69years, who were invited during 2015-2016 for screening by the Catalan Breast Cancer Screening Program (Spain). Multiple logistic regression models were performed to assess the association between age, screening history, socioeconomic status and reasons for contacting the program and the outcome variables (contact with the program; contact through information and communication technology (ICT) channels). Among the 141,684 women invited for BC screening, 22.5% contacted the screening office mainly to reschedule (42.2%) and cancel (29.2%) appointments. While the communication channel mostly used was the telephone, 24.8% of the women used ICT. ICT was more frequently used by women who had never been screened. Women who wanted to change their appointment were 65% (OR 1.65, 95%CI 1.54-1.76) more likely to use ICT than women who wanted to cancel it. This study showed the need to reinforce communication between women and breast cancer screening programs and the importance of offering communication channels suiting all women's needs to facilitate appointments' rescheduling and cancelling and therefore improve screening programs' efficiency.

Implementing a Population-Based Breast Cancer Risk Assessment Program

BackgroundPersonalized breast cancer risk assessment is important in identifying and managing women at increased risk for breast cancer. However, there has been little evaluation of the practical aspects of implementing a population-based program that identifies and refers high-risk patients for further evaluation. Patients and MethodsWe implemented a semiautomated approach to collect personal and family history to identify women at high risk of breast cancer. On the basis of the survey, women identified as elevated risk received letters inviting them to telephone consultations with licensed breast health genetic counselors (BHGCs). High-risk women's history was verified and counseling and referrals provided, as appropriate. ResultsAmong 20,558 women screened, 2000 (9.7%) women were identified as high risk on the basis of patient initial report. However, most (1,580) were excluded from receiving risk communication after BHGC review of risk information with the woman or because of previous attention to breast cancer risk or an abnormal mammogram. Among 420 subjects who received risk letters, 225 received a BHGC consultation. Of these 225 women, 63 were reclassified as average risk, 158 were referred to high-risk clinics, and 5 consultations were incomplete after determining that further information was needed. Of the 158 women referred to high-risk breast clinics, 51 attended an appointment. ConclusionThis study highlights the complex nature of a population-based breast cancer screening program in a clinical setting and shows the substantial effort needed to identify newly discovered women at high risk for breast cancer and refer them to appropriate services.

Abstract P6-05-03: Exploring the microRNA landscape of nipple aspirate fluid in the context of mammographic breast density

Abstract Background High mammographic density is an established risk factor for breast cancer but studies are needed to elucidate the etiological pathways underlying this relationship. The identification of factors (indirectly) regulating the accumulation of fat and connective tissue may help explain why high mammographic density is linked to breast cancer risk. Those factors may provide markers for predicting and even clues for modifying this risk. MicroRNAs could regulate specific cellular processes involved in regulating mammographic density, like fat accumulation, connective tissue density and immune response. Nipple aspirate fluid represents an excellent opportunity for biomarker detection within the breast microenvironment. Materials and Methods MicroRNA expression profiling was performed using TaqMan OpenArray Human MicroRNA Plates (ThermoFisher Scientific) in 40 pooled (paired left and right breast) nipple aspirate fluid samples obtained from age-matched women participating in a population-based breast cancer screening program with 'extremely dense' (n=20) and 'almost entirely fatty' breasts (n=20), without further abnormalities on mammography. Breast density was assessed using Volpara software in categories comparable to American College of Radiology (ACR) breast density categories. Results 25 significantly differentially expressed microRNAs were identified, including hsa-miR-19a-3p (p=0.001; upregulated in 'extremely dense' versus 'almost entirely fatty'), hsa-miR-324-5p (p=0.003; upregulated), hsa-miR-425-5p (p=0.001; upregulated), hsa-miR-660-5p (p=0.004; upregulated), hsa-miR-29b-3p (p=0.011; upregulated) and hsa-miR-187-3p (p=0.024; downregulated). Based on expression profiles of the 8 most significantly dysregulated microRNAs alone, nipple aspirate fluid samples could reliably be classified into 'extremely dense' and 'almost entirely fatty' mammographic density groups (31/40 (78%) samples correctly classified). Several of the dysregulated microRNAs have been associated with regulation of collagen deposition or crosslinking (e.g. miR-29, miR-222 and let-7) and adipocyte differentiation and proliferation (e.g. miR-29, miR-222, miR-155 and let-7), suggesting that these aberrant miRNAs may play a role in the development of breast tissue with high mammographic density. In addition, pathway enrichment analysis demonstrated an enrichment of the 'proteoglycans in cancer' pathway suggesting that proteoglycan dysregulation is intimately linked to microRNA dysregulation. Conclusions In summary, microRNA profiling has resulted in a panel of microRNAs that might help explain why high mammographic density is linked to breast cancer risk and may ultimately result in a biomarker panel for predicting this risk, or provide attractive targets for future breast cancer preventive strategies. Further validation in an independent set of nipple aspirate fluid samples from 'extremely dense' and 'almost entirely fatty' categories is currently ongoing. Citation Format: Moelans CB, Patuleia SI, Bakker MF, van der Wall E, van Diest PJ, van Gils CH. Exploring the microRNA landscape of nipple aspirate fluid in the context of mammographic breast density [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-05-03.

External validation of the PREDICT tool in Spanish women with breast cancer participating in population-based screening programmes.

To externally validate the PREDICT tool in a cohort of women participating in a population-based breast cancer screening programme who were diagnosed with breast cancer between 2000 and 2008 in Spain. A total of 535 women were included in the validation study. We calculated predicted 5-year survival using the beta values from the development of the PREDICT model and predicted and observed events for a given risk groups. Model fit, discrimination, and calibration were evaluated. Seeking to improve the model, we also explored the impact on discrimination of the inclusion of additional variables, not in the PREDICT algorithm. In patients who were oestrogen receptor (ER) positive (negative), PREDICT overestimated (underestimated) the 5-year overall survival in all the subgroups studied. Analysis of model performance showed good calibration but modest discrimination (C-index, 0.697 [ER negative] and 0.768 [ER positive]). When updating the model, no additional variables were found to be significant in ER-negative patients, but for ER-positive patients, concurrent liver disease was a significant factor, its inclusion improving model discrimination (C-index, 0.817). The PREDICT tool does not discriminate well in our population considering only the variables of the original algorithm. More accurate tools are needed to obtain a better discrimination.

Overdiagnosis in the population-based organized breast cancer screening program estimated by a non-homogeneous multi-state model: a cohort study using individual data with long-term follow-up

BackgroundOverdiagnosis, defined as the detection of a cancer that would not become clinically apparent in a woman’s lifetime without screening, has become a growing concern. Similar underlying risk of breast cancer in the screened and control groups is a prerequisite for unbiased estimates of overdiagnosis, but a contemporary control group is usually not available in organized screening programs.MethodsWe estimated the frequency of overdiagnosis of breast cancer due to screening in women 50–69 years old by using individual screening data from the population-based organized screening program in Stockholm County 1989–2014. A hidden Markov model with four latent states and three observed states was constructed to estimate the natural progression of breast cancer and the test sensitivity. Piecewise transition rates were used to consider the time-varying transition rates. The expected number of detected non-progressive breast cancer cases was calculated.ResultsDuring the study period, 2,333,153 invitations were sent out; on average, the participation rate in the screening program was 72.7% and the average recall rate was 2.48%. In total, 14,648 invasive breast cancer cases were diagnosed; among the 8305 screen-detected cases, the expected number of non-progressive breast cancer cases was 35.9, which is equivalent to 0.43% (95% confidence interval (CI) 0.10%–2.2%) overdiagnosis. The corresponding estimates for the prevalent and subsequent rounds were 15.6 (0.87%, 95% CI 0.20%–4.3%) and 20.3 (0.31%, 95% CI 0.07%–1.6%), respectively. The likelihood ratio test showed that the non-homogeneous model fitted the data better than an age-homogeneous model (P <0.001).ConclusionsOur findings suggest that overdiagnosis in the organized biennial mammographic screening for women 50–69 in Stockholm County is a minor phenomenon. The frequency of overdiagnosis in the prevalent screening round was higher than that in subsequent rounds. The non-homogeneous model performed better than the simpler, traditional homogeneous model.

Screen-Round–Based Risk Strategies for Population-Based Mammography Screening

Background: The widespread use of organized screening strategies of mammography screening at population level stood a chance of reducing the threat to women's life from breast cancer. However, such a population-wide strategy is often faced with the questions like “How many rounds of mammography screening are require before detecting cancer in question?” and “Can the attendee be classified the low risk after several negative screening rounds?” In addition to the concerns on resource allocation for the purpose of planning an efficient population-based screening program, the recent emergence in precision medicine also makes it attractive for considering such a risk-based decision on breast cancer prevention under the context of mass screening. Aim: To quantify number of screen rounds required for detecting an asymptomatic cancer in question and dispensing with further invitation to screen. Methods: By applying a series of Bayesian negative–binomial family–based stochastic process models taking sensitivity and specificity into account, we elucidated the aforementioned issues based on the empirical data on population-based breast cancer screening program in Finland with international collaboration. The Finnish nationwide biennial mammographic screening program was implemented and targeted to women aged 50-59 years since 1988. The panel data on the regular invitation of eligible population by Pirkanmaa screening center excluding the women who had been diagnosed by breast cancer before their first invitation were enrolled in this study. Results: Based on the estimated results, we are able to determine the rounds of screens required before detecting an asymptomatic breast cancer according to the risk profile determined by age and the performance of screening tool. Based on the empirical data, an average of 2.77 (95% CI, 2.61-2.91) screen rounds will be required to detect an asymptomatic breast cancer cases. A woman may not be invited after a series of negative findings of 8 rounds of screen. Considering the sensitivity of 83% (95% CI, 61%–95%), the required screen rounds become 2.81 (95% CI, 2.65-2.94). The screening rounds required for the young (&lt;55 years) and the old (≥55 years) age group, the corresponding figures was 2.81 (95% CI, 2.55-3.11) and 2.76 (95% CI, 2.43-3.05). Conclusion: We quantified the screen round, 2.77 on average, required to detect an asymptomatic breast cancer and 8 rounds of screen to dispense with further invitation based on the risk and the performance of screening tool. The findings may aid in risk-based interscreening interval determination but also provide information on resources required by different screening policies with target population with different risk levels.

Identifying Coordination and Continuity of Care Indicators for Population-Based Cancer Screening Programs: A Delphi Study.

Continuity of care and care coordination are critical issues in virtually all healthcare systems. European guidelines for the quality of screening programs for breast and colorectal cancer describe process, structure, and outcome indicators, but none specifically evaluate coordination and continuity of care during the cancer screening process. The aim of this study was to identify indicators reflecting care coordination and continuity in population-based breast and colorectal cancer screening program. A two-round Delphi study was conducted in a sample of 30 cancer screening nurses to identify quality indicators. The final Delphi consensus resulted in six core indicators for the cancer screening program: adequacy of the referral of the target population from the screening program to other health services, waiting time for referral to other health services, understanding of the screening program by professionals involved in the process, effective information flow between professionals involved in the process, participants' perception of the screening program, and, finally, participants' understanding of information about the program. The evaluation of indicators is crucial for quality improvement and should allow a measuring system to be established that would allow a comparison of outcomes for all population-based cancer screening programs.

A health systems approach to identifying barriers to breast cancer screening programmes. Methodology and application in six European countries

The benefits of population-based screening for breast cancer are now accepted although, in practice, programmes often fail to achieve their full potential. In this paper, we propose a conceptual model that situates screening programmes within the broader health system to understand the factors that influence their outcomes. We view the overall screening system as having multiple sub-systems to identify the population at risk, generate knowledge of effectiveness, maximise uptake, operate the programme, and optimise follow-up and assurance of subsequent treatment. Based on this model we have developed the Barriers to Effective Screening Tool (BEST) for analysing government-led, population-based screening programmes from a health systems perspective. Conceived as a self-assessment tool, we piloted the tool with key informants in six European countries (Estonia, Finland, Hungary, Italy, The Netherlands and Slovenia) to identify barriers to the optimal operation of population-based breast cancer screening programmes. The pilot provided valuable feedback on the barriers affecting breast cancer screening programmes and stimulated a greater recognition among those operating them of the need to take a health systems perspective. In addition, the pilot led to further development of the tool and provided a foundation for further research into how to overcome the identified barriers.

Comparison of breast cancers detected in the Verona screening program following transition to digital breast tomosynthesis screening with cancers detected at digital mammography screening.

The Verona population-based breast cancer (BC) screening program provides biennial mammography to women aged 50-69years. Based on emerging evidence of enhanced detection, the program transitioned to digital breast tomosynthesis (DBT) screening. This is a prospective pilot evaluation of DBT with synthesised 2D mammography screening implemented during April 2015-March 2017; the rate and characteristics of cancers detected at DBT screening were compared with those detected at the preceding digital mammography (DM) screening round (April 2013-March 2015) in the same screening program. Distribution of imaging and tumour characteristics were compared. Amongst 34,071 women screened in the Verona DBT pilot, 315 BCs were detected; 153 BCs were detected amongst 29,360 women in the DM screening round. Estimated CDRs were 9.2/1000 (95% CI 8.3-10.3) DBT screens versus 5.2/1000 (95% CI 4.4-6.1) DM screens, P < 0.001. Statistically significant differences were found in the distribution of whether recall by one/both screen readers (more BCs recalled by both readers at DBT than DM); whether detected on one/two views (higher proportion detected on only one view at DBT than DM); type of radiological lesions; tumour stage, pT and histological categories (lower proportion of DCIS/pTis, higher proportions of pT1a and pT1b, and higher proportion of invasive cancers of special types, at DBT than DM); and tumour grade (higher proportion of grade I at DBT than DM). There were no differences in distributions of nodal and hormone receptor (ER/PR) status. Our findings provide early insights into the extent that transitioning to DBT screening may modify the characteristics of screen-detected breast cancer to inform discussion regarding pros and cons of DBT screening; although our data provide some reassurance that DBT does not increase the proportion of screen-detected DCIS, they highlight mixed findings on comparative tumour characteristics, suggesting a potential for enhancing screening benefit and possibly also over-diagnosis from DBT screening.

Abstract P4-15-13: When is cancer not really cancer? The PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION)* initiative

Abstract Background Ductal carcinoma in situ (DCIS) now represents 20-25% of all breast neoplasia due to large-scale detection by widely adopted population-based breast cancer screening programs. As a result, thousands of women are confronted with DCIS each year: more than 8,000 in the UK, 2,500 in the Netherlands, and some 50,000 in the US. Conventional management includes surgery, supplemented by radiotherapy and/or endocrine therapy, but overtreats the majority of DCIS as ˜1% recur annually and breast cancer mortality is ˜3% at 20 years. Uncertainty as to which DCIS lesions will progress to invasive cancer or, after excision, which will return with recurrent DCIS or invasive breast cancer drives this overtreatment. This urges us to learn how to distinguish DCIS that may progress to invasive breast cancer from the majority of indolent DCIS. Such distinction may be best achieved by synergistic international collaboration between leading global experts from various disciplines, driven by the essential input from patient voices as full members of the research team. Aim PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) aims to save thousands of women with low risk DCIS the burden of intensive inappropriate treatment of DCIS (surgery, radiation therapy, hormonal therapies) through the discovery of new data and development of novel tests that promote informed and shared decision-making between patients and clinicians, without compromising the excellent outcomes for DCIS management presently achieved. Methods First, three large DCIS cohorts and supplementary resources will be collected enabling in depth molecular studies. Second, extensive genomic characterization, immune profiling and imaging analysis will be performed. In vivo and in vitro modeling will be performed to study the biology of DCIS in detail. Finally, all clinical, immune, and molecular data will be incorporated into a clinical risk prediction model. This risk prediction model will be validated in three prospective randomized DCIS trials in the US (COMET trial), UK (LORIS trial), and mainland Europe (LORD trial). How the results of this research will be used The discoveries from our laboratory studies, including a risk stratification model, will be cross-validated in three prospective trials of DCIS active surveillance versus conventional treatment (the COMET, LORIS and LORD trials). As such, the main result of this study will be that we can identify a group of women for which active surveillance for DCIS could be a safer alternative to intensive treatment. Ultimately, this may also contribute to a more reassuring perception of risk regarding non-life threatening precancerous lesions in general, reducing anxiety and preserving quality of life. * The PRECISION Team is a Cancer Research UK Grand Challenge Award 2017 winning team and will be jointly funded by Cancer Research UK and the Dutch Cancer Society. Citation Format: Wesseling J, Thompson A, Nik-Zainal S, Futreal A, Hwang S, Jonkers J, Lips E, Rea D, On Behalf of the PRECISION Team. When is cancer not really cancer? The PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION)* initiative [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-13.

Women’s Knowledge of Breast Cancer: A Cross-Sectional Study

Background: There is a recognised need for a mass populationbased breast cancer screening programme in Bahrain. Better understanding of the level of knowledge and the different perceptions regarding breast cancer among women in Bahrain can potentially aid in the development of a culturally appropriate and efficient educational campaign. This study set out to explore the knowledge of women in Bahrain with regards to breast cancer risk factors, screening and treatment options. Methods: This study is a cross-sectional study including 300 participants from breast clinics in the primary health care centres in Bahrain. Questionnaires were completed via face to face interviews. Results: In terms of risk factor knowledge, 51.3% of respondents answered “yes” on whether family history is a risk to developing breast cancer. This was closely followed by 51% of participants answering “yes” with regards to BRCA genetic mutation being a risk factor. Mammogram was exceedingly the method rated as most effective for detecting BC; 13.7% gave it a rank of 1 (best). Physical examination came second in terms the percentage of respondents ranking it as the best. Furthermore, 91.0% of respondents believed that BC screening is safe. In addition, there was a statistically significant negative relationship between age of respondents and how safe screening was perceived. Education was a statistically significant positive predictor with regards to whether screening was thought to improve survival. Surgery was chosen by the majority as the most important treatment for cancer (43.7%). Conclusions: The findings of this study point to improved screening knowledge level but limited knowledge regarding risk factors and treatment. These areas can be targeted in future educational campaigns.

Influence of breast compression pressure on the performance of population-based mammography screening

BackgroundIn mammography, breast compression is applied to reduce the thickness of the breast. While it is widely accepted that firm breast compression is needed to ensure acceptable image quality, guidelines remain vague about how much compression should be applied during mammogram acquisition. A quantitative parameter indicating the desirable amount of compression is not available. Consequently, little is known about the relationship between the amount of breast compression and breast cancer detectability. The purpose of this study is to determine the effect of breast compression pressure in mammography on breast cancer screening outcomes.MethodsWe used digital image analysis methods to determine breast volume, percent dense volume, and pressure from 132,776 examinations of 57,179 women participating in the Dutch population-based biennial breast cancer screening program. Pressure was estimated by dividing the compression force by the area of the contact surface between breast and compression paddle. The data was subdivided into quintiles of pressure and the number of screen-detected cancers, interval cancers, false positives, and true negatives were determined for each group. Generalized estimating equations were used to account for correlation between examinations of the same woman and for the effect of breast density and volume when estimating sensitivity, specificity, and other performance measures. Sensitivity was computed using interval cancers occurring between two screening rounds and using interval cancers within 12 months after screening. Pair-wise testing for significant differences was performed.ResultsPercent dense volume increased with increasing pressure, while breast volume decreased. Sensitivity in quintiles with increasing pressure was 82.0%, 77.1%, 79.8%, 71.1%, and 70.8%. Sensitivity based on interval cancers within 12 months was significantly lower in the highest pressure quintile compared to the third (84.3% vs 93.9%, p = 0.034). Specificity was lower in the lowest pressure quintile (98.0%) compared to the second, third, and fourth group (98.5%, p < 0.005). Specificity of the fifth quintile was 98.4%.ConclusionResults suggest that if too much pressure is applied during mammography this may reduce sensitivity. In contrast, if pressure is low this may decrease specificity.

Breast cancer screening effectiveness in Portugal central Region.

The central region of Portugal is covered by an organized population-based breast cancer screening programme. We designed a case-referent study to investigate the association of overall mortality with mammographic screening attendance. The study population (SP) included women aged 50-69 years who received at least one invitation to the breast cancer screening programme. A case was defined as a woman from the SP diagnosed with breast cancer between 2000 and 2006 who died before 1 August 2015. Index invitation (IV) was defined as the most recent invitation before diagnosis of the case. For each case, two referents were sampled from the SP. Referents were women who did not have a breast cancer diagnosis at the IV of the case and alive at time of death of the case. Exposure to screening was defined as participation in the screening examination following the IV and/or participation in the screening round preceding the IV. To correct for self-selection bias, we used a summary correction factor on the basis of published ones. We used conditional logistic regression to estimate the odds ratio (OR) and 95% confidence interval (CI). A total of 227 cases and 454 referents were considered. The overall OR showed a mortality reduction of 47% (OR=0.53, 95% CI: 0.37-0.78). The estimated correction factor was 1.15 (95% CI: 1.06-1.25). This factor was used to correct the crude OR, resulting in a mortality reduction of 33% (OR=0.67, 95% CI: 0.45-1.00). Our results are in agreement with other case-referent studies worldwide, supporting the contribution of screening practices towards the decreasing breast cancer mortality in Portugal.

Desigualdades en la realización de mamografías y citologías cervicales en las mujeres españolas según las encuestas nacionales de salud

ObjectiveTo analyse the frequencies of mammographic screening, mammographic follow-up through a population-based screening programme, and cytological screening by autonomous community and social class in Spanish women aged 25 to 69 years. MethodsObservational study. The information source was the National Health Surveys (NHS) for 2003, 2006 and 2011. The study population consisted of women aged 25 to 69 years (N=7,844 for NHS-2003, N=12,845 for NHS-2006 and N=7,695 for NHS-2011). The dependent variables were periodic mammographic screening, periodic mammographic screening through a population-based programme, and periodic cervical screening. The independent variables were age, social class (manual/non-manual), autonomous community, the number of years since the start of the programme, and year of the NHS. Prevalence ratios with their 95% confidence intervals (95% CI) were calculated. ResultsIn 2006, participation in periodic population-based mammographic screening was 49.2% among women from a non-manual social class versus 61.5% among those from a manual social class (prevalence ratios NHS-2006: 0.81; 95% CI 0.75-0.88). In NHS-2011, participation was 53.6% among women from a non-manual social class versus 68.0% among those from a manual social class. For NHS-2003, participation in periodic cytological screening was 90.2% among women from a non-manual social class versus 86.7% among those from a manual social class (prevalence ratios NHS-2003: 1.04; 95% CI 1.01-1.06). ConclusionsNo differences were observed by social class in periodic mammographic screening. Population-based breast cancer screening programmes compensate for differences in social class in mammographic follow-up. Cytological screening was more frequent among women from a non-manual social class.

Is breast compression associated with breast cancer detection and other early performance measures in a population-based breast cancer screening program?

We aimed to investigate early performance measures in a population-based breast cancer screening program stratified by compression force and pressure at the time of mammographic screening examination. Early performance measures included recall rate, rates of screen-detected and interval breast cancers, positive predictive value of recall (PPV), sensitivity, specificity, and histopathologic characteristics of screen-detected and interval breast cancers. Information on 261,641 mammographic examinations from 93,444 subsequently screened women was used for analyses. The study period was 2007-2015. Compression force and pressure were categorized using tertiles as low, medium, or high. χ 2 test, t tests, and test for trend were used to examine differences between early performance measures across categories of compression force and pressure. We applied generalized estimating equations to identify the odds ratios (OR) of screen-detected or interval breast cancer associated with compression force and pressure, adjusting for fibroglandular and/or breast volume and age. The recall rate decreased, while PPV and specificity increased with increasing compression force (p for trend <0.05 for all). The recall rate increased, while rate of screen-detected cancer, PPV, sensitivity, and specificity decreased with increasing compression pressure (p for trend <0.05 for all). High compression pressure was associated with higher odds of interval breast cancer compared with low compression pressure (1.89; 95% CI 1.43-2.48). High compression force and low compression pressure were associated with more favorable early performance measures in the screening program.