Screen-detected Women Research Articles

Factors associated with being diagnosed with high severity of breast cancer: a population-based study in Queensland, Australia.

This study explores factors that are associated with the severity of breast cancer (BC) at diagnosis. Interviews were conducted among women (n = 3326) aged 20-79 diagnosed with BC between 2011 and 2013 in Queensland, Australia. High-severity cancers were defined as either Stage II-IV, Grade 3, or having negative hormone receptors at diagnosis. Logistic regression models were used to estimate odds ratios (ORs) of high severity BC for variables relating to screening, lifestyle, reproductive habits, family history, socioeconomic status, and area disadvantage. Symptom-detected women had greater odds (OR 3.38, 2.86-4.00) of being diagnosed with high-severity cancer than screen-detected women. Women who did not have regular mammograms had greater odds (OR 1.78, 1.40-2.28) of being diagnosed with high-severity cancer than those who had mammograms biennially. This trend was significant in both screen-detected and symptom-detected women. Screen-detected women who were non-smokers (OR 1.77, 1.16-2.71), postmenopausal (OR 2.01, 1.42-2.84), or employed (OR 1.46, 1.15-1.85) had greater odds of being diagnosed with high-severity cancer than those who were current smokers, premenopausal, or unemployed. Symptom-detected women being overweight (OR 1.67, 1.31-2.14), postmenopausal (OR 2.01, 1.43-2.82), had hormone replacement therapy (HRT) < 2years (OR 1.60, 1.02-2.51) had greater odds of being diagnosed with high-severity cancer than those of healthy weight, premenopausal, had HRT > 10years. Screen-detected women and women who had mammograms biennially had lower odds of being diagnosed with high-severity breast cancer, which highlighted the benefit of regular breast cancer screening. Women in subgroups who are more likely to have more severe cancers should be particularly encouraged to participate in regular mammography screening.

Deprivation and mass screening: Survival of women diagnosed with breast cancer in France from 2008 to 2010

BackgroundSome studies have investigated the role of socio-demographic inequalities in the association between screening and survival. However, in France, no study has been conducted to describe the socio-demographic characteristics and survival of women with breast cancer based on their participation to mass screening. The aim of this study was to assess the impact of socio-demographic inequalities on the association between participation in mass screening program and survival of women with breast cancer. MethodsData for 2,244 women aged 50–74 years diagnosed with breast cancer over the period 2008–2010 were obtained from the cancer registry and the screening structure of Gironde. We used the aggregated European Deprivation Index (EDI) to define the deprivation level of women. Net survival rates were estimated with the Pohar-Perme method, with and without correcting for lead-time bias. ResultsSurvival rates were lower for non-attenders than for screen-detected women (83.8% vs 97.3%, p < 0.0001), even after correcting for lead-time bias. Among the most deprived women, the survival rate was significantly different between non-attenders and screen-detected women (78.1% vs 95.6%, p = 0.0002), suggesting an important effect of mass screening in this group. ConclusionThe introduction of incentive actions in deprived areas could play a key role in the adherence of women to mass screening and in improving their survival in case of a breast cancer diagnosis.

Role of participation in organized screening on the survival of women with breast cancer according to socioeconomic disparities: A population-based study

Several observational studies have suggested the impact of socioeconomic disparities in breast cancer diagnosis. Living in a deprived area was associated to advanced tumor stage at diagnosis and poor prognosis. The participation in organized breast cancer screening (OBCS) program can help to detect cancers at an early stage and to reduce mortality. This study aimed at describing survival of women with cancer according to their participation in OBCS and socioeconomic characteristics in the department of Gironde. All cases of breast cancer in situ or invasive diagnosed over the period 2008–2010, in women aged 50 to 74 years were extracted from Gironde Cancer Registry. The participation in OBCS program was obtained from the Gironde Screening Coordination Structure (AGIDECA). Women were categorized in 4 groups according their participation in the OBCS. The socioeconomic environment was measured by an aggregated indicator of deprivation: the French European Deprivation Index (EDI). EDI was categorized in quintiles (quintile 1: women most affluent and quintile 5: women most deprived). We estimated net survival rates at 1 and 5 years using the Pohar-Perme method according to the participation in OBCS and socioeconomic deprivation. A correction of the advance bias at diagnosis (or lead time bias) was taken into account by modifying the survival time of the screened women according a method established by Duffy et al. During the 2008–2010 period, 2,244 women were diagnosed with first breast cancer in Gironde department. In this population, 297 deaths were reported. Among all these women, 57% had participated in OBCS, 24% were non-screened, 14% had interval cancer (cancer diagnosed between 2 screening test) and 5% were diagnosed more than 2 years after the last screening test. Net survival was higher in the group of screen-detected women compared to non-screened women (97.3% vs. 83.8%, P < 0.0001). Non-screened women had lower net survival when they were deprived (quintile 1: 91.1% vs. quintile 5: 78.1%, P < 0.0106). Taking into account socioeconomic disparities, survival was higher for screened women than for non-screened women, but the difference was significant only in most deprived areas (quintiles 3 to 5). After correction for the bias in advance of diagnosis, the survival rates of screen-detected women were lower than without correction, but they remained higher than those of women who were not screened. Women with breast cancer participating in OBCS in Gironde had better net survival at five years compared to women who were non-screened. The role of OBCS on breast cancer survival seemed to be stronger for women in most deprived areas. The implementation of incentive actions in deprived areas in order to foster women to participate in OBCS could improve their survival in case of breast cancer diagnosis.

Absence of socioeconomic inequalities in access to good-quality breast cancer treatment within a population-wide screening programme in Turin (Italy).

Several studies suggest that population-based breast cancer screening programmes might help reduce social inequalities in breast cancer survival both by increasing early diagnosis and by improving access to effective treatments. To start disentangling the two effects, we evaluated social inequalities in quality of treatment of screen-detected breast cancer in the city of Turin (Italy). Combining data from the Audit System on Quality of Breast Cancer Treatment and the Turin Longitudinal Study, we analysed 2700 cases in the screening target age class 50-69 diagnosed in the period 1995-2008. We selected 10 indicators of the pathway of care, relative to timeliness and appropriateness of diagnosis and treatment, and three indicators of socioeconomic position: education, occupational status and housing characteristics. For each indicator of care, relative risks of failure were estimated by robust Poisson regression models, controlling for calendar period of diagnosis, size of tumour and activity volume of the surgery units. The principal predictor of failure of the good care indicators was the calendar period of diagnosis, with a general improvement with time in the quality of diagnosis and treatment, followed by size of the tumour and volume of activity. Socioeconomic indicators show only a marginal independent effect on timeliness indicators. The observed associations of quality indicators with socioeconomic characteristics are lower than expected, suggesting a possible role of the screening programme in reducing disparities in the access to good-quality treatments thanks to its capability to enter screen-detected women into a protected pathway of care.

What might explain deprivation-specific differences in the excess hazard of breast cancer death amongst screen-detected women? Analysis of patients diagnosed in the West Midlands region of England from 1989 to 2011.

BackgroundBreast cancer survival is higher in less deprived women, even amongst women whose tumor was screen-detected, but reasons behind this have not been comprehensively investigated.MethodsThe excess hazard of breast cancer death in 20,265 women diagnosed with breast cancer, followed up to 2012, was estimated for screen-detected and non-screen-detected women, comparing more deprived to less deprived women using flexible parametric models. Models were adjusted for individual and tumor factors, treatment received and comorbidity. For screen-detected women, estimates were also corrected for lead-time and overdiagnosis.ResultsThe excess hazard ratio (EHR) of breast cancer death in the most deprived group, adjusted only for age and year of diagnosis, was twice that of the least deprived among screen-detected women (EHR=2.12, 95%CI 1.48-2.76) and 64% higher among non-screen-detected women (EHR=1.64, 95%CI 1.41-1.87). Adjustment for stage at diagnosis lowered these estimates by 25%. Further adjustment had little extra impact. In the final models, the excess hazard for the most deprived women was 54% higher (EHR=1.54, 95%CI 1.10-1.98) among screen-detected women and 39% higher (EHR=1.39, 95%CI 1.20-1.59) among non-screen-detected women.ConclusionA persistent socio-economic gradient in breast cancer-related death exists in this cohort, even for screen-detected women. The impact of differential lifestyles, management and treatment warrant further investigation.

Modeling the Cost-Effectiveness of Alternative Upper Age Limits for Breast Cancer Screening in England and Wales

BackgroundCurrently in the United Kingdom, the National Health Service (NHS) Breast Screening Programme invites all women for triennial mammography between the ages of 47 and 73 years (the extension to 47–50 and 70–73 years is currently examined as part of a randomized controlled trial). The benefits and harms of screening in women 70 years and older, however, are less well documented. ObjectivesThe aim of this study was to examine whether extending screening to women older than 70 years would represent a cost-effective use of NHS resources and to identify the upper age limit at which screening mammography should be extended in England and Wales. MethodsA mathematical model that allows the impact of screening policies on cancer diagnosis and subsequent management to be assessed was built. The model has two parts: a natural history model of the progression of breast cancer up to discovery and a postdiagnosis model of treatment, recurrence, and survival. The natural history model was calibrated to available data and compared against published literature. The management of breast cancer at diagnosis was taken from registry data and valued using official UK tariffs. ResultsThe model estimated that screening would lead to overdiagnosis in 6.2% of screen-detected women at the age of 72 years, increasing up to 37.9% at the age of 90 years. Under commonly quoted willingness-to-pay thresholds in the United Kingdom, our study suggests that an extension to screening up to the age of 78 years represents a cost-effective strategy. ConclusionsThis study provides encouraging findings to support the extension of the screening program to older ages and suggests that further extension of the UK NHS Breast Screening Programme up to age 78 years beyond the current upper age limit of 73 years could be potentially cost-effective according to current NHS willingness-to-pay thresholds.

Population-based service mammography screening: the Icelandic experience

This study analyzes the efficacy of the Icelandic population-based service mammography screening. Women aged 40-69 were invited for screening at 2-year intervals starting in November 1987. The study evaluates: (A) attendance and other screened performance parameters during 1998-2010; (B) trends in age-standardized and age-specific incidence rates during 1969-2010 and mortality rates during 1969-2010; and (C) distribution of risk factors and disease specific death rates according to mode of detection. (A) In the age group of 40-69, the average 2-year attendance was 62%, recall rate was 4.1%, needle biopsy rate was 1.3%, surgery rate was 0.6%, invasive cancer rate was 0.4%, and ductal carcinoma in situ (DCIS) rate was 0.06%. (B) The linear incidence trend after the start of screening decreased significantly in the age group 40-49, increased significantly in the age group 50-69, but decreased non-significantly in the age group 70-79. The decreased age-specific incidence in the 70-79 age group was, however, greater than the increased age-specific incidence at the ages 50-69. The mortality rate decreased 41% for all age groups and the linear mortality trend decreased significantly at ages 40-49, 50-69, and 70-79. In the age group 40-74 years, the age-specific mortality decreased by 6.9 cases per 2000 during a 10-year period. (C) Screen-detected women had significantly smaller tumors, more favorable tumor grade, fewer axillary metastases and, after correction for other risk factors, the likelihood of dying from cancer decreased 54% (hazard ratio: 0.46; 95% confidence interval: 0.31-0.69) for these patients compared to cases of nonparticipators. The study results confirm acceptable rates of recalls and referrals for further diagnosis and treatment, and significantly decreased breast cancer mortality rate after starting screening.

Socio-economic inequalities in survival from screen-detected breast cancer in South West England: population-based cohort study

Socio-economic inequalities in breast cancer survival have been reported worldwide, but whether these exist in screen detected as well as symptomatic women has not been established. Making this distinction will allow inferences about the relative contributions of pre- and post-diagnostic delay to these inequalities. Screening-eligible women diagnosed with breast cancer in South West England (2002-06) were followed-up to 2007. Five-year relative survival ratios (RSRs) were calculated for each deprivation quintile, using deprivation-specific life-tables and a period approach. The 'deprivation gap' in survival was calculated as the slope index of inequality between least and most deprived women. The study included 11 018 women, of whom 1176 died during follow-up. Screening status of 54% of women was missing. A clear gradient in survival across deprivation groups ranged from 83.6% [95% confidence interval (CI) 80.0, 86.6] in the most deprived to 90.8% (95% CI 89.0, 92.3) in the least deprived group. Comparing the most deprived to least deprived women, the estimated deprivation gap was -9.42% (95% CI -12.80, -6.04, P = 0.003). Among screen-detected women, inequalities were attenuated, but persisted, ranging from 95.6% (95% CI 90.6, 98.0) in the most deprived to 98.2% (95% CI 95.9, 99.2) in least deprived; the estimated deprivation gap was -3.03% (95% CI -5.75, -0.85, P = 0.023). The deprivation gap in survival does not appear as marked with screen-detected breast cancer as the other groups, though still apparent. Efforts to eliminate inequalities should consider both increasing breast screening participation and ensuring equal access through secondary care systems for women of lower socio-economic position.

Flat epithelial atypia is a common subtype of B3 breast lesions and is associated with noninvasive cancer but not with invasive cancer in final excision histology

The biological behavior and the optimal management of benign breast lesions with uncertain malignant potential, the so-called B3 lesions, found in breast needle core biopsies is still under debate. We addressed this study to compare histologic findings in B3 needle core biopsies with final excision specimens to determine associated rates of malignancy. Consecutive needle core biopsies were performed in a 3-year period (January 1, 2006-December 31, 2008). Biopsies were image-guided (31 by ultrasound, 85 stereotactic vacuum-assisted, 6 unknown) for evaluation of breast abnormalities. We reviewed 122 needle core biopsies with B3 lesions of 91 symptomatic patients and 31 screen-detected women and compared the B3 histologic subtypes with the final excision histology. A total of 1845 needle core biopsies were performed and B3 lesions comprised 6.6% of all B categories. The most common histologic subtype in biopsies was flat epithelia atypia in 35.2%, followed by papillary lesions in 21% and atypical ductal hyperplasia in 20%. Reports on excision specimens were available in 66% (81 patients). Final excision histology was benign in 73 (90.2%) and malignant in 8 (9.8%) patients (2 invasive cancer, 6 ductal carcinoma in situ). Of all B3 subtypes, atypical ductal hyperplasia and flat epithelial atypia were associated with malignancy, whereas only atypical ductal hyperplasia was accompanied by invasive cancer. Of all lesions, flat epithelial atypia was most frequently found in excision specimens (18%). In our study, flat epithelial atypia and atypical ductal hyperplasia are common lesions of the B3 category in needle core biopsies of the breast. Both lesions are associated with malignancy, whereas only atypical ductal hyperplasia was related to invasive cancer. We conclude that an excision biopsy after diagnosis of flat epithelial atypia is recommended depending on clinical and radiologic findings.

Changes in use of breast-conserving therapy in years 1978-2000

The treatment of breast cancer patients has changed rapidly in the past decade, but empirical data at local and national level are scarce. Predicting the consequences of screening for primary treatment is consequently difficult. The aim of this analysis of records on admissions to hospital of women with breast cancer and/or for breast surgery (1975-90) together with a survey of all Dutch radiotherapy departments (1986-88) is to show the change in breast-conserving therapy and other primary treatment before the start of breast cancer screening in The Netherlands. There was a modest increase in breast-conserving therapy after 1981, coinciding with the first publication on its trial, followed by a sharp increase between 1985 and 1990, after the second publication. At the end of that 5 year period, 36% of all women with newly diagnosed invasive breast cancer underwent this type of surgery. Breast-conserving surgery is always followed by radiotherapy, but there has been a clear reduction in post-operative radiation after mastectomy. The percentage of breast-conserving therapy is at present higher in The Netherlands than in the USA. Implementing the Dutch screening programme will result in a maximum increase in breast-conserving therapy at national level of 34%, which stabilises at +21%, or a 50% maximum increase at local level. The number of women treated by mastectomy will ultimately decrease by 9%. Given the rapidity of change towards the use of breast-conserving surgery, which is enhanced by screening, recent information will be needed in predicting capacity and assessing whether screen-detected women are treated adequately.