Accuracy of Visual Inspection with Acetic Acid (VIA) for Early Detection of Cervical Dysplasia in Tehran,Iran

Objective: To evaluate the accuracy of visual inspection with 5% acetic acid (VIA) when used to detect cervical ‍cancer and its precursors. ‍Methods: The study population included women attended Family Planning and Gynecological Clinic in Bagher ‍Abad Health Center and Mirza Koochak Khan Hospital for regular cervical screening tests. After obtaining informed ‍consent from each woman, VIA was performed. One hundred with a positive VIA test and 100 women with a ‍negative VIA test were randomly selected for this study. Cytology and colposcopy examination were performed for ‍all 200 cases and cervical biopsies were conducted for those individuals showing abnormal colposcopic findings. ‍Results: Nine cases in VIA-positive group and two cases in VIA-negative group had an abnormal cytology. Ninety ‍five women in the VIA-positive group and 25 in the VIA-negative group had abnormal colposcopic findings. From ‍biopsy examination, 67 (71%) of cases in the VIA-positive group and 3 (12%) cases in the VIA-negative group had ‍a final diagnosis of dysplasia. Among biopsied samples, only 7 cases of VIA-positive group showed abnormal result ‍and the remaining were normal. Based on these results, VIA test sensitivity and specificity were 95.7% and 44.0% ‍respectively, while they were 10% and 92% for cytology tests. ‍Conclusions: The results of this study indicate that although VIA is a sensitive screening test for detection of ‍cervical dysplasia, it can not be used by itself. Applying VIA along with Pap smears helps to detect a higher number ‍of cases with cancer precursor lesions.     

Fight Against Cancer in Countries with Limited Resources: The Post-genomic Era Scenario

The enormous advances in science and technology in the 20th century have facilitated the process of globalization ‍with the aim of a better quality of life for all. Paradoxically, the gap between the rich and the poor, for both nations ‍and people, is constantly widening. The actual trends in human genome research are leading towards promising ‍genomic medicine, but it will be expensive and inaccessible for many. Also, it may not offer a quick fix ‘cure’ for ‍various types of cancers. The biggest challenge before the clinicians now is the management of the rising incidence of ‍cancer in developing countries, with little prospect of more resources becoming available to fight the disease. The ‍death rate from cancer in the developing countries is set to rise at least 3-fold by the year 2025 largely due to the ‍increased life expectancy, containment of infectious diseases and changing lifestyles. It is estimated that about 50% ‍of cancers are curable if they are detected early and treated appropriately. Screening has a major role in early ‍diagnosis. However, in the developing world around 80% of cancer patients have late stage incurable disease when ‍they are diagnosed. Moreover, in a developing country like India, about 70% of the population obtain medical help ‍from private practitioners. Nearly half of those who seek medical help utilize alternative and traditional systems of ‍medicine. Appalling poverty, poor hygiene and complex social dynamics, pose major hurdles in this regard. Many in ‍the private sector who call themselves doctors have no medical degree. By 2030 tobacco is expected to kill 10 million ‍people worldwide, out of which 70% of the deaths will occur in the developing countries. Control of usage of tobacco ‍has still not achieved a conducive atmosphere. It is now realized that the research information and knowledge ‍generated in the west may neither be relevant nor applicable to developing countries, due to differences in social and ‍cultural attitudes, lifestyles and lack of sophisticated technologies. Though the sequencing of the human genome will ‍have a major impact on the prevention, diagnosis, treatment, monitoring, and outcome of cancer, the cancer scenario ‍in the developing countries for the next 20 years is likely to be more or less the same, rather than presenting a ‍radically different picture. Cancer awareness and screening programs for early detection thus should be continue to ‍be given utmost attention .     

Awareness of Oral Cancer and Precancer Among Patients Attending a Hospital in Sri Lanka

Objective: To assess awareness about oral cancer and precancer among patients attending for dental treatment ‍at a University Dental hospital. ‍Methods and materials: A self-administered questionnaire was used to collect information from 410 randomly ‍selected outpatients attended the Dental Hospital (teaching), Faculty of Dental Sciences, University of Peradeniya, ‍Sri Lanka. The questionnaire included questions to ascertain information on socio-demographic parameters, ‍awareness of oral cancer and precancer, habits of betel chewing, smoking and alcohol consumption. ‍Results: Ninety five percent of the respondents were aware of the possibility of occurrence of cancer in the mouth ‍while only 44.9% (n=184) were aware about precancer. Of the 390 individuals who were aware of the existence of ‍oral cancer, 80.7% were knowledgeable about the causal relationship between betel chewing habit and oral cancer. ‍Forty-seven and 17 per cent were aware of links with tobacco smoking and alcohol consumption, respectively. However, ‍out of those who had knowledge of oral cancer, 18 % (n= 69) were not knowledgeable about associations with habits. ‍Conclusions: This survey revealed that the patients attending the hospital were well informed about oral cancer. ‍However, awareness about precancer was relatively low. Knowledge about the causal relationships with tobacco ‍smoking and use of alcohol was low compared to that for betel chewing.     

Knowledge and Concerns about Cancer in Patients with Primary Gynecologic Cancers

Objective: The aim of this study was to measure the level of knowledge about cancer among patients with primary ‍gynecologic cancers and the rate of awareness for diagnosis. ‍Methods: Two hundred patients with primary gynecologic cancers in Vaie Asr & Mirza Kochak Khan hospitals, ‍Tehran/Iran, participated and entered the study and were interviewed by trained nurses. The interview included ‍questions about knowledge of their cancer and risk factors. ‍Results: One hundred fifteen of 200 subjects (58%) knew that their disease was malignant, of which 56 were ‍aware of the exact diagnosis. Fifty six percent of the subjects believed that doctors must say the true diagnosis. The ‍level of general knowledge about cancer was poor in 34%of cases. Regarding cancer risk factors, 47% had a poor ‍level of knowledge. Misconception about injury and depression as predisposing factors were common. Level of ‍general knowledge was significantly higher in younger than in older patients (p<0.05). Also patients with a greater ‍length of formal education had a higher level of knowledge (p<0.0001). Patients who received information from ‍medical personnel and who were aware of diagnosis had a higher level of knowledge (p<0.0001). ‍Conclusion: The level of knowledge about cancer should be promoted in both the general public and in patients. ‍Medical personnel may play a great role in this field. ‍     

A Model of Practical Cancer Prevention for Out-patients Visiting a Hospital: the Hospital-based Epidemiologic Research Program at Aichi Cancer Center (HERPACC)

To promote a cancer prevention program at hospital, we started the hospital-based epidemiologic research program at ‍Aichi Cancer Center (HERPACC) in 1988. Because patients visiting hospitals are very concerned not only about their ‍own health condition but also practical way of disease prevention, we consider outpatients, especially those free of ‍cancer, as ideal targets to make a model program and a practical cancer prevention strategy for general people. To ‍confirm risk and protective effects of lifestyle factors like dietary habits, smoking and drinking, and exercise on cancer ‍in Japanese, we have been undertaking large-scale case-referent comparative studies of main cancer sites (stomach, ‍colorectal, lung, breast and uterine cancers) using the data generated by HERPACC. The risk of respiratory tract cancer ‍was definitely elevated by habitual smoking and that of upper digestive tract cancer by combined habitual smoking and ‍drinking. Frequent intake of raw vegetables and/or fruit in contrast reduced the risk of lung cancer among smokers. ‍Current obesity was positively associated with risk of post-menopausal breast cancer, recently on the increase in Japan. ‍However, all sites of cancer were linearly decreased with frequency of exercise in both males and females. Based on ‍these pieces of evidence and other main results obtained from the HERPACC studies, prevention trials with provision ‍of information about protective and risk factors for main sites of cancers to outpatients have been planned in parallel to ‍continuation of HERPACC.     

Report: 15th Asian Pacific Cancer Conference

To promote a cancer prevention program at hospital, we started the hospital-based epidemiologic research program at ‍Aichi Cancer Center (HERPACC) in 1988. Because patients visiting hospitals are very concerned not only about their ‍own health condition but also practical way of disease prevention, we consider outpatients, especially those free of ‍cancer, as ideal targets to make a model program and a practical cancer prevention strategy for general people. To ‍confirm risk and protective effects of lifestyle factors like dietary habits, smoking and drinking, and exercise on cancer ‍in Japanese, we have been undertaking large-scale case-referent comparative studies of main cancer sites (stomach, ‍colorectal, lung, breast and uterine cancers) using the data generated by HERPACC. The risk of respiratory tract cancer ‍was definitely elevated by habitual smoking and that of upper digestive tract cancer by combined habitual smoking and ‍drinking. Frequent intake of raw vegetables and/or fruit in contrast reduced the risk of lung cancer among smokers. ‍Current obesity was positively associated with risk of post-menopausal breast cancer, recently on the increase in Japan. ‍However, all sites of cancer were linearly decreased with frequency of exercise in both males and females. Based on ‍these pieces of evidence and other main results obtained from the HERPACC studies, prevention trials with provision ‍of information about protective and risk factors for main sites of cancers to outpatients have been planned in parallel to ‍continuation of HERPACC.     

Brustkrebsfrüherkennung

In 2004 Germany implemented a national screening program closing up to other European countries. The effect on breast cancer mortality reduction has been proven with the highest level of evidence. The goal of any secondary preventive strategy is always nil nocere, therefore risks and undesired side-effects should be critically addressed and continuously evaluated to offer the possibility of early control. The women participating need comprehensive, understandable information to give informed consent. This aspect needs further improvement as well as the quality assurance of early breast cancer detection beyond mammography screening and the recommendations of the National Guidelines on Early Breast Cancer Detection should be integrated into routine medical care.     

Cancer Mortality in a Hanoi Population,Viet Nam, 1996-2005

Background: Hitherto, cancer mortality data have not been available in Viet Nam, so that the real public health ‍problem with this disease has yet to be addressed and recognized in the country with a population of over 80 million ‍in South East Asia. The aim of the present pilot study was to examine cancer mortality in a commune population of ‍Hanoi city, 1996-2005. Methods: Cancer data was accessed from the database of the population-routine-based death ‍registration performed by medical workers at commune health stations based on the guidelines of the Ministry of ‍Health at Hanoi city. All deaths occurring in the community were registered. This registration process was monthly ‍reviewed for each fatal case regarding the name, age, sex, address, occupation, date - place - cause of death, and ‍information concerning to pre - death medical care during the study period from Jan. 1996 to Dec. 2005. The list of ‍death and residents of the study population was carefully cross-checked with other information sources to avoid ‍under- or over-registration. The world population structure was used to estimate Age-standardized cancer mortality ‍rates per 100,000, (ASR). Results: During 60,770 person-years estimated from Jan. 1996 to Dec. 2005, 320 deaths ‍and their causes were registered. Among them, 100 cancer cases of all sites (66 males and 34 females) were included. ‍Cancer mortality rates were 222 and 109 (Crude), 353 and 115 (ASR), for males and females, respectively. For both ‍genders combined, lung cancer was the most common, 27 cases, followed by liver, 26 cases and stomach, with 19. ‍Proportion of death from cancer was about 31% of all causes. Conclusions: The present findings suggest that in Viet ‍Nam, a developing country, cancer is indeed an important public health problem.     

The First Cross Sectional Survey on Intracranial Malignancy in Kolkata,India: Reflection of the State of the Art in Southern West Bengal

Recent increase in the occurrence of intracranial malignancies and poor performance of therapeutic measures ‍have established the disease as an important concern of medical sciences. The lack of information about the disease ‍pattern throughout India creates problems for maintaining community health for prevention. The present study on ‍the hospital population of Kolkata was conducted to determine the incidence pattern of the disease in the population ‍of southern West Bengal, focusing on distribution with age, sex, occupation and religion in different districts of the ‍region, and characterizing diagnostic and therapeutic measures. Among a total of 39,509 cancer patients from 21 ‍health centers of Kolkata, 2.4% had brain cancers and among these more than 60% are gliomas. A cross-sectional ‍study for a period of 3 years reported the occurrence of 15 types of intracranial malignancy, which demonstrated ‍astrocytomas (36.8%), glioblastoma multiforme (GBM) (7.9%) and meningiomas (11.6%) to be predominant. Brain ‍tumors occur more frequently in males with few exceptions and the incidence was found to be highest among the 40- ‍49 year old group (20.2%). No specific trend for religion and occupation was apparent. However, the district wise ‍distribution showed maximum incidences among industrial areas, namely, Kolkata (33.1%), North 24-Parganas ‍(18.2%), Howrah (9.3%) and Hoogly (7.6%). Diagnosis of the disease was by CT scan, MRI and histological ‍identification (pre and post operative). Therapeutic procedures rely mainly on surgery and radiotherapy, whereas ‍chemotherapy was used as an adjuvant for about 10% of the cases. Evaluation of the scenario regarding intracranial ‍malignancy in this region was a long awaited requirement which should ultimately serve an important function in ‍pointing to risk zones within the population and allow better control measures to be introduced for the disease.     

Cervical Cancer Prevention and Early Detection; The Role of Nurse and Midwives

Worldwide 31% of cancers in women are in the breast or uterine cervix. Cancer of the uterine cervix is one of the ‍leading causes of cancer death among women. The estimated new cancer cervix cases per year is 500.000 of which ‍79% occur in the developing countries, where it is consistently the leading cancer and there are in excess of 233.000 ‍deaths from the disease. The major risk factors for cervical cancer include early age at first intercourse, multiple ‍sexual partners, low socioeconomic status, HSV, HPV infection, cigarette smoking and extended use of oral ‍contraceptives. Well organized and applied public education and mass screening programmes can substantially ‍reduce the mortality from cervical cancer and the incidence of invasive disease in the population. Women who are ‍health conscious are more likely to have used screening services (mammogram, pap-smear test) and performed ‍breast-self examination and genital hygiene. There are both opportunities and burdens for nurses and midwives ‍working in primary health care settings. This is a prime example of a role of public education in cancer prevention ‍with reference to population-based cancer screening programs. ‍     

Social and Geographic Predictors of Cancer Survival: Role of the Population-based Cancer Registry in Cancer Control

One of the objectives of a cancer registry is to provide survival information on subsections of the population that ‍have unfavorable outcomes. A cancer control strategy can be planned on the basis of such information. In the present ‍study, the data of the Songkhla Cancer Registry were analyzed to determine if social and geographic parameters ‍can be used to predict cancer survival. A total of 3423 cases identified in the population-based cancer registry of ‍Songkhla Province registered during 1990-1994, were the subjects of this study. The rest were excluded because of ‍unknown primary cancer sites. Eight leading primary cancer sites were focused on: oral cavity, pharynx, esophagus, ‍colorectum, lung, liver, breast, and cervix uteri. Predictors of survival were derived from items recorded in the ‍registry. Age, gender, extent of disease, cultural belief, life-style, and access to medical care were the predictors of ‍interest. Religion, urban environment, and distance to tertiary care centers were proxies for the last three parameters. ‍Kaplan-Meier plots, Cox regression, and log-rank tests were used for analysis of the hazard ratios. The results ‍revealed a significance of disease extent for survival from oral, colorectal, breast, and cervical cancers. Muslim ‍people had poorer survival rates than those of Buddhists for oral, breast, and cervical cancers. Women with breast ‍cancer living in distant from tertiary medical care centers had a poorer prognosis. For the non-aggressive cancers, ‍early detection and pretreatment counseling for the prevention of unnecessary incomplete treatment is recommended ‍for prolonged survival. With aggressive cancers such as lung, liver, and pharyngeal cancers, there were no significant ‍differences with these parameters investigated. Good quality of life provided by palliative care, not prolongation of ‍survival, is the ultimate goal of medical care services to such patients.     

Screening and Management of PreCancerous Lesions To Prevent Cervical Cancer in Low-Resource Settings

Cervical cancer is a leading cause of cancer death among women in low-resource settings, but it is completely ‍preventable by screening for and treating precancerous lesions. In this article, the current approaches to screening, ‍confirmation, and treatment of precancerous lesions of the cervix are reviewed from the perspective of low-resource ‍settings. Cervical cytology is compared to visual inspection with acetic acid (VIA) for screening women to detect ‍precancerous lesions. The use of colposcopy to confirm findings in women with positive screening test results and ‍various treatment methods are discussed. With one examination, cytology appears to detect fewer precancerous ‍lesions than VIA, but VIA has a lower specificity and labels proportionately more women falsely positive. When ‍available, colposcopy may be used to obtain directed biopsies from abnormal areas of the cervix to pathologically ‍confirm the findings in women with positive screening tests. Treatment with cryotherapy appears to be a safe, ‍acceptable, and effective procedure for the majority of precancerous lesions. Lesions that are not suitable for ‍cryotherapy because of endocervical canal involvement or large size are amenable to outpatient treatment by loop ‍electrical excision procedure (LEEP). HIV/AIDS and immune system suppression are associated with more rapid ‍CIN progression and HIV-positive women generally have high recurrence rates of CIN after treatment. Women ‍tempora may more readily transmit the virus after cryotherapy and, therefore, they require counseling regarding ‍abstinence and condom use. Highly active antiretroviral therapy (HAART) may cause CIN to regress and may ‍decrease the risk of cervical cancer in HIV-infected women. Cost-effectiveness modeling using South African data ‍shows that use of a single lifetime VIA test and immediate cryotherapy saves costs compared to cytology or to no ‍screening. VIA and cryotherapy are appropriate services for low-resource settings. Colposcopy and LEEP services ‍should be available on a referral basis. ‍     

Prostate Cancer Ambassadors: Enhancing a Theory-Informed Training Program for Informed Decision-Making

Despite the high burden of prostate cancer in African American communities, there is a paucity of knowledge about prostate health. This paper describes the enhancement of a curriculum for training lay health advisors, called prostate cancer ambassadors, on informed decision-making for prostate cancer screening. Adult learning theory informed the structuring of the training sessions to be interactive, self-directed, and engaging. Trainings were developed in a manner that made the material relevant to the learners and encouraged co-learning. The research team developed strategies, such as using discussions and interactive activities, to help community members weigh the pros and cons of prostate-specific antigen (PSA) screening and to make an informed decision about screening. Furthermore, activities were developed to bolster four social cognitive theory constructs: observational learning, self-efficacy for presenting information to the community and for making an informed decision themselves, collective efficacy for presenting information to the community, and outcome expectations from those presentations. Games, discussions, and debates were included to make learning fun and encourage discovery. Practice sessions and team-building activities were designed to build self-efficacy for sharing information about informed decision-making. Topics added to the original curriculum included updates on prostate cancer screening, informed decision-making for screening, skills for being a lay health advisor, and ethics. This dynamic model and approach to lay health advisor (ambassador) training is flexible: while it was tailored for use with prostate cancer education, it can be adjusted for use with other types of cancer and even other diseases.     

Cervical Cancer: Etiology,Pathogenesis, Treatment,and Future Vaccines

Cervical cancer is a sexually transmitted disease caused by the human papillomavirus (HPV), especially HPV-16 ‍and -18. Of the half million new cases of cervical cancer reported yearly, 20% occur in India. Mass cancer screening ‍programs to detect and treat cervical cancer and its precursor lesions are not available in India and most other ‍developing countries because of the lack of resources. Curative and palliative treatments are not the same for all ‍patients with cervical cancer because the result depends on the immunological response of the patient. This article ‍describes the natural history of cervical carcinogenesis and the rational behind various modalities of prevention and ‍treatment for the practising gynecological oncologist. Prophylactic vaccines against HPV-16 and -18 and therapeutic ‍vaccines against cervical cancers should be able to overcome the logistical problems that now exist to screen, diagnose ‍and treat cervical cancer and its precursor lesions. ‍     

'The doctor knows best' revisited: physician perspectives

An ethnographic study was undertaken to observe in vivo medical encounters between oncology physicians and breast cancer patients. The aim of the study was to gain an inside view of how physicians and patients conceptualize the decision making process during cancer diagnosis and treatment. The confluence of the changes in the role of women in society, the shifting requirements for the delivery of medical services and a complex array of medical options have all contributed to changes in the role of the physician from 'the doctor knows best' to a more reciprocal role. The study revealed physician-patients perspectives that may facilitate future medical encounters. In addition, some troubling practices were observed that raise dilemmas about the parameters of informed consent and ethical concerns regarding how medical options are presented.     

The Coverage of Cervical Cancer Screening in Khon Kaen,Northeast

Cervical cancer is a common cancer in Thai women and one of the only cancers that can be readily cured if early ‍detection is successful. The Pap smear is an accepted as an appropriate means for cervical cancer screening at ‍present. However, there are still some management problems with early detection programmes. Since data showing ‍how many women have been screened by Pap smear are limited in Thailand, the present study was conducted with ‍the aim of determining coverage in a defined population in the sample area, Thakaserm sub- district in Nampong ‍district, Khon Kaen province, Thailand. The investigation was carried out during June-August 2000 to collect ‍information on history of screening for cervical cancer using questionnaires. All women aged 20 and above were ‍asked to answer the set of questionnaires a total of 1,199 women responded. There were 66.9% that reported having ‍received a Pap smear test for screening for cervical cancer at least once. However, there were 33.1 % that had never ‍undergone a Pap smear in their life. It is important to find a strategy to increase the coverage of cervical cancer ‍screening programme for this population. ‍     

Bioethical issues and principles in cancer treatment]

Bioethics was established as a new area of interdisciplinary studies focusing on human conduct in the field of the life sciences and health care in the light of moral values and principles in the 1960's and the beginning of the 1970's. Physicians abiding by classical medical ethics based upon the Oath of Hippocrates became subject to criticism because they behaved paternalistically in relation to their patients and provided medical treatment dogmatically without adequate explanation concerning conditions and diagnoses of patients' diseases, what kinds of treatments they were to receive and the possible benefits and risks thereof, along with their prognoses. During the patients' rights' movement, law suits against paternalistic physicians increased in number and the courts tried to establish ethical and legal principles for judgments in law suits using the Ethical Code of Neurenberg (1947) as an excellent model. The legal principles established as "informed consent" include obligations of physicians to provide their patients with adequate explanation and truth-telling, and the rights of patients to autonomy, choice, self-determination, and to give consent to physicians. Besides these rights, patients also have the right to put their veto on their own rights. In such cases, truth-telling by physicians, who believe in truth-telling, such as the disclosure of the diagnosis of cancer to these patients, can legally result in infringement of the patient's rights. It is important for physicians to respect the wishes and opinions of patients based on their own values and not to insist on personal dogmatic opinions. The disclosure of cancer diagnosis to terminal patients is certainly one of the most difficult procedures in medical practice and requires profound medical experience and bioethical insight.     

Misperceptions of medical understanding in low-literacy patients: implications for cancer prevention.

BACKGROUND: Patients with limited literacy skills often have difficulty understanding medical information, are less likely to undergo cancer screening, and present with cancer at later stages than patients with better literacy skills. Since primary care physicians are responsible for performing or initiating the majority of cancer screening in the United States, they need to be able to not only identify patients who might not understand medical information but also communicate effectively with them about cancer prevention and screening. METHODS: To determine whether family medicine residents could identify patients who might have difficulty understanding medical information because of limited literacy, we measured the literacy skills of patients in a university-based family medicine clinic using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). After the patients completed their office visits with a physician, we asked family medicine residents to rate the patients' ability to understand medical information. RESULTS: Among 140 patients who met with 18 family medicine resident physicians, 24% had limited literacy skills based on testing with the S-TOFHLA. Residents identified only about half of these patients as having poor or below average understanding of medical information. CONCLUSIONS: IN many cases, family medicine residents are unable to identify patients who, based on assessment of their literacy skills, are likely to have difficulty understanding medical information. When working with residents, medical educators should promote the habit of taking poor literacy into account when communicating with patients.     

Changes in Incidence of in situ and Invasive Breast Cancer by Histology Type following Mammography Screening

Objective: To investigate secular trends and correlates of incidence of breast cancer by histology type following ‍the introduction of population-based mammography screening. Methods: Analysis of age-standardised incidence ‍rates for 1,423 in situ and 16,157 invasive carcinomas recorded on the South Australian population-based cancer ‍registry for the 1985-2004 diagnostic period. Multiple logistic regression was undertaken to compare sociodemographic ‍characteristics by histology. Progression from in situ disease was investigated using the Kaplan-Meier ‍method. Results: The incidence of in situ lesions increased approximately seven-fold over the 20-year period, compared ‍with an increase of about 40% for invasive cancers. The increase for in situ lesions was due to increases for ductal ‍carcinomas, with little change for lobular lesions. By comparison, the percentage increase in incidence for invasive ‍cancer was greater for lobular than ductal cancers. Both for in situ and invasive cancers, percentage increases were ‍greatest for the screening target age range of 50-69 years. One in 14 in situ cases was found to progress to invasive ‍cancer within seven years of diagnosis, but insufficient detail was available to determine whether the invasive cancers ‍were a progression of the in situ lesions or whether they originated separately. These invasive cancers were smaller ‍than generally applying for other invasive cancers of the female breast. Conclusions: The larger secular increases in ‍incidence for in situ than invasive cancers would reflect the dominant role of mammography in the detection of ‍ductal carcinoma in situ. The lack of an increase for lobular in situ lesions may have resulted from their poorer ‍radiological visibility. The greater percentage increase for lobular than ductal invasive lesions may have been due to ‍an increase in imaging sensitivity for these lesions, plus real increases in incidence. The smaller sizes of invasive ‍cancers found in women with a prior in situ diagnosis may have resulted from more intensive medical surveillance, ‍although the possibility of biological differences cannot be discounted.