Early breast cancer deaths in women aged 40-74 years diagnosed during the first 5 years of organised mammography service screening in north Sweden

The aim of this study was to analyse individual cases of lethal breast cancer and not to evaluate the screening programme. Women aged 40-74 years who were diagnosed with breast cancer in 1990-94 and died on or before 31 December 1998, during the gradual introduction of organised mammography service screening in north Sweden, were included in the study. Out of 342 breast cancer deaths, 280 (82%) were in symptomatic patients whose cancers were clinically detected. Most breast cancers that proved fatal were already in an advanced stage and/or of high histological grade at the time of detection. A shift towards a lower stage was seen among screen-detected and interval-detected fatal cases. In a few of the cases with fatal outcome, in patients primarily presenting with histological grade I tumours of various sizes or small screen-detected tumours less than 10mm in size, early diagnosis by mammography followed by state-of-the-art treatment did not seem to have been enough to prevent death.     

A comparative audit of prevalent,incident and interval cancers in the Avon breast screening programme.

The 4th year of the Avon breast screening programme comprises two distinct groups: those called for screening for the first time (prevalent group) and those who were initially screened 3 years earlier (incident group). The cancer detection rate, stage of disease and rate of interval cancers in these patients have been compared. For the prevalent groups of year 1 and year 4 there was no statistically significant difference in the cancer detection rate, proportion of small tumours or node positivity. For the prevalent and incident groups of year 4, there was no statistically significant difference in the cancer detection rate or proportion of small tumours. There were significantly fewer node-positive tumours in the incident group (5/45 vs 8/23; P < 0.05). Fifty-six interval cancers presented in the 3-year period between years 1 and 4 of screening; 28 (50%) after 24 months. The screening programme may result in tumours being detected at an earlier stage, but this may be offset by the high rate of interval cancers. This suggests that the time between screens may need to be reduced to 2 years.     

Dual reading in a non-specialized breast cancer screening programme

This paper evaluates the contribution of dual reading to cancer detection rates in a non-specialized breast cancer screening programme in the Bouches-du-Rh e district (France). All mammograms were read first by one of 120 field radiologists and secondly by one of six experts at the coordinating centre. All women with at least one positive reading were recalled. 2799 of the 77 236 women screened were recalled by the field radiologist and 1770 by the expert. The expert detected an additional 15% (62/427) of cancers. 49% of these tumours were smaller than 10 mm and 38% of grade 1. The marginal cost of dual reading was $4,040 per additional cancer detected and 4.6% of total programme costs. In our decentralized programme, dual reading allows for the detection of good prognosis cancers which are missed by an isolated reader. The effects of dual reading on screening quality greatly outweigh its costs.     

Screen‐detected breast cancer compared to symptomatic presentation: An analysis of surgical treatment and end‐points of effective mammographic screening

Background : Mammographic screening has been shown to reduce mortality from breast cancer and to offer more opportunity for breast conservation surgery (BCS). The minimum standards (or surrogate end‐points) that need to be achieved by a screening programme if it is to reduce mortality have been derived from the Two County Study. Three surrogate end‐points that can be used to gauge the quality of the screening service are that 50% of the identified infiltrating cancers should be < 15 mm; at least 30% of grade 3 cancers should be < 15 mm; and 70% of screen‐detected cancers should have a negative axillary dissection. The present study assesses these end‐points of effective screening in an urban population referred to The Strathfield Breast Centre (TSBC). The screening end‐points and surgical treatment of one group of women referred with a BreastScreen New South Wales (NSW)‐detected breast cancer (screen group) were compared to all the other, mostly symptomatic, breast cancer referrals (symptom group). The problems with the current pattern of acceptance of mammographic screening in TSBC’s referral area are discussed. Methods : A prospective non‐randomized study was done via analysis of the prospective database at The Strathfield Breast Centre (TSBC). Results : There were 224 women in the screen group and 657 women in the symptom group. The mean tumour size was 18.1 mm in the screen group and 22.1 mm in the symptom group. There were significantly more small invasive cancers (< 15 mm) in the screen group (58%) compared with the symptom group (33%; P < 0.001). In the screen group there were more low‐grade tumours but 30% of grade 3 tumours were < 15 mm compared with 16% in the symptom group (P = 0.009). In patients with invasive cancers who underwent axillary dissection, there was a significant difference in axillary node negativity, being 72% in the screen group and 59% in the symptom group (P = 0.003). In the screen group 64% of women had BCS compared with 51% in the symptom group (P = 0.002). Conclusions : These end‐points of effective mammographic screening were met in the BreastScreen NSW group of women who were referred to TSBC despite the biases involved which could lessen the effectiveness of the screening programme. This crudely translated into a significant reduction in breast cancer mortality but selection and lead time bias has to be taken into account in evaluation of these data. There was a significantly greater chance of BCS in the screen group.     

Breast cancer screening programme in The Netherlands: an interim review

The year 1988 saw the introduction of a nationwide breast cancer screening programme in the Netherlands. Some 10 years on, a network that extended throughout the country was in place and all women in the target group had been invited to undergo screening at least once. Of the original target group, which was made up of women aged 50-70, around 80% responded to this invitation, an indication of their trust. Is that trust justified? and do the results justify the enormous effort of all those who make the screening programme possible, the cooperation of the nearly 4 million women who by now have taken part and the 17 million pound sterling that are currently needed per year to fund the programme? The time has come to assess and review. The ultimate test is obviously whether women participating in the screening programme have a lower chance of dying of breast cancer than women not participating in the programme. Yet, as the breast cancer screening programme is one of the best documented facilities in the Dutch health care system, a reliable mid-term review can be made. The article by Fracheboud that appears in this issue provides a number of important results. Important elements of this programme are considered in this review.     

Practicalities of developing a breast magnetic resonance imaging screening service for women at high risk for breast cancer

Background: Demand for screening breast magnetic resonance imaging (MRI) for women with a hereditary predisposition to breast cancer has increased since the introduction of a medicare item number. To aid future service planning, we examined the practicalities of establishing and running a breast MRI screening programme for high risk women and to describe the early outcomes of our screening programme. Methods: We undertook a retrospective audit of prospectively collected data. Women <50 years of age with an inherited BRCA1 or BRCA2 gene mutation were invited to undergo annual breast screening with MRI in addition to mammography and clinical breast examination. We assessed process times for booking, performing and reporting MRIs; MRI findings and ease of interpretation; patient recall rate; MRI cancer detection rate; and patient satisfaction via questionnaire. Results: From 2006 to 2009, 82 women completed a round one screening MRI and 45, 21 and one women completed second, third and fourth round annual MRI studies, respectively. Median MRI process times were: booking 20 min; attendance in radiology department 90 min; imaging duration 45 min; reporting by one radiologist 30 min. Of the 82 round one studies, 23 (28%) were reported as ≥Breast Imaging Reporting and Data System three requiring further investigation. Of the round two and three studies completed, 13/45 (28%) and 2/21 (9%) have been recalled, respectively. Seven malignancies were detected. Questionnaires revealed women were satisfied with the service. Conclusions: Significant time, staff and equipment is required to run an effective breast MRI screening programme and this must be considered by future service providers.     

Survival after treatment for breast cancer in a geographically defined population

BACKGROUND: South East Sweden with 976 000 inhabitants is served by nine hospitals with specialized breast surgeons. Population-based mammographic screening was introduced in 1986 for women aged 40-74 years. Patients with primary breast cancer were treated according to a joint management programme. METHODS: All patients were reported to a regional cancer registry from which breast cancer incidence, treatment and survival in this defined population were reported. RESULTS: A total of 7892 women had their first invasive breast cancer diagnosed between 1986 and 1999. The median tumour size was 17 mm and 29.9 per cent had axillary metastases. Some 49.8 per cent of these women had a modified radical mastectomy and 31.9 per cent had a segmental resection with axillary clearance. Postoperative radiotherapy was given to 40.3 per cent of the women after mastectomy and to 87.1 per cent after breast-conserving surgery. Tamoxifen and chemotherapy were used as adjuvant treatment except in low-risk patients. Breast cancer-specific survival rate for all stages was 83.5 per cent at 5 years and 74.0 per cent at 10 years. Respective values were 95.8 and 90.9 per cent for patients with stage T1 N0 M0 tumours, and 77.7 and 62.4 per cent for those with T1-2 N1 M0 tumours. CONCLUSION: Breast specialists treating women with breast cancer according to a joint management programme have achieved very good survival rates.     

CHARACTERISTICS AND TREATMENT OF BREAST CANCERS 10 MM OR LESS DETECTED BY A MAMMOGRAPHIC SCREENING PROGRAMME

Background : Small invasive breast cancers up to 10 mm in size have an excellent prognosis and are being detected in increasing numbers by mammographic screening, yet optimal treatment remains controversial. Methods : A review was made of pathology and treatment data relating to 100 consecutive invasive breast cancers up to 10 mm in size detected among 52 126 women who were screened over a 32-month period. Results : The most common radiological finding was a stellate lesion (44%). Thirty-three cases had an extensive in situ component in addition to the invasive tumour, and included among these were seven ductal carcinoma in situ (DCIS) cases with microinvasion. Of 79 patients who had axillary dissections, seven (9%) were node-positive. Tumours ≤ 5 mm were as likely to be node-positive (11%) as those 6–10 mm in size (8%). Positive nodes were found only in patients with more than five nodes excised. Breast conservation surgery was performed in 84% of patients treated by surgeons associated with the programme, and 63% of patients were treated by other surgeons (P= 0.054, exact test). Breast radiation after breast conservation surgery was used in 44% of the cases, but was almost twice as likely to be used if the tumours were > 5 mm (51%) than if the tumours were >5 mm (29%). Adjuvant tamoxifen was given to 61% of the cases. Conclusions : We found that small invasive breast cancers are commonly treated by breast conservation, which usually includes axillary dissection. Even the smallest may be node-positive, and there is uncertainty about the place of adjuvant radiation therapy and tamoxifen.     

THE COSTS OF TREATING BREAST CANCER IN AUSTRALIA AND THE IMPLICATIONS FOR BREAST CANCER SCREENING

The aim of the study was to determine if there is a relationship between the stage of breast cancer at the time of detection and the costs of treatment and to assess whether any such relationship would have an influence on the cost of a mammographic screening programme. A retrospective analysis of the stage at presentation for primary breast cancer and the treatment costs over the duration of treatment was made. Multiple regression analysis was employed, with treatment cost as the dependent variable and categorical variables to represent stage at detection. A total of 301 women whose treatment for breast cancer commenced at the Royal Brisbane Hospital participated in the study. A statistically signficiant relationship was found between the stage of disease at the time of detection and subsequent treatment costs; more advanced stages of disease incurred higher treatment costs. This relationship was robust even after taking into account the age of patients, their discharge status, and differences between patients in the duration of treatment. When the effect of earlier detection on treatment cost was assessed in relation to a breast screening programme, cost savings were estimated to be in the range of 8–36% of total screening costs. There are treatment cost savings to be gained from breast cancer screening as a result of the detection of earlier stages of disease. These treatment cost savings should be offset against the cost of a mammographic screening programme.     

Does the location of colorectal carcinoma differ between screened and unscreened populations?

Aim Screening for colorectal malignancy using faecal occult blood testing is established across the UK. In NHS Grampian the programme was introduced in 2007. Previous studies have reported no difference in anatomical locations of cancers detected by screening programmes compared with those in unscreened populations. This study aims to review the location of tumours detected in an established screening programme compared with those diagnosed through symptomatic presentation within the same population. Method All patients discussed at the regional multidisciplinary meeting between June 2007 and August 2011 were included. Data were collated prospectively from multidisciplinary team records while site of tumour was documented from radiology, endoscopy, operative and pathology reports. Comparative statistics (χ²) were performed using spss 19. Results Of 1487 patients included 255 were detected via the screening programme and 1232 from symptomatic presentation. More left sided tumours (splenic flexure to rectosigmoid) were detected via screening (P = 0.005). Of non‐screened patients (n = 1232), 456 (37%) tumours were right sided (caecum to distal transverse colon), 419 (34%) were left sided and 357 (29%) were in the rectum. This compares with the screened group (n = 255): right sided 74 (29%), left sided 113 (44%) and rectal 68 (27%). Conclusion More left sided tumours appear to be detected in screened patients compared with symptomatic presentation, contrary to previously published work. These results may be worthy of further consideration given the ongoing debate on the optimal means of screening.     

Interval breast cancer: is it a different type of breast cancer?

We have compared tumour type, tumour size, tumour grade and axillary lymph node status in three groups of women, 230 interval breast cancers (IC) in the West Sussex Breast Screening programme and 625 screen detected (SD) cancers and 916 symptomatic (S) cancers treated at Worthing Hospital between July 1989 to April 1996. Our true interval cancer detection rates were 5.28, 11.28 and 15.3 per 10,000 screened women for the 1st, 2nd and 3rd year after screening. The proportionate incidences of true interval cancer were 29%, 61% and 82% for the 1st, 2nd and 3rd year, similar to others' programmes in UK. In our programme a large proportion (42%) of IC and more than half of the true IC presented in the 3rd year after screening. Out of 230 interval cancers, 40% (90) were unclassifiable, the remaining 60% (140) were classified as: True interval cancers (T) 54% (76), False Negative Subtle (FNS) 12% (16), Occult (O) 12% (17), and 22% (31) as False Negative (FN). Analysis of interval cancers according to their classification did not demonstrate any significant difference with respect to tumour size (chi2 5.59, df 4, P=0.22), tumour grade (chi2 5.29, df 4, P=0.25) and axillary node status (chi2 3.16, df 4, P=0.53) thus establishing interval cancers as a single group. Invasive ductal carcinoma of no specific type was the main tumour type in all three groups. Analysis of variance (ANOVA) showed significant differences in size between the groups (df 2, F=71.36, p<0.0001). Symptomatic cancers were 1.19 times the size of IC while SD were 0.83 times the size of IC. The difference in groups in terms of tumour grade was significant (Kruskal-Wallis test chi2 33.31, df 2, P<0.0001). The incidence of grade 2 tumours was similar in the three groups while a third of the IC and S were grade 3 tumours. Comparison of axillary node status showed a significant difference between the three groups (chi2 26.59, df 2, P<0.0001). When means and 75th percentiles were compared IC had the greatest number of positive nodes while SD had the smallest number of positive nodes. Interval cancers are the middle spectrum between symptomatic and screen detected breast cancers and represent small cancers (<10 mm) not detected at the time of screening and de novo cancers developing in the screening interval. The need for improving the sensitivity of current screening methods and identifying newer methods of breast cancer detection is highlighted by our study.     

Tumour size distribution in mammography screening

Many mammography screening programmes have not been able to show higher percentages of small invasive cancers detected at subsequent screens than at initial screens. This has been a matter of serious concern as it contradicts the very theory of screening. Based on data from the county of Fyn, Denmark we evaluated the distribution based on point estimates, as well as on the entire tumour size distribution. The programme changed the amount of tumours less than 15 or 20 mm, but did not change the amount of tumours less than 10 mm. We evaluated the entire tumour size distribution and found that screen number was the only significant factor, implying that the number of screens changed the tumour size distribution. We recommend that the entire tumour size distribution is used to evaluate the ability of a programme to detect small breast cancers, instead of only point estimates as has previously been the practice.     

MAMMOGRAPHIC FOLLOW UP: A VITAL COMPONENT OF BREAST CANCER MANAGEMENT

Women with proven breast cancer are at high risk for development of a second breast malignancy or a recurrence. An important component of clinical care is regular mammographic follow up, to enable pre-clinical diagnosis and avoid delay in treatment. One hundred and forty-two women with previous breast cancer attended a pilot mammographic screening program. Eleven had suspicious mammographic lesions, all clinically occult; nine breast cancers were diagnosed (two recurrences and seven new tumours). The cancer detection rate in this high-risk group of women was 6.3%, compared with 0.8% in 16 283 women screened with no history of breast cancer. Examination of the mammographic history of the 142 women showed that mammography was used infrequently as part of their clinical surveillance, and this led to a delay in diagnosis of the new or recurrent cancer. Recommendations for an appropriate regimen for use of mammography in new and established cases of breast cancer are made.     

What about the other breast? A review of a series of bilateral breast carcinomas

The BreastScreen Queensland Brisbane Southside BreastScreen Service reports on a study of 10 cases of bilateral breast carcinomas from a total cancer population of 217 cases. All cases were patients of screening examinations that were recalled for a suspicious lesion in one breast. Two cases were mammographically suspicious of bilateral tumours. In eight cases, tumours were ultrasonically visible in both breasts and in two further cases, the suspicion of bilateral malignancy was raised by the presence of bilateral microcalcification. It is not the purpose of this paper to provide a statistical analysis of the occurrence of bilateral breast cancer. This is a radiological paper from a breast screening service reporting on findings that conventional wisdom may find unusual. The incidence of bilateral breast malignancy in the study was found to be somewhat higher than expected. These cases have been diagnosed by the utilization of a particularly high standard of ultrasound and mammography, performed and interpreted by diagnosticians possessing an elevated level of suspicion of the possible presence of a second primary lesion. It is therefore proposed that an increased rate of diagnosis of bilateral tumours is possible with an evolution of assessment protocols, combined with quality ultrasound and mammography.     

Alteration in colonic epithelial cell DNA associated with intestinal neoplasia: selection of high risk patients

The proliferative activity of the colonic crypts of patients who are at high risk of developing colonic tumours has been assessed. Cells from the upper parts of the colonic crypts were collected at colonoscopy, and were stained for DNA by the Feulgen technique. Using a microdensitometer the DNA content of the cells was measured and a proliferative index calculated. Patients with single neoplasms had a proliferative index similar to controls although individual patients with hyperplastic mucosa could be identified. Patients with multiple neoplasms had an elevated proliferative index. These results may form the basis of a screening programme for colonic tumours.     

Nationwide breast cancer screening programme fully implemented in The Netherlands

The period 1990-1997 saw the implementation of a nationwide breast cancer screening programme in the Netherlands, which provided biennial mammography for all women aged 50-69 years (50-75 years at present). The National Evaluation Team monitors the programme annually collecting regional data on screening outcomes; regional cancer registries provide data on interval cancers and on breast cancers in unscreened women by linkage of cancer registry data to data on screened women. Of 4 million women invited, 78.5% attended for screening. Screening resulted in 13.1 referrals, 9.2 biopsies and 6.1 breast cancers detected per 1000 women screened initially (6.9, 4.5 and 3.5 per 1000 in subsequently screened women, respectively). Within the first 2 years following screening 0.95 interval cancers per 1000 women-years were diagnosed. The stage distribution of screen-detected cancers was more favourable than that of interval cancers and of those diagnosed in unscreened women. The results are largely consistent with expectations. Results may nonetheless be further improved, particularly the detection rate in subsequent screens.     

Importance of early diagnosis in the improvement of prognosis in breast carcinoma: non-palpable lesions. Preliminary results

There are still marked differences in the current indications for breast screening proposed by the various international school of oncology. Epidemiological data to the effect that breast screening in asymptomatic women aged over 50 reduces the death rate due to breast cancer now appears to be widely accepted, but an analogous finding for women aged between 40-49 has not yet been confirmed. Following a brief analysis of the most important breast screening programmes carried out to date, the Authors report the preliminary results regarding the identification and biopsy of non-palpable breast lesions during the course of a screening programme in 1986 by the Dept. of Cancer Surgery. Of a total of 1128 breast scans in asymptomatic patients aged between 40 and 73, 24 suspect (1.9%) non-palpable lesions were found of which 5 (20.8%) proved to be carcinomas.     

Film reading practice of UK breast screening units

The objective was to review current film reading practices of UK breast screening units, particularly double reading of mammograms, the use of non-radiologists, and workload using a postal questionnaire survey sent to directors of all UK breast screening units. There are wide variations between screening units in manpower, workload, the use of nonradiologists, and methods of film reading and the rationale for them. Approximately 76% of all screening films in the UK are currently double read. Given that double reading is widespread in the UK, steps may need to be taken to ensure that it is done as cost-effectively as possible. Manpower, training and resource issues will need to be addressed if any further extensions to the UK breast screening programme are considered.     

Women's acceptance of MRI in breast cancer surveillance because of a familial or genetic predisposition

Magnetic resonance imaging (MRI) of the breasts is a promising screening modality for early detection in women at increased breast cancer risk. We investigated the subjective experiences with MRI and the preferences for MRI, mammography or clinical breast examination in 178 high-risk women adhering to a breast cancer surveillance programme. MRI was reported to cause limited discomfort. About 44% preferred MRI as a screening test (mammography: 14%). MRI provided the most reassurance of breast cancer being absent in case of a favourable test result. MRI seems to be acceptable as a screening test for women at increased breast cancer risk and is preferred by them over mammography.     

Immunohistochemical detection of a germline BRCA1 mutation in a breast and ovarian cancer family

Tumours from four individuals in a breast and ovarian cancer family with a known deleterious germline BRCA1 mutation, were analyzed using BRCA1 antibodies. In addition, we examined tumours from 96 female patients with early-onset breast cancer, who were not selected because of any family history. Paraffin-embedded tumour sections were examined by standard immunohistochemical analysis. Three familial tumours from BRCA1 carriers displayed focal negativity. This observation was not seen in a non-mutation carrier from the same family. It was found that 9/96 (9%) early-onset breast tumours had total BRCA1 negativity. In addition, 2/2 (100%) medullary breast carcinomas displayed negativity for both antibodies. Our results indicate that BRCA1 antibodies can discriminate between familial tumours with and without a deleterious mutation from one family. Further mutation studies in early-onset breast cancer group will be necessary to evaluate the use of immunohistochemistry as a rapid, initial screening technique to identify BRCA1 mutations.