The characteristics of interval breast cancer in mass screening.

To investigate the characteristics of interval breast cancer in mass screening, comparisons were made of the following three groups: interval group (21 interval breast cancer cases), mass screening group (87 breast cancer cases detected by mass screening) and outpatient group (266 breast cancer cases diagnosed at outpatient clinics). There were no differences among the three groups in terms of the case distribution by age or obesity, but significant differences in the case distribution according to nodal involvement and tumor size. Histological grading of the malignancy of the primary tumors disclosed that the incidence of breast cancer showing frequent mitoses was high in the interval group compared to the mass screening and outpatient groups. The 7-year cumulative disease-free survival rate was 75.3% in the interval group, 90.0% in the mass screening group and 83.1% in the outpatient group. The mean tumor size of the interval cases at the time of mass screening, back-calculated on the basis of the estimated tumor doubling time, was 1.5 cm in diameter, smaller than that of the mass screening group. It is surmised that interval breast cancer is characterized by marked proliferation of the tumor cells and has a poorer prognosis than the other group cases. These findings might be due to the marked proliferation of interval breast cancer rather than because of cases having been overlooked at the time of the last screening.     

Mammography screening and trust: The case of interval breast cancer

Interval cancer is cancer detected between screening rounds among screening participants. In the Norwegian Breast Cancer Screening Programme, 19 per 10,000 screened women are diagnosed with interval cancer. We conducted semi-structured interviews with 26 such women. The women interpreted their interval breast cancer in two ways: that mammography can never be completely certain, or as an experience characterized by shock and doubts about the technology and the conduct of the medical experts. Being diagnosed with interval cancer thus influenced their trust in mammography, but not necessarily to the point of creating distrust. The women saw themselves as exceptions in an otherwise beneficial screening programme. Convinced that statistics had shown benefits from mammography screening and knowing others whose malignant tumours had been detected in the programme, the women bracketed their own experiences and continued trusting mammography screening. Facing a potentially lethal disease and a lack of alternatives to mammography screening left the women with few options but to trust the programme in order to maintain hope. In other words, trust may not only be a basis for hope, but also a consequence of it.     

The evolving role of new imaging methods in breast screening

The potential to avert breast cancer deaths through screening means that efforts continue to identify methods which may enhance early detection. While the role of most new imaging technologies remains in adjunct screening or in the work-up of mammography-detected abnormalities, some of the new breast imaging tests (such as MRI) have roles in screening groups of women defined by increased cancer risk. This paper highlights the evidence and the current role of new breast imaging technologies in screening, focusing on those that have broader application in population screening, including digital mammography, breast ultrasound in women with dense breasts, and computer-aided detection. It highlights that evidence on new imaging in screening comes mostly from non-randomised studies that have quantified test detection capability as adjunct to mammography, or have compared measures of screening performance for new technologies with that of conventional mammography. Two RCTs have provided high-quality evidence on the equivalence of digital and conventional mammography and on outcomes of screen-reading complemented by CAD. Many of these imaging technologies enhance cancer detection but also increase recall and false positives in screening.     

Compliance after 17 years of breast cancer screening: Factors associated with reattendance for periodic breast screening

The motives and reasons for regular attendance, irregular attendanceand drop-out were studied in women who were enrolled in a biennialbreast screening programme in 1975 and who were invited to eachsubsequent screening round until 1992. Three compliance groupswere compared: ‘attended all rounds’ (group A, n=79),‘missed 1 or 2 rounds’ (group B, n=73) and ‘missedmore than 2 rounds’ (group C, n=64). The groups did notdiffer with respect to background variables such as sociodemographiccharacteristics, actual health problems or preventive healthorientations, but significant differences were found in generalattitudes to breast screening and to the organizational aspectsof screening procedures. The results suggest that during thecourse of a screening programme, for a substantial group ofnot strongly motivated women, the recurring negative aspectsof mammography (pain and anxiety) are increasingly becominga burden. ‘Circumstantial factors’ like waitingfor one's turn, the distance to the screening centre and incidentaldissatisfaction with handling by screening staff, appear totrigger the decision to skip screening rounds or to drop outof the programme. From the perspective of maintaining a regularattendance throughout the programme this is an important group.Special efforts must be made to encourage these women to stayin the programme.     

Time interval since last test in a breast cancer screening programme: a case-control study in Italy.

STUDY OBJECTIVE: To evaluate a population based screening programme for breast cancer. DESIGN: This was a case-control study of women dying of breast cancer between 1977 and 1987 who had been invited to take part in a screening programme. SETTING: Community based study of women aged between 40 and 70 years (total population about 35,000 at 1981 census), living in 23 small towns near Florence, Italy. PARTICIPANTS: 103 cases were identified from death certification, and 515 living controls (five per case) selected for year of birth and town of residence. MEASUREMENTS AND MAIN RESULTS: Screening history was obtained from computer archive. Sociodemographic information was obtained from town registry offices and directly from relatives of the deceased and from the controls by postal questionnaire, and if necessary telephone or personal interview. Analysis was carried out on two age groups--40-49 years and 50+ years at diagnosis--and considered the number of screening tests and the time interval since the last test, separately and together. In the older age group, women with at least one screening test in the previous 2 1/2 years showed a 50% reduction in risk (odds ratio 0.49, 95% confidence interval [CI] 0.25-0.95). If they had also had another previous negative screen the risk was reduced to one third (odds ratio 0.35, 95% CI 0.14-0.85). There was a significant trend of decreasing risk with increasing number of screens in older women. No clear evidence of a similar protective effect was shown for women in the 40-49 year age group. CONCLUSIONS: A significant protective effect of the screening programme is evident in older women but not in younger ones. The data do not allow an assessment of optimal screening interval because of the small number of previously screened cases.     

The concept of screening medicine in oncology

Screening medicine is a basis of a suggested new concept; it comprises: an evaluation of the basic health fund within the terms of real time; continuity of the medical, ecological, epidemical, congenital and genetic information collected within the medical passport; as well as synthesis of the obtained data and monitoring of patients. The above concept enables a qualitatively new approach to coping with issues of individual health and to rendering a high-quality medical care in oncology.     

Adjusting for covariates in studies of diagnostic, screening, or prognostic markers: an old concept in a new setting

The concept of covariate adjustment is well established in therapeutic and etiologic studies. However, it has received little attention in the growing area of medical research devoted to the development of markers for disease diagnosis, screening, or prognosis, where classification accuracy, rather than association, is of primary interest. In this paper, the authors demonstrate the need for covariate adjustment in studies of classification accuracy, discuss methods for adjusting for covariates, and distinguish covariate adjustment from several other related, but fundamentally different, uses for covariates. They draw analogies and contrasts throughout with studies of association.     

The pretentions and achievements of cancer screening,in particular breast cancer screening

The 'Vereniging Nederlands Tijdschrift voor Geneeskunde' (Dutch Journal of Medicine Association) recently held a conference about the doubts expressed in recent publications concerning the value of cancer screening and breast-cancer screening in particular. In this the discussion mainly focused on whether disease-specific mortality or overall mortality should be taken as an endpoint in the evaluation of the screening procedure. In a recent advisory report, the Health Council of the Netherlands stated that the present form of breast cancer screening ought to be continued in the Netherlands for the time being. However, during the conference it was emphasized that cancer screening must be viewed as a highly complex system. Therefore, it is impossible to measure the effects of screening by considering just one end-point, such as cancer-specific mortality. The opinion was also expressed that with the introduction of new forms of cancer screening (e.g. colon or prostate-cancer screening), experience should first of all be gained with the small-scale screening of persons with an elevated risk. This is a task in which the government should lead the way. Furthermore, the government will also need to regulate the enthusiasm that can be expected for various types of secondary preventative diagnostics offered on the free market, including cancer screening. Another important aspect of cancer screening is ensuring that the general public are thoroughly and carefully informed about the pros and cons of cancer screening. The public must know that although cancer screening can save lives, it also causes harm. People scarcely realise that screening may more often involve a loss of carefree years of life than a small chance of living longer.     

Simulated lifetime costs of three types of employer-based, periodic, breast cancer screening programs for working-age women

PURPOSE. To estimate the lifetime cost of three types of employer-sponsored breast cancer screening programs and to identify factors influencing cost. DESIGN. A computerized decision analysis model was constructed to compare lifetime costs of providing breast cancer screening in each of three screening programs: on-site within an employer, mobile unit visiting the employer, and off-site. SUBJECTS. Three hypothetical cohorts of 10,000 female employees 38 years of age at time of first screening. INTERVENTION. A cohort was enrolled in each screening program and received screening from age 38 through age 64. Employees continued to receive benefits related to breast cancer until age 100 or death. MEASURES. Costs in the model included those for screening, workup for a suspicious mammogram, treatment for breast cancer, short-term losses in employee productivity, and disability due to breast cancer. APPROACH. The model was used to estimate the mean lifetime cost per employee, to the employer, of the On-Site program. This cost was compared to the cost of the other programs. RESULTS. Mean lifetime cost per employee was $5,485 for the On-Site screening program. This cost was significantly (P < .0001) lower than in the Off-Site program (by $311) or the Mobile program (by $212). The baseline results for the On-Site program were quite sensitive to the cost of screening, the sensitivity and specificity of screening, age at initiation of screening, and the underlying incidence of breast cancer in the population. CONCLUSION. Employers and other entities should consider these factors such as location and content in selecting the most efficient and effective breast cancer screening program.     

Effect of mammographic breast density on breast cancer screening performance: a study in Nijmegen, The Netherlands

STUDY OBJECTIVE: To study the implications of breast density on mammographic screening performance. DESIGN: Screening outcomes of women with dense breast patterns were compared with those of women with lucent breast patterns (dense > 25% densities, lucent < or = 25% densities); the women were screened in different periods (before/after improvement of the mammographic technique in 1982). SETTING: Nijmegen, the Netherlands, 1977-1994. PARTICIPANTS: Between 1977 and 1994, 73,525 repeat screenings were performed in 19,152 participants (aged 50-69 years) in the Nijmegen breast cancer screening programme (repeat screenings were defined as mammographic examinations that were preceded by an examination in the previous screening round). Participants were screened biennially with mammography. There were 258 screen detected and 145 interval cancers. MAIN RESULTS: Before 1982 (rounds 2-4) the predictive value of a positive screening test (PV+) was lower in women with dense breasts than in those with lucent breasts (dense 29% v lucent 52%, p = 0.003). Also, the ratio of screen detected cancers to the total number of screen detected plus interval cancers (as a proxy for sensitivity) was lower in this group (based on a one year interval: dense 63% v lucent 92%, p = 0.001 and based on a two year interval: dense 41% v lucent 68%, p = 0.002). Moreover, the survival rate was less favourable for those with dense breasts (p = 0.07). In rounds 5- 10, there were no important differences with respect to PV+ (dense 66% v lucent 62%, p = 0.57) or survival (p = 0.48). Moreover, sensitivity based on a one year interval was nearly as high in women with dense breasts as in those with lucent breasts (85% v 86%, p = 0.75). However, based on a two year interval sensitivity was lower (dense 59% v lucent 72%, p = 0.04). CONCLUSIONS: In the early screening years (rounds 2-4) high breast density had an unfavourable effect on screening performance. Nowadays, the situation has improved with respect to PV+, survival and detecting tumours in dense breasts with a lead time of up to one year, but little improvement has occurred in the detection of tumours with a lead time greater than one year.

 

     

No major difference between population screening for cervical carcinoma at the present screening interval of 5 years and the former interval of 3 years

OBJECTIVE: To assess the effect of extending the screening interval from 3 to 5 years on the detection of premalignant changes and invasive cervical carcinoma in the restructured population screening programme. DESIGN: Retrospective follow-up study. METHOD: The results were collected of the 1st round (1996-2000; 277, 377 women) and a part of the 2nd round (2001; 49,622 women; screening interval: 5 years) of the screening programme in Region West, the Netherlands. Histoscores for cervical intraepithelial neoplasia (CIN) 3 and squamous cell carcinoma (n/100 women investigated) and the hit count (sum of the histoscores for CIN 3, adenocarcinoma in situ and (micro)invasive cervical carcinoma) were calculated. Data of women with adenocarcinoma in situ and endocervical (adeno)carcinoma were recorded separately. The results of the 1st and 2nd round of the current screening programme (commenced in 1996) were compared with those of the historical screening programme that commenced in 1976 (screening interval: 3 years). RESULTS: From the 1st to the 2nd round of the historical screening programme that commenced in 1976, the histoscores for CIN 3 (3.33, 1.88) and squamous cell carcinoma (0.53, 0.19) and the hit count (3.92, 2.15) all diminished significantly. The current restructured programme, which commenced in 1996, showed low starting values for all three parameters, comparable to those in the 2nd round of the 1976 programme; a further reduction (0.16, 0.08; p < 0.01) was seen only in the histoscore for squamous cell carcinoma. In both rounds of both programmes, the histoscores for adenocarcinoma in situ (0.02, 0.02, 0.05, 0.04, respectively) and endocervical adenocarcinoma (0.04, 0.06, 0.05, 0.04) remained stable. CONCLUSION: In the current cervical carcinoma screening programme, with a screening interval of 5 years, the hit count of serious abnormalities remained constant while the incidence of squamous cell carcinoma decreased; this is in contrast to the historical screening programme (commenced in 1976), when both the hit count and the histoscore for CIN 3 diminished significantly. There were indications that cervical screening has no beneficial effect on the prevention of cervical adenocarcinoma.     

Working together in a new policy concept

Gerald Wistow suggests that joint working of all kinds has been an area of major disappointment and failure in the recent history of community care. Compared with the expectations of the mid-seventies, when current collaboration arrangements were put in place, achievements have been modest.     

The recommended interval for cervical cancer screening: Victorian women's attitudes to an extended interval

Aim: To determine Victorian women's knowledge of the recommended Pap test screening interval and support for extending the interval from two years to three years, in light of possible changes to the National Cervical Screening Program. Methods: A random sample of 2,360 women aged 18–69 was interviewed by telephone about their knowledge of the recommended interval, their willingness to change to three‐yearly screening if recommended and reasons for their preference. Results: More than 91% of women were aware of the current screening recommendation and nearly half (48.7%) indicated they would be willing to change to three‐yearly screening. Women were less likely to support the change if they were up‐to‐date with screening (45.7%, p<0.01), of low socioeconomic status (43.8%, p<0.01) or aged 50–69 (44.4%, p<0.01). Dislike of having a Pap test was reason for some women to want a longer interval, but most needed to be confident a longer interval was safe to be willing to change. Conclusions and implications: A longer interval between screening tests would readily be accepted by some women, but others will need to be persuaded of the safety of a new recommendation. The current interval is widely known and a clear communication strategy will be needed explain the change and its rationale.     

The Copper-Fix (Cu-Fix): a new concept in IUD technology

The Copper-Fix (Cu-Fix) is a thread-type copper-bearing device designed to overcome the most common IUD-related problems: bleeding and pain. Two distinctive features—virtual absence of a frame and provision of an anchoring system—make this new intrauterine device the first radical departure from current IUD technology. The Cu-Fix 390 was inserted at intervals in 382 women, and 4851 woman-months of experience had been accumulated at 18 months. The device was exceedingly well retained by the uterus (expulsion rate 0.6 at 18 months) and the removal rate for bleeding/pain was low (3.1 at 18 months). Serious complications did not occur; the pregnancy rate amounted to 0.3 at 18 months, with a continuation rate of 87.6%, which includes an 8.1% removal rate for pregnancy wish. Cardinal event rates were not influenced by the age or gravidity status of the recipient.

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Resumen El Copper-Fix (Cu-Fix) es un dispositivo portante de un hilo cobre, diseñado para corregir los problemas más comunes relacionados con los DIU: sangrado y dolor. Dos características sobresalientes — virtual ausencia de un esqueleto y de provisión de un sistema de fijación — hacen que este nuevo dispositivo intrauterino difiera radicalmente de la tecnología actual de DIU. El Cu-Fix 390 fué insertado a intervalos en 382 mujeres y en 18 meses se acumularon 4851 meses-mujer de experiencia. El dispositivo fué retenido notablemente bien por el útero (tasa de expulsión 0,6 an los 18 meses) y la tasa de remoción por sangrado/dolor fué baja (3,1 a los 18 meses). No ocurrieron complicaciones serias; la tasa de embarazo fué de 0,3 a los 18 meses con una tasa de continuidad de 87,6% la que incluye una tasa de 8,1% de remoción por deseo de embarazo. Las tasas de eventos pricipales no estuvieron influenciadas por la edad ni por la gravidez previa de las mujeres.

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Resumé Le Copper-Fix (Cu-Fix) est un dispositif de type filiforme chargé de cuivre, qui a été étudié en vue de remédier aux problèmes les plus fréquents liés au port des DIU: pertes sanguines et douleurs. Les deux caractéristiques qui le distinguent — pratiquement absence de cadre et possibilité d'ancrage — apportent à ce dispositif intra-utérin le premier changement radical dans la conception actuelle des DIU. Le Cu-Fix 390 a été inséré par intervalles chez 382 femmes et une expérience de 4851 mois-femme a été accumulée en 18 mois. Ce dispositif a été extrêmement bien retenu par l'utérus (taux d'expulsion 0,6 à 18 mois) et le taux de retrait dû à des saignements ou des douleurs a été faible (3,1 à 18 mois). Il n'y a eu aucun cas de complications graves; le taux de grossesses a atteint 0,3 à 18 mois, avec un taux de continuation de 87,6% qui tient compte des 8,1% de retraits effectués en vue d'une grossesse désirée. Les taux d'événements importants n'ont été influencés ni par l'âge ni par l'état de gestation de l'utilisatrice.

     

Participation in breast screening programs: a review

Despite recommendations by the American Cancer Society and other organizations for use of screening mammography, data on reported utilization of this procedure by American women show that these guidelines are not being met. We reviewed published studies that reported participation rates or that examined factors associated with participation in selected breast screening programs. In general, women at high risk due to age and family or personal history of breast disease were not more likely to participate in breast screening programs than women without those risk factors. The one group of variables that was fairly consistently associated with participation was the practice of other preventive health behaviors. Women who expressed more concern about their health and who were more knowledgeable about breast cancer screening and its benefits also were more likely to complete mammography. Approaches to increasing participation are discussed in the context of the literature on this subject.