An analysis of screen-detected invasive cancers by grade in the English breast cancer screening programme: are we failing to detect sufficient small grade 3 cancers?

Abstract Objective Randomised controlled trials have shown a reduction in breast cancer mortality from mammography screening and it is the detection of high-grade invasive cancers that is responsible for much of this effect. We determined the detection rates of invasive cancers by grade, size and type of screen and estimated relative sensitivities with emphasis on grade 3 detection. Methods This observational study analysed data from over 11 million screening episodes (67,681 invasive cancers) from the English NHS breast screening programme over seven screening years 2009/2010 to 2015/2016 for women aged 45–70. Results At prevalent (first) screens (which are unaffected by screening interval), the detection rate of small (< 15 mm) invasive cancers was 0.95 per 1000 for grade 1, but for grade 3 only 0.30 per 1000. The ratio of small (< 15 mm) to large (≥ 15 mm) cancers was 1.8:1 for grade 1 but reversed to 0.5:1 for grade 3. We estimated that the relative sensitivity for grade 3 invasive cancers was 52% of that for grade 1 and the relative sensitivity for small (< 15 mm) grade 3 only 26% of that for small (< 15 mm) grade 1 invasive cancers. Conclusions Sensitivity for small grade 3 invasive cancers is poor compared with that for grade 1 and 2 invasive cancers and larger grade 3 malignancies. This observation is likely a limitation of the current technology related to the absence of identifiable mammographic features for small high-grade cancers. Future work should focus on technologies and strategies to improve detection of these clinically most significant cancers. Key Points • The detection of small high-grade invasive cancers is vital to reduce breast cancer mortality. • We estimate the sensitivity for small grade 3 invasive cancers may be only 26% of that of small grade 1 invasive cancers. This is likely to be associated with the non-specific mammographic features for these cancers. • New technologies and appropriate strategies using current technology are required to maximise the detection of small grade 3 invasive cancers.

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Evaluation of the Effect on Breast Cancer Mortality of Population Based Mammography Screening Programmes

Journal of Medical Screening ◽

10.1177/096914139400100310 ◽

1994 ◽

Vol 1 (3) ◽

pp. 184-187 ◽

Cited By ~ 31

Author(s):

Sven Törnberg ◽

John Carstensen ◽

Timo Hakulinen ◽

Per Lenner ◽

Thomas Hatschek ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Mortality ◽

Mammography Screening ◽

Screening Programme ◽

Breast Cancer Mortality ◽

Time Lag ◽

Statistical Modelling ◽

Population Based ◽

Mortality Data ◽

Full Effect

To evaluate, by analysis of breast cancer mortality data from all the 26 Swedish counties for the years 1971 to 1990, whether the effect of the introduction of mammography screening in Sweden can be assessed by observation from existing mortality data. A Poisson regression model was used to study whether a decrease in breast cancer mortality among women aged 50–74 years was associated with the extent of mammography screening in different counties and periods. In regions where mammography screening had been introduced, breast cancer mortality tended to be decreased, on average, compared with regions with-'out screening. If a 10 year time lag between the start of screening and its full effect on mortality is assumed then the estimated reduction in breast cancer mortality associated with introduction of screening was 19% with a 95% confidence interval ranging from 3% to 37%. The results suggest that the effect of mammography screening may be studied using existing routine mortality data and appropriate statistical modelling. This way of assessing the outcome of the screening is valuable when continuously monitoring a screening programme that has become a public health routine.

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Programme sensitivity and effectiveness of mammography service screening in Helsinki, Finland

Journal of Medical Screening ◽

10.1136/jms.9.4.153 ◽

2002 ◽

Vol 9 (4) ◽

pp. 153-158 ◽

Cited By ~ 41

Author(s):

A. Anttila ◽

J. Koskela ◽

M. Hakama

Keyword(s):

Breast Cancer ◽

Birth Cohort ◽

Cancer Mortality ◽

Cumulative Incidence ◽

Screening Programme ◽

Breast Cancer Mortality ◽

Breast Cancers ◽

Birth Cohorts ◽

Female Population ◽

Incident Cases

OBJECTIVES: To evaluate the effectiveness of mammography service screening. SETTING: Helsinki (population 0.5 million), the capital of Finland, the breast cancer service screening programme was started gradually in 1986. MATERIALS AND METHODS: The study was based on the data from the breast cancer screening programme in Helsinki. All incident cases of breast cancer and rates in the female population in Helsinki during the period 1970–97, and information on the subsequent breast cancer mortality were derived from the files of the Finnish Cancer Registry. To estimate the sensitivity of the programme, the number of screen detected cancers were compared with the overall number of breast cancers at the targeted age groups. Effects of screening were estimated for cumulative incidence and for the refined mortalities among the birth cohorts screened. RESULTS: Altogether 144 400 invitations had been sent during 1986–97 among the 50–9 year old women as targeted in Helsinki. The average attendance rate was 82%; and 545 breast cancers were detected by screening, with a detection rate of 0.46%. In the birth cohort of women born between the start of 1935 and the end of 1939—namely, those subjected to most complete screening and long follow up time since the onset of the programme—there was an increase in the cumulative incidence of breast cancer (relative risk (RR) 1.18, 95% confidence interval (95% CI) 1.09 to 1.27). The estimated sensitivity of the screening programme was 58%; and 53% if corrected for overdiagnosis. There was also a decrease of 19% (RR 0.81, 95% CI 0.62 to 1.05) in the refined mortality within this screened birth cohort, compared with the death rate of women of comparable ages in the non-screened reference cohort. CONCLUSION: The study provides further support to the hypothesis that service screening with mammography reduces the risk of breast cancer mortality.

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Repeated mammographic screening reduces breast cancer mortality along the continuum of age

Journal of Medical Screening ◽

10.1136/jms.9.4.163 ◽

2002 ◽

Vol 9 (4) ◽

pp. 163-167 ◽

Cited By ~ 20

Author(s):

M.J.M. Broeders ◽

A.L.M. Verbeek ◽

H. Straatman ◽

P.G.M. Peer ◽

P.C.M. Pasker-de Jong ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Screening ◽

Breast Cancer Screening ◽

Cancer Mortality ◽

Screening Programme ◽

Breast Cancer Mortality ◽

Mammographic Screening ◽

Protective Effects ◽

Age Group ◽

The Continuum

OBJECTIVE: The optimal age boundaries for breast cancer screening are still under debate. A case-referent design was used to describe the effect of mammographic screening on breast cancer mortality along the continuum of age, based on a 20 year follow up period. SETTING: The population based breast cancer screening programme in Nijmegen, The Netherlands, which has biennially invited women over 35 years since 1975. METHODS: Cases, defined as women who died from primary breast cancer between 1987 and 1997, were selected from the group of women who received at least one invitation to the screening programme. For 157 cases, 785 women from the same group were selected as referents. Information on the index screening (the screening examination preceding diagnosis of the case) was collected for both cases and referents. The risk of dying from breast cancer was calculated per 10 year moving age group for women who had attended the index screening versus those who had not. RESULTS: The youngest 10 year age group showing an effect in our study were women aged 45–54 at their index screening. Breast cancer mortality for women in this group who attended the index screening was 32% lower, although not significant, than for women who did not (odds ratio (OR) 0.68, 95% confidence interval (95% CI) 0.33 to 1.41). This reduction in risk was not explained solely by an effect in women over 50 because the OR in women aged 45–49 was 0.56 (95% CI 0.20 to 1.61). Reductions in mortality became smaller with increasing age. Nevertheless, for women over 60 at index screening, participation in screening over a maximum 4 year period before diagnosis of the case yielded protective effects at least up to an age around 80. CONCLUSIONS: Although our results are based on a relatively small number of cases, they suggest that even in a programme with a 2 year screening interval there may be a benefit of starting screening around age 45. Also older women who participate at least once every 4 years still have much to gain from screening.

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Effectiveness of a small breast screening programme: 25 year evaluation (25 year breast screening evaluation)

BJR|Open ◽

10.1259/bjro.20180018 ◽

2019 ◽

Vol 1 (1) ◽

pp. 20180018

Author(s):

Andrew Patric Nisbet ◽

Andrew Borthwick-Clarke ◽

Nic Scott ◽

Helen Goulding ◽

Harwood Jane

Keyword(s):

Breast Cancer ◽

Quality Control ◽

Cancer Mortality ◽

Breast Screening ◽

Screening Programme ◽

Breast Cancer Mortality ◽

Interval Cancers ◽

Breast Screening Programme ◽

Small Breast ◽

The Impact

Objective: To evaluate mammography screening quality on the Island of Jersey over a 25-year period from Jan 1990 to end March 2015 from females invited between ages 50 to 75 using a 2 yearly screening interval. Jersey had a population of only around 67,000 at onset, rising to around 100,000 at the end of the 25 years. Methods: An analysis was performed of key routinely collected measures that are important to determining if a screening programme is on course to reduce breast cancer mortality such as uptake, recall rates, screen detected cancer and interval cancer rates. Further supporting indicators including grade, stage and comparative deaths from breast cancer in screen detected and not screen detected females were also assessed. Results: Over the 25-year period 19,768 females were invited to screening and 16,866 attended, giving an uptake of 85.2%. There were 501 screen detected cancers of which 400 were invasive, and 101 DCIS. 125 interval cancers presented outside screening over the 25 years. The annual recall rate over the last 20 years was <6% for prevalent round and 4% for incident round screening. Based on the standardized detection ratio (SDR) and uptake, the estimated reduction in mortality from breast cancer was calculated as 40.2%. Conclusions: Recommended population sizes for breast units range from a quarter to half a million people. For very small units like Jersey serving smaller populations, rigorous quality control is essential to maintain credibility. Despite the small size of the programme evidence shows a similar detection rate to the UK NHS Breast screening programme was achieved. In small programmes careful monitoring of rates of uptake, recall, cancer detection and interval rates are required over adequate time periods together with supporting information to show that small units can achieve national standards and detection rates necessary to reduce breast cancer mortality. Advances in knowledge: Running a small breast cancer screening programme is challenging for quality control. The impact on mortality can be predicted for small screening programmes despite their size. 10-year group survival in screen detected invasive breast cancer >90%. Interval cancers are more advanced than screen detected invasive cancers, so high suspicion is still required in breast symptoms after "normal" screen result. Mortality in lapsed/ceased attenders suggest that extending age range could be beneficial.

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Non-Participation in Breast Cancer Screening in Spain and Potential Application in the Present and Future: A Cross Sectional Study

Cancers ◽

10.3390/cancers13174331 ◽

2021 ◽

Vol 13 (17) ◽

pp. 4331

Author(s):

Juan José Muñoz-Sanz ◽

María Jiménez-Palomares ◽

Elisa María Garrido-Ardila ◽

Juan Rodríguez-Mansilla

Keyword(s):

Breast Cancer ◽

Cancer Screening ◽

Older Women ◽

Breast Cancer Screening ◽

Cancer Mortality ◽

Screening Programme ◽

Breast Cancer Mortality ◽

Screening Methods ◽

Cross Sectional ◽

Screening Programs

Background: Currently, we are beginning to observe a stabilisation and even a decrease in breast cancer mortality in the world, which may be related, among other reasons, to breast cancer screening. Methods: The objective of this study was to analyse the different reasons why women do not participate in the Breast Cancer Early Detection Programme in Extremadura (Spain) and to discuss the results, offering possible tools to improve the screening programs. This is an observational, descriptive, cross-sectional and retrospective study. A questionnaire with 14 questions was carried out by telephone or mail. Results: A total of 3970 questionnaires were collected. However, only 2507 were valid. A total of 70.36% of young and educated women underwent mammographic controls. The type of women who did not attend the screening programme appointment corresponded to a woman of approximately 60 years of age, with no formal studies, married, with children, who does not work outside their home and who lived in the health area of Badajoz. Among the main reasons for not going to the appointment, 53.9% of the women surveyed indicated that they had check-ups with their gynaecologist, and this specialist referred them for a mammograph. These women were younger and have a higher level of education. Women with a lower educational level and older women did not have any mammography done and did not undergo screening. They indicated that they did not go to the appointment because they were afraid of having a mammography (44%) or because they did not receive the appointment in time (31.6%). A total of 26.9% of the women who did not attend the appointment for other reasons stated that they had problems in attending because they had a physical limitation (dependency). Conclusions: Women who did not participate in the breast cancer screening programme in Extremadura had low educational levels and were older women. Specifically, fear of having a mammogram was the main argument raised by these women. In addition, a small group stated that they did not consider mammography to be useful. At present and in the future, good quality screening programs must be carried out to contribute to the reduction in breast cancer mortality. Furthermore, enhancing the participation of women is essential to increase the attendance rate and, therefore, the success of the screening programmes.

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