Effect of Screening Mammography on Breast Cancer Detection and Mortality

This widely discussed study by Bleyer and Welch published in The New England Journal of Medicine (NEJM) “The Effects of Three Decades of Screening Mammography on Breast Cancer Incidence” concluded that screening mammography leads to a substantial overdiagnosis of early breast cancer (estimated 69% increase) while only having a small effect on late-stage breast cancer (estimated 8% decrease). In a population-based observational study, the authors utilized trend data from the Surveillance, Epidemiology and End Results (SEER) database to examine trends on the incidence and stage of early- versus late-stage breast cancer at the time of diagnosis. They compared 2 time frames: prior to widespread mammography screening (1976–1978) and after mammography screening was introduced in the United States (2006––2008). This article reviews this NEJM article and describes several methodological assumptions by the authors that have been soundly criticized and the associated limitations. As a result of these limitations, there was an exaggeration of the overdiagnosis of early-stage disease with mammography and, more importantly, a substantial underestimate of the impact of mammography on decreasing late-stage breast cancer.

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Stage migration in breast cancer: Better detection or semantics in staging?

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18800 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18800-e18800

Author(s):

Leah Elson ◽

Nadeem Bilani ◽

Hong Liang ◽

Elizabeth Blessing Elimimian ◽

Diana Saravia ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Incidence ◽

Late Stage ◽

Early Stage ◽

Breast Cancer Incidence ◽

Incidence Rates ◽

Information Criteria ◽

Stage Migration ◽

Cancer Data ◽

Best Fit

e18800 Background: As oncology treatment has evolved to become more individualized, prognostic rationale has also undergone important changes. In breast cancer, disease staging was historically based upon anatomic features of the primary tumor, in combination with involvement of adjacent/distant tissues. However, as the understanding of molecular/genomic involvement became more advanced, staging definitions were redefined to incorporate receptors, histologic grade, and genetic expression. In this analysis, we use autoregressive integrated moving average (ARIMA) forecasting to understand how AJCC updates to prognostic definitions have contributed to stage migration, and to comment on whether better detection, or definitional changes, may be responsible for the increasing incidence in early stage breast cancer. Methods: In this time series forecast, ARIMA models, per stage (early: stage I/II vs. late: stage III/IV) were constructed based on 2004-2016 historic breast cancer incidence rates, as reported by the NCDB. Multiple models were generated, using differing autoregressive parameters; the most predictive model was chosen using the lowest Bayesian Information Criteria (BIC), and mean absolute percentage error (MAPE) to ensure best fit. Similar methodology has already been published to predict prostate cancer incidence. The best fit models were applied to forecast annual incidence, in the NCDB, in 2017. These data were compared to the real-world data captured in 2017. Statistics were performed using modeling systems in SPSS, version 27. Results: n=1,661,971 cases were included for these models, and 12 years of pre-AJCC updated NCDB breast cancer data were used. Using ARIMA modeling, best fit, stationary averages were identified, with autoregressive and difference terms which contributed to the lowest BIC, and MAPE < 5%, for both models. The best fit models forecasted 2017 incidence, by stage, without AJCC updates to staging criteria, and this data is compared to actual 2017 incidence with current updated AJCC 8th staging criteria (Table). Conclusions: During 2017, the first year of AJCC staging updates, there was an observed decrease in late stage diagnoses, and increase in early stage diagnoses, when compared with incidence rates that were forecasted using the old, anatomic AJCC criteria. Therefore, part of the stage migration noted may be a product of staging semantics, using updated definitions. Confirming appropriate improvement in long-term outcomes, based on new staging would be helpful. It is also important for clinicians and public health officials to bear this in-mind when interpreting epidemiologic data, for allocating resources, as shifts in staging may be a product of guideline changes, and not necessarily screening efficacy or early detection only.[Table: see text]

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Financial and employment toxicity related to breast reconstruction following mastectomy in a diverse population-based cohort.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.78 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 78-78

Author(s):

Nicholas L. Berlin ◽

Adeyiza O. Momoh ◽

Paul Abrahamse ◽

Steven J. Katz ◽

Reshma Jagsi ◽

...

Keyword(s):

Breast Cancer ◽

Breast Reconstruction ◽

Employment Status ◽

Early Stage ◽

Insurance Coverage ◽

The United States ◽

Population Based ◽

Early Stage Breast Cancer ◽

Financial Barriers ◽

Spanish Speaking

78 Background: Despite mandated private insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed onto women who seek these procedures through cost-sharing arrangements and high-deductible health plans. In this population-based study, we sought to characterize financial and employment toxicities related to pursuing breast reconstruction following mastectomy. Methods: Women (white, African American, and Latina-English and Spanish speaking) with early stage breast cancer (stages 0-II) diagnosed between July 2013 to September 2014 and who underwent mastectomy were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries and surveyed. Primary outcome measures included patient-reported appraisal of financial toxicity and employment status following breast cancer treatment using previously developed measures. Multivariable models evaluated the association between breast reconstruction and self-reported financial and employment status. Results: Among 868 breast cancer patients who underwent mastectomy, 43.5% (n = 378) did not undergo breast reconstruction and 56.5% (n = 490) underwent reconstruction. 43.4% of the cohort reported being worse off financially since their diagnosis (49.4% with reconstruction vs. 35.0% without reconstruction, P< .001). Among women who were employed at time of breast cancer diagnosis (n = 535), 70.2% who underwent reconstruction reported being worse off regarding employment status compared to 51.1% who did not undergo reconstruction ( P< .001). Receipt of reconstruction was independently associated with a self-reported decline in financial status (Odds Ratio (OR) 2.1, 95% Confidence Interval (CI) 1.4-3.4, P= .001). Similarly, reports of being worse off regarding employment status were also higher in those who underwent reconstruction vs. not (OR 2.2, 95% CI 1.2-3.8, P= .006). Spanish-speaking Latina women more often reported being worse off regarding employment status (OR 4.3, 95% CI 2.1-9.0, P< .001) than white women. Conclusions: In this diverse cohort of women who underwent mastectomy for early stage breast cancer, women who elected to undergo reconstruction experienced more self-reported financial and employment toxicities. Patients should be counseled regarding the potential costs related to these procedures. Policy-makers should be aware of the financial barriers for women who undergo reconstruction despite mandatory insurance coverage in the United States.

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Frequency of late-stage breast cancer diagnoses despite high mammography screening rates in an HMO

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.1526 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. 1526-1526

Author(s):

R. Haque ◽

J. E. Schottinger ◽

M. H. Kanter ◽

C. C. Avila ◽

R. Contreras ◽

...

Keyword(s):

Breast Cancer ◽

Late Stage ◽

Mammography Screening ◽

Early Stage ◽

Advanced Tumor Stage ◽

Early Stage Disease ◽

Advanced Tumor ◽

Stage Disease ◽

Late Stage Diagnosis ◽

The Impact

1526 Background: Kaiser Permanente Southern California (KPSC) led the nation in screening women for breast cancer (BCa) with a mammography rate of nearly 90% in 2007 according to 2008 Healthcare Effectiveness Data and Information Set (HEDIS) measures. Despite successes in improving screening rates in this health plan that serves 3+ million diverse members, the percentage of women diagnosed with late stage BCa (stage III, IV) remained stable, varying from 12.9% (N∼323) in 2003 to 10.8% (N∼270) in 2007. To identify patient and health care factors associated with late stage diagnosis and the impact of its enhanced screening implementation guidelines, KPSC undertook this study. Methods: This cross-sectional study included a cohort of 10,580 BCa patients from 2003–2007. We compared women diagnosed with late stage disease versus those with early stage disease (stages I, II). P values (2-sided) were based on the chi-square distribution. Adjusted odds ratios and 95% confidence intervals were estimated using unconditional logistic regression. Results: Factors that were positively associated with late stage diagnosis in the univariate analyses included age, lack of recent mammography screening, worse tumor features, 80+ years of age, minority race, lower geocoded household income, increased healthcare visits, and use of Pap testing (P < 0.01 for all variables). Factors significantly associated with late stage diagnosis in the multivariate model included only lack of recent mammography screening (OR = 1.35, 95% CI: 1.14–1.58) and worse tumor features including high grade (grade 3, OR = 2.58, 95% CI: 1.96–3.40), positive lymph nodes (OR = 53.49, 95% CI: 39.90–71.72), and HER-2+ tumors (OR = 1.40, 95% CI: 1.13–1.72). Conclusions: Targeting older women, those with lower utilization, and women who did not have a recent mammogram may help further lower the prevalence of late stage diagnoses. However, given the extent of the health plan's previous efforts to enhance BCa screening rates, a ceiling effect may limit additional benefit. Additional efforts to decrease the rate of advanced tumor stage at diagnosis may include improving interpretation of mammograms or earlier detection of aggressive tumors by enhanced BRCA genetic testing. No significant financial relationships to disclose.

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Breast Cancer Incidence and Mortality Trends, Variation by State and Race/Ethnicity, and Association With Obesity, Physical Activity, and Mammography Screening in the United States

SSRN Electronic Journal ◽

10.2139/ssrn.3963787 ◽

2021 ◽

Author(s):

Zhaomin Xie ◽

Wei Xie ◽

Yuanke Liang ◽

Haoyu Lin ◽

Jundong Wu ◽

...

Keyword(s):

Breast Cancer ◽

Physical Activity ◽

United States ◽

Cancer Incidence ◽

Mammography Screening ◽

Breast Cancer Incidence ◽

The United States ◽

Mortality Trends ◽

Incidence And Mortality ◽

Race Ethnicity

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Community-Based Use of Chemotherapy and Hormonal Therapy for Early-Stage Breast Cancer: 1987-2000

Journal of Clinical Oncology ◽

10.1200/jco.2005.03.5840 ◽

2006 ◽

Vol 24 (6) ◽

pp. 872-877 ◽

Cited By ~ 57

Author(s):

Linda C. Harlan ◽

Limin X. Clegg ◽

Jeffrey Abrams ◽

Jennifer L. Stevens ◽

Rachel Ballard-Barbash

Keyword(s):

Breast Cancer ◽

Adjuvant Therapy ◽

Hormonal Therapy ◽

Early Stage ◽

The United States ◽

Population Based ◽

Early Stage Breast Cancer ◽

Community Based ◽

Node Negative ◽

Er Positive

Purpose We describe trends in the use of chemotherapy and hormonal therapy by nodal and estrogen receptor (ER) status in women with early-stage breast cancer. Methods Cases were randomly sampled from the population-based Surveillance, Epidemiology and End Results (SEER) program and physician verified treatment was examined. A total of 9,481 women, aged 20 years and older, diagnosed with early-stage breast cancer in 1987 to 1991, 1995, and 2000 were included in the study. Results The use of chemotherapy plus tamoxifen increased between 1995 and 2000 for women with node-negative, ER-positive breast cancer ≥ 1 cm (8% to 21%). Nearly 23% of women with node-negative and ER-positive tumors ≥ 1 cm received no adjuvant therapy. The use of chemotherapy alone increased to nearly 60% in women with node-negative, ER-negative tumors ≥ 1 cm (48% to 59%). However, in 2000, 16% of women with node-positive and ER-negative tumors received no adjuvant therapy and an additional 6% received tamoxifen alone. The influence of age can clearly be seen. Chemotherapy is given much less often in women 70 years or older. Conclusion The results from SEER areas across the United States suggest that physicians quickly responded to publications and guidelines regarding breast cancer therapy. The lack of definitive findings from clinical trials on the use of adjuvant therapy in women 70 years and older may explain the lower use in this group of women.

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Divergent Patterns and Trends in Breast Cancer Incidence, Mortality and Survival Among Older Women in Germany and the United States

Cancers ◽

10.3390/cancers12092419 ◽

2020 ◽

Vol 12 (9) ◽

pp. 2419

Author(s):

Lina Jansen ◽

Bernd Holleczek ◽

Klaus Kraywinkel ◽

Janick Weberpals ◽

Chloé Charlotte Schröder ◽

...

Keyword(s):

Breast Cancer ◽

United States ◽

Cancer Incidence ◽

Mammography Screening ◽

Breast Cancer Incidence ◽

Relative Survival ◽

The United States ◽

The Us ◽

The Impact

Background: Breast cancer treatment has changed tremendously over the last decades. In addition, the use of mammography screening for early detection has increased strongly. To evaluate the impact of these developments, long-term trends in incidence, mortality, stage distribution and survival were investigated for Germany and the United States (US). Methods: Using population-based cancer registry data, long-term incidence and mortality trends (1975–2015), shifts in stage distributions (1998–2015), and trends in five-year relative survival (1979–2015) were estimated. Additionally, trends in five-year relative survival after standardization for stage were explored (2004–2015). Results: Age-standardized breast cancer incidence rates were much higher in the US than in Germany in all periods, whereas age-standardized mortality began to lower in the US from the 1990s on. The largest and increasing differences were observed for patients aged 70+ years with a 19% lower incidence but 45% higher mortality in Germany in 2015. For this age group, large differences in stage distributions were observed, with 29% (Germany) compared to 15% (US) stage III and IV patients. Age-standardized five-year relative survival increased strongly between 1979–1983 and 2013–2015 in Germany (+17% units) and the US (+19% units) but was 9% units lower in German patients aged 70+ years in 2013–2015. This difference was entirely explained by differences in stage distributions. Conclusions: Overall, our results are in line with a later uptake and less extensive utilization of mammography screening in Germany. Further studies and efforts are highly needed to further explore and overcome the increased breast cancer mortality among elderly women in Germany.

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Do we still need breast cancer screening in the era of targeted therapies and precision medicine?

Insights into Imaging ◽

10.1186/s13244-020-00905-3 ◽

2020 ◽

Vol 11 (1) ◽

Cited By ~ 1

Author(s):

Rubina Manuela Trimboli ◽

Paolo Giorgi Rossi ◽

Nicolò Matteo Luca Battisti ◽

Andrea Cozzi ◽

Veronica Magni ◽

...

Keyword(s):

Breast Cancer ◽

Precision Medicine ◽

Mammography Screening ◽

Early Stage ◽

Growth Factor Receptor ◽

Relative Survival ◽

Screening Mammography ◽

Curative Intent ◽

Novel Treatments ◽

Systemic Treatments

Abstract Breast cancer (BC) is the most common female cancer and the second cause of death among women worldwide. The 5-year relative survival rate recently improved up to 90% due to increased population coverage and women’s attendance to organised mammography screening as well as to advances in therapies, especially systemic treatments. Screening attendance is associated with a mortality reduction of at least 30% and a 40% lower risk of advanced disease. The stage at diagnosis remains the strongest predictor of recurrences. Systemic treatments evolved dramatically over the last 20 years: aromatase inhibitors improved the treatment of early-stage luminal BC; targeted monoclonal antibodies changed the natural history of anti-human epidermal growth factor receptor 2-positive (HER2) disease; immunotherapy is currently investigated in patients with triple-negative BC; gene expression profiling is now used with the aim of personalising systemic treatments. In the era of precision medicine, it is a challenging task to define the relative contribution of early diagnosis by screening mammography and systemic treatments in determining BC survival. Estimated contributions before 2000 were 46% for screening and 54% for treatment advances and after 2000, 37% and 63%, respectively. A model showed that the 10-year recurrence rate would be 30% and 25% using respectively chemotherapy or novel treatments in the absence of screening, but would drop to 19% and 15% respectively if associated with mammography screening. Early detection per se has not a curative intent and systemic treatment has limited benefit on advanced stages. Both screening mammography and systemic therapies continue to positively contribute to BC prognosis.

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