Clinical outcomes of patients with ductal carcinoma in situ in Hong Kong: 10-year territory-wide cancer registry study.

BACKGROUND: Incidence of ductal carcinoma in situ (DCIS) has increased in recent decades because of breast cancer screening. This study comprised a long-term survival analysis of DCIS using 10-year territory-wide data from the Hong Kong Cancer Registry. METHODS: This study included all patients diagnosed with DCIS in Hong Kong from 1997 to 2006. Exclusion criteria were age <30 years or ≥70 years, lobular carcinoma in situ, Paget's disease, and co-existing invasive carcinoma. Patients were stratified into those diagnosed from 1997 to 2001 and those diagnosed from 2002 to 2006. The 5- and 10-year breast cancer-specific survival rates were evaluated; standardised mortality ratios were calculated. RESULTS: Among the 1391 patients in this study, 449 were diagnosed from 1997 to 2001, and 942 were diagnosed from 2002 to 2006. The mean age at diagnosis was 49.2±9.2 years. Overall, 51.2% of patients underwent mastectomy and 29.5% received adjuvant radiotherapy. The median follow-up interval was 11.6 years; overall breast cancer-specific mortality rates were 0.3% and 0.9% after 5 and 10 years of follow-up, respectively. In total, 109 patients (7.8%) developed invasive breast cancer after a considerable delay. Invasive breast cancer rates were comparable between patients diagnosed from 1997 to 2001 (n=37, 8.2%) and those diagnosed from 2002 to 2006 (n=72, 7.6%). CONCLUSION: Despite excellent long-term survival among patients with DCIS, these patients were more likely to die of breast cancer, compared with the general population of women in Hong Kong.

Health gains, costs and cost-effectiveness of a population-based screening programme for abdominal aortic aneurysms.

BACKGROUND: Abdominal aortic aneurysm (AAA) rupture carries a high fatality rate. AAAs can be detected before rupture by abdominal ultrasound imaging, allowing elective repair. Population-based screening for AAA in older men reduces AAA-related mortality by about 40 per cent. The UK began an AAA screening programme offering one-off scans to men aged 65 years in 2009. Sweden has a similar programme. Currently, there is no AAA screening programme in New Zealand. This cost-utility analysis aimed to assess the cost-effectiveness of a UK-style screening programme in the New Zealand setting. METHODS: The analysis compared a formal AAA screening programme (one-off abdominal ultrasound imaging for about 20 000 men aged 65 years in 2011) with no systematic screening. A Markov macrosimulation model was adapted to estimate the health gains (in quality-adjusted life-years, QALYs), health system costs and cost-effectiveness in New Zealand. A health system perspective and lifetime horizon was adopted. RESULTS: With New Zealand-specific inputs, the adapted model produced an estimate of about NZ $15 300 (€7746) per QALY gained, with a 95 per cent uncertainty interval (UI) of NZ $8700 to 31 000 (€4405 to 15 694) per QALY gained. Health gains were estimated at 117 (95 per cent UI 53 to 212) QALYs. Health system costs were NZ $1·68 million (€850 535), with a 95 per cent UI of NZ $820 200 to 3·24 million (€415 243 to €1·65 million). CONCLUSION: Using New Zealand's gross domestic product per capita (about NZ $45 000 or €22 100) as a cost-effectiveness threshold, a UK-style AAA screening programme would be cost-effective in New Zealand.

A comparison of ovarian cancer mortality in women with BRCA1 mutations undergoing annual ultrasound screening or preventive oophorectomy.

OBJECTIVE: To compare the survival experience of women with a BRCA1 mutation who enrolled in an ovarian cancer screening program with that of women who opted for preventive oophorectomy. METHODS: We followed 1964 women with a BRCA1 mutation and two ovaries intact in a prospective study. No women had ovarian cancer or had a bilateral oophorectomy prior to study initiation. There were 1814 women in the cohort who had at least one screening ultrasound. They were followed from the date of first ultrasound until the date of preventive oophorectomy, death or last follow-up. There were 659 women in the cohort who had preventive oophorectomy. They were followed from the date of preventive oophorectomy until death or last follow-up. RESULTS: Among the 1196 women who had one or more ultrasound examinations and no oophorectomy, there were 73 incident cancers detected and 27 deaths from ovarian/fallopian cancer. The ten year cumulative risk of death was 2.0%. Among the 659 women who had a preventive oophorectomy there were 12 incident cancers (9 detected at oophorectomy and 3 in the follow up period) and two deaths from ovarian cancer. The ten year cumulative risk of death was 0.5%. The hazard ratio for oophorectomy versus ultrasound was 0.23 (95% CI: 0.05 to 0.97; p = 0.05). CONCLUSION: The survival of women diagnosed with ovarian cancer enrolled in an ultrasound screening program is relatively poor and screening is not a viable alternative to preventive oophorectomy.

Comparative analysis of breast cancer mortality following mammography screening in Denmark and Norway.

BACKGROUND: Denmark and Norway are the best countries to study effects of mammography screening, because they are the only countries with stepwise introduction of nationwide mammography screening, enabling comparative effectiveness studies of high quality. Although Denmark and Norway are countries with similar populations and health care systems, reported reductions in breast cancer mortality (incidence-based) caused by screening differed vastly; 25% in Denmark versus 10% in Norway. This study explores reasons for this difference. PATIENTS AND METHODS: We compared two published studies from the Danish and Norwegian screening programs (Olsen et al., 2005; Kalager et al., 2010) investigating biennial mammography screening for women age 50-69 years. Four comparison groups of women were constructed ('current' and 'historical screening groups'; 'current' and 'historical nonscreening groups') based on county of residence. We calculated incidence-based breast cancer mortality in the current versus the historical period for screening and nonscreening groups, using mortality rate ratios (MRR) in the two countries, accounting for concomitant changes in breast cancer mortality. RESULTS: In the screening groups, similar reductions in breast cancer mortality were found when periods preceding and following start of screening were compared, in Denmark [25%; MRR 0.75; 95% confidence interval (CI) 0.64% to 0.88%] and in Norway (28%; MRR 0.72; 95% CI 0.63% to 0.81%). However, mortality increased in Denmark in the current nonscreening group compared with the historical nonscreening group; for women >59 years, breast cancer mortality increased by 14% (MRR 1.14, 95% CI 1.07-1.22), whereas in Norway a 19% reduction was seen (MRR 0.81, 95% CI 0.72-0.92). This increase accounts for the different relative effect of screening in Denmark and Norway; 25% breast cancer mortality reduction in Denmark, 10% in Norway. CONCLUSIONS: The seemingly larger effect of screening in Denmark may not be solely attributable to screening itself, but to increased breast cancer mortality in women older than 59 years not invited to screening.

Correction of first trimester biochemical aneuploidy screening markers for smoking status: influence of gestational age, maternal ethnicity and cigarette dosage.

OBJECTIVE: To examine the gestational age, maternal ethnicity and cigarette dosage effects of the reduction of maternal serum pregnancy-associated plasma protein A (PAPP-A) and free-ß human chorionic gonadotrophin (free hCGß) in smokers. METHODS: Maternal serum PAPP-A and free hCGß corrected for confounders, excluding smoking, in first trimester smokers and nonsmokers were compared by gestational age, maternal ethnicity and cigarette dosage. A small set of second trimester smokers and nonsmoker controls were analysed for PAPP-A along with free hCGß and assessed for gestational age effects of smoking. RESULTS: Pregnancy-associated plasma protein A reduction by smoking in the first trimester was not influenced by gestational age, however free hCGß levels were only significantly reduced in weeks 12 and 13 in smokers. Ethnicity and cigarette dosage were also found to influence the reduction of both makers in smokers in the first trimester. In second trimester smokers, PAPP-A was found to be reduced by less and free hCGß reduced by more than in the first trimester, although no second trimester gestational age effect on smoking was found. CONCLUSIONS: Current methods of correcting for smoking status may be an oversimplification of a more complex subject.

[Lung cancer screening - an overview about chances and risks]. / Früherkennung von Lungenkrebs - eine Übersicht über Chancen und Risiken.

Lung cancer is a leading cause of death worldwide. Patients are usually diagnosed at an advanced stage and have a very poor prognosis. In Switzerland, lung cancer is the most frequent cause of cancer death in men and the second most frequent cause of cancer death in women. Programmes to prevent individuals from initiating to smoke and to support smokers to quit are the most effective lung cancer prevention strategy. Whether routine screening for lung cancer in smokers is effective to reduce lung cancer related morbidity and mortality remains questionable. We summarize the evidence of five recent randomised controlled trials on routine screening for lung cancer in smokers. One study found no benefit of periodic conventional chest X-rays as compared to usual care without regular imaging for reducing lung cancer death. In four other trials, low-dose computer tomography (LDCT) was compared to conventional chest X-rays and to usual care. Only the largest trial, the US based National Lung Cancer Screening Trial (NLST), demonstrated a statistically significant reduction of lung cancer mortality of LDCT compared to conventional chest X-rays whereas three European trials could not prove any benefit. The results of the NLST need to be interpreted with care due to limited generalizability to European settings. LDCT screening had an unacceptable high rate of false positive findings resulting in an enormous use of resources for diagnostic work-up. Whether LDCT screening is associated with an acceptable incremental cost-effectiveness ratio still warrants further investigation.

Measuring mortality reductions in cancer screening trials.

Randomized trials involving large numbers of people and long follow-up have helped measure the mortality reductions achievable by screening for cancer. However, in many of these trials, the reported reductions have been modest. Part of the reason is the inappropriate way the reductions have been calculated. Analyses have largely ignored the fact that there is a time window in the first several years after screening begins in which there cannot be a sizable mortality reduction, followed by one in which the reductions become evident, and-unless screening is continued-a third window in which mortality rates in the screened group revert to those in the unscreened group. This review uses time-specific mortality ratios to address the timing and extent of the reductions achieved in trials of screening for prostate, breast, and colorectal cancer. The author finds that the mortality reductions reported in the literature have substantially underestimated what might be accomplished with continued screening. The natural history of the disease, the frequency of screening, and the duration of follow-up determine the time patterns in the reductions observed in trials. Without appropriate analyses, results from cancer screening trials will be distorted.

Addressing the impact of trauma before diagnosing mental illness in child welfare.

Congress set requirements for child welfare agencies to respond to emotional trauma associated with child maltreatment and removal. In meeting these requirements, agencies should develop policies that address child trauma. To assist in policy development, this study analyzes more than 14,000 clinical assessments from child welfare in Illinois. Based on the analysis, the study recommends child welfare agencies adopt policies requiring that (1) mental health screenings and assessments of all youth in child welfare include measures of traumatic events and trauma-related symptoms; (2) evidence-based, trauma-focused treatment begin when a youth in child welfare demonstrates a trauma-related symptom; and (3) a clinician not diagnose a youth in child welfare with a mental illness without first addressing the impact of trauma. The study also raises the issue of treatment reimbursement based on diagnosis.

Association of Inclusion of More Black Individuals in Lung Cancer Screening With Reduced Mortality.

Importance: The potential to achieve greater reductions in lung cancer mortality than originally estimated by the National Lung Screening Trial with the inclusion of more Black participants stresses the importance of improving access to lung cancer screening for Black current and former smokers, a population presently with the highest lung cancer morbidity and mortality. Objective: To estimate lung cancer and all-cause mortality reductions achievable with lung cancer screening via low-dose computed tomography (LDCT) of the chest in populations with greater proportions of Black screening participants than seen in the original NLST cohort. Design, Setting, and Participants: This cohort study was conducted as a secondary analysis of existing data from the National Lung Screening Trial, a large national randomized clinical trial conducted from 2002 through 2009. NLST participants were current or former smokers, aged between 55 and 74 years, with at least 30 pack-years of smoking history and less than 15 years since quitting. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% CIs of lung cancer mortality and all-cause mortality according to LDCT screening compared with chest radiograph screening. Using a transportability formula, we estimated outcomes for LDCT screening among hypothetical populations by varying the distributions of Black individuals, women, and current smokers. Data were analyzed between September 2020 and March 2021. Exposures: Lung screening with LDCT of the chest compared with chest radiography. Main Outcomes and Measures: Lung cancer mortality and all-cause mortality. Results: This study included a total of 53 452 participants enrolled in the NLST. Of 2376 Black individuals and 51 076 non-Black individuals, 21 922 (41.0%) were women and the mean (SD) age was 61.4 (5.0) years. Over a median (interquartile range) follow-up of 6.7 (6.2-7.0) years, LDCT screening among the synthesized population with a higher proportion of Black individuals (13.4%, mirroring US Census data) was associated with a greater relative reduction of lung cancer mortality (eg, Black individuals: HR, 0.82; 95% CI, 0.72-0.92; vs entire NLST cohort: HR, 0.84; 95% CI, 0.76-0.96). Further reductions in lung cancer mortality by LDCT screening were found among a hypothetical population with a higher proportion of men or current smokers, along with a higher proportion of Black individuals (ie, 60% Black participants; 20% to 40% women) (HR, 0.68; 95% CI, 0.48-0.97). Conclusions and Relevance: The potential to achieve greater reductions in lung cancer mortality than originally estimated by the NLST with the inclusion of more Black participants stresses the critical importance of improving access to lung cancer screening for Black current and former smokers.

Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial.

BACKGROUND: The aim was to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. METHODS: All men aged 64-73 years living in Viborg County were randomized to be controls (n = 6306) or invited for abdominal ultrasonography at a regional hospital (n = 6333). Mortality and AAA-related interventions were recorded in national databases. The cost of initial screening was based on actual costs of the programme. Incremental cost-effectiveness ratios (ICERs) were calculated on gains in life years and Quality Adjusted Life Years (QALY). Discounting (3 per cent) was applied to both costs and effects, and all costs were adjusted to euros at 2007 prices. RESULTS: The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0.34, 95 per cent confidence interval (c.i.) 0.20 to 0.57). The corresponding risk reduction in all-cause mortality was 2 per cent (hazard ratio 0.98, 95 per cent c.i. 0.93 to 1.03). The ICER was estimated at euro157 (-3292 to 4401) per life year gained and euro179 (-4083 to 4682) per QALY gained. Screening was found to be cost effective at a probability above 0.97 for a willingness-to-pay threshold of only euro5000. One-way sensitivity analysis demonstrated that this result was robust to various alternative assumptions, as the probability did not drop below 0.90 for any scenario. CONCLUSION: The mortality benefit of screening for AAA in men aged 64-73 years was maintained in the longer term and screening was cost effective.

Optimal treatment increased survival of hepatocellular carcinoma patients detected with community-based screening.

BACKGROUND AND AIM: The early detection of hepatocellular carcinoma (HCC) and opportunity to select appropriate treatment are important benefits of HCC screening. Our aim in the present study was to investigate the survival rate, prognostic factors and treatment effects in HCC patients of community-based screening. METHODS: Community-based ultrasound (US) screening for HCC in adults with platelet counts (< 150 x 10(3)/mm(3)) and/or alpha fetoprotein (AFP) > 20 ng/mL was conducted in 2002 and 2004. As per the Barcelona Clinic Liver Cancer (BCLC) stage, 90 cases of intermediate or earlier stage HCC were detected and 88 cases had sufficient information for analysis (49 men and 39 women, aged 65.8 +/- 9.6 years). The tumor diameter was mostly less than 5 cm (76.1%). The follow up was continued until June 2008. RESULTS: The 4-year overall survival rate was 46.8%. Old age (> or = 70 years) (P = 0.046), later stage of HCC (intermediate vs earlier) (P = 0.012), low platelet count (< 100 x 10(3)/mm(3)) (P = 0.013) and refusal of modern treatment (P = 0.026) were independent poor prognostic factors. Curative treatment increased survival in patients of all ages. Both curative treatment and transcatheter arterial embolization (TAE) increased survival in cases of intermediate HCC. However, treatment benefits were not found for patients with (very) early stage HCC. CONCLUSIONS: Early detection and prompt treatment of HCC leads to increased survival. For elderly patients this benefit was seen only for early stage cases receiving curative treatment. Differences between treatment types for patients with (very) early stage HCC might emerge with a longer follow-up period.

Estimating the impact of wide scale uptake of screening and medications for opioid use disorder in US prisons and jails.

BACKGROUND: Medications for opioid use disorder (OUD) are the most effective treatment for OUD, but uptake of these life-saving medications has been extremely limited in US prisons and jail settings, and limited data are available to guide policy decisions. The objective of this study was to estimate the impact of screening and treatment with medications for OUD in US prisons and jails on post-release opioid-related mortality. METHODS: We used data from the National Center for Vital Statistics, the Bureau of Justice Statistics, and relevant literature to construct Monte Carlo simulations of a counterfactual scenario in which wide scale uptake of screening and treatment with medications for OUD occurred in US prisons and jails in 2016. RESULTS: Our model predicted that 1840 (95% Simulation Interval [SI]: -2757 - 4959) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated. The model also predicted that approximately 4400 (95% SI: 2675 - 5557) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated and were retained in treatment post-release. These estimates correspond to 668 (95% SI: -1008 - 1812) and 1609 (95% SI: 972 - 2037) lives saved per 10,000 persons incarcerated, respectively. CONCLUSIONS: Prison and jail-based programs that comprehensively screen and provide treatment with medications for OUD have the potential to produce substantial reductions in opioid-related overdose deaths in a high-risk population; however, retention on treatment post-release is a key driver of population level impact.

The Impact of National Surveillance for Liver Cancer: Results from Real-World Setting in Korea.

Background/Aims: The National Liver Cancer Surveillance Program (NLCSP) was established in 2003 to reduce the socioeconomic burden imposed by liver cancer (LC). We aimed to investigate the effectiveness of the NLCSP in South Korea with respect to survival benefits and cost, after adjusting for various confounding factors. Methods: We used the National Health Insurance Service claims data linked with the NLCSP from 2004 to 2015. The Cox proportional hazard model and generalized linear model were used to determine the effects of the NLCSP on the early detection of LC, survival, and medical costs. Results: From 2006 to 2010, 66,632 patients (surveillance group: 10,527 and no surveillance group: 56,105) newly diagnosed with LC were included in the study. The odds of the early detection of LC was 1.82 (95% confidence interval [CI], 1.73 to 1.93) times higher among patients who participated in the NLCSP once within the 2-year period prior to the diagnosis of LC than among those who did not participate in the surveillance program. The mortality rate of patients who participated in the NLCSP was 22.0% lower (hazard ratio, 0.78; 95% CI, 0.76 to 0.80) than that of those who did not participate. When compared with the group who did not participate in surveillance, the group who participated in the NLCSP had higher total medical costs; however, their cost per day was lower after adjustment during the follow-up period. Conclusions: This study highlights the survival benefit in patients who participated in the NLCSP and the need for continuous improvements of the NLCSP in South Korea.

[Clinical research on prostate cancer detected in Tone central hospital--comparison of survival rates between patients diagnosed with prostate cancer in and outside screening system].

OBJECTIVES: We investigated a clinical features and outcomes of prostate cancer detected in Tone Central Hospital. MATERIALS AND METHODS: We investigated clinical features of 532 patients with pathologically confirmed prostate cancer detected in our hospital between 1987 and 2006. Furthermore, we compared survival rates of screen detected prostate cancer (SC group) with those of non-screen detected prostate cancer (NSC group) for 362 cases diagnosed with prostate cancer after 1999. 362 cases consist of 223 patients in SC group and 139 patients in NSC group. RESULTS: Since 1987, the annual number of newly diagnosed patients has gradually increased and we recognized stage migration, a tendency toward an annual decrease in the incidence of stages A and D and an increase in that of stage B. The stage distributions of SC group (223 cases) and NSC group (139 cases), respectively, were 0.4% (1/223) and 9.4% (13/139) in stage A (p = 0.0011), 71.3% (159/223) and 31.7% (44/139) in stage B (p < 0.0001), 24.2% (54/223) and 23.7% (33/139) in stage C (p = 0.9182), and 4.0% (9/223) and 34.6% (46/223) in stage D (p < 0.0001). The 3, 5 and 7-year overall survival rates, respectively, were 95.6%, 92.7% and 84.1% in SC group, and 83.2%, 74.3% and 60.8% in NSC group (p < 0.0001). Furthermore, the 3, 5 and 7-year cause-specific survival rates, respectively, were 98.8%, 97.3% and 95.9% in SC group, and 90.2%, 87.7% and 79.4% in NSC group (p < 0.0001). CONCLUSIONS: Clinical stage distribution has been changed between 1987 and 2006. Furthermore, overall and cause specific survival rates were better in screen detected prostate cancer than non-screen detected prostate cancer, because of increases in earlier stage of prostate cancer in SC group.

Comparison of nonbreast cancer incidence, survival and mortality between breast screening program participants and nonparticipants.

Comparisons of cancer mortality between users and nonusers of screening are potentially biased because of the effects of self-selection. Previous studies of breast screening have found that individuals likely to participate have lower breast cancer mortality than those unlikely to participate. This study compares the incidence, survival and mortality for all cancer types other than breast between participants and nonparticipants in a service screening mammography program. British Columbian females having their first mammogram between the ages of 40 and 79 and the years 1988 and 2004 were identified as a cohort of "participants". Person-years of follow-up of participants were aggregated by age and year. Nonparticipant person-years were obtained by subtraction from the total female population. Cancer diagnoses other than breast were identified for participants and nonparticipants. Age, calendar year, and income adjusted relative risks of cancer incidence were estimated from generalized additive models with Poisson errors. Hazard ratios were estimated by Cox regression. Observed cancer mortality in participants was compared with expected mortality generated from nonparticipant incidence and survival rates. Incidence rates of cancer showed a mixed relationship with some elevated, some decreased and others similar to nonparticipant rates. Cancer survival was higher among participants for most cancer types, with an overall hazard ratio of 0.76 (0.73-0.79). Observed mortality in participants was less than expected for most cancers, with an overall mortality ratio of 0.60 (0.58-0.62). The general cancer experience of screening program participants is different from that of the general population.

Evaluation of service mammography screening impact in Italy. The contribution of hazard analysis.

12,987 invasive breast cancer cases were diagnosed in women aged 50-69 upto the year 2001 in nine Italian areas where a screening programme was active. Cases were followed up in 2005 for a total of 1921 breast cancer failures. The 10-year survival rates were 85.3% for the invited group against 75.6% for the non-invited. A time dependent analysis was performed using 5-year intervals. Crude hazard ratios for the invited group in comparison to the not invited group were 0.52 and 0.64 respectively in the (0-5) year and [5-10] year time windows. Hazard ratio adjusted for tumour characteristics was 0.96 in the [5-10] year time window, suggesting minimal or any length bias. Consistent with the results of randomised trials, these analyses of service screening data document a mortality reduction of 36% at 5-10 years after diagnosis.

Decreased death from gastric cancer by endoscopic screening: association with a population-based cancer registry.

OBJECTIVE: To determine death rates from gastric cancer when using endoscopic screening. MATERIAL AND METHODS: In this historical cohort study comprising 11,763 participants aged from 40 to 75 years without gastric disorders between 1990 and 1992, 2192 were examined by gastric endoscopy while 9571 were not examined by endoscopy or X-ray. The relative risk of gastric cancer death was compared between the two groups. RESULTS: When screened with endoscopy, 41 patients were diagnosed with gastric cancer and the ratio of early cancer was 78%. On matching the population-based cancer registry (the Fukui Cancer Registry), 63 patients in the examined group were diagnosed with gastric cancer within 10 years after the initial screening including the above 41 patients. In the non-examined group, 147 patients were diagnosed with gastric cancer in the same period. In the examined and non-examined groups, 5 and 63 patients, respectively, died from gastric cancer. The relative risk for gastric cancer death in the examined group was 0.3465 (95% CI: 0.1396-0.8605) when compared with the non-examined group. For male patients, the relative risk was 0.2174 (95% CI: 0.0676-0.6992). CONCLUSIONS: The death rate from gastric cancer decreased when endoscopic screening was used. Endoscopy is recommended as a population-based screening method for gastric cancer in regions or countries where mortality from this disease is high.

Limitations in the Effect of Screening on Breast Cancer Mortality.

PURPOSE: Randomized, controlled trials showed that screening reduces breast cancer mortality rates, but some recent observational studies have concluded that programmatic screening has had minor effect on breast cancer mortality rates. This apparent contradiction might be explained by the use of aggregated data in observational studies. We assessed the long-term effect of screening using individual-level data. MATERIALS AND METHODS: Using data from mammography screening in the Copenhagen and Danish national registers, we compared the observed breast cancer mortality rate in women invited to screening with the expected rate in absence of screening. The effect was examined using the "naïve model," which included all breast cancer deaths; the "follow-up model," which counted only breast cancer deaths in women diagnosed after their first invitation to screening; and the "evaluation model," which is similar to the follow-up model during screening age, but after screening age, which counted only breast cancer deaths and person-years in women diagnosed during screening age. RESULTS: We included 18,781,292 person-years, 976,743 of which were from women invited to screening. The naïve and follow-up models showed, respectively, 10% and 11% reduction in breast cancer mortality after invitation to screening. However, many breast cancer deaths occurred in women whose cancer was diagnosed when they were no longer eligible for screening. Accounting for this dilution, the evaluation model showed a 20% (95% CI, 10% to 29%) reduction in breast cancer mortality after invitation to screening. CONCLUSION: Screening had a clear long-term beneficial effect with a 20% reduction in breast cancer-associated mortality in the invited population. However, this effect was, by nature, restricted to breast cancer deaths in women who could potentially benefit from screening. Our study highlights the complexity in evaluating the long-term effect of breast cancer screening from observational data.

Identifying Dyslexia Risk in Student-Athletes: A Preliminary Protocol for Concussion Management.

Learning disability (LD) has been identified as a potential risk factor for a sport-related concussion, yet students with LD are rarely included in concussion research. Here, we draw special attention to dyslexia, a common but often underdiagnosed LD. Reading and learning problems commonly associated with dyslexia are often masked by protective factors, such as high verbal ability or general intelligence. Hence, high-achieving individuals with dyslexia may not be identified as being in a high-risk category. To ensure that students with dyslexia are included in LD concussion research and identified as LD in baseline testing, we provide athletic trainers with an overview of dyslexia and a preliminary screening protocol that is sensitive to dyslexia, even among academically high-achieving students in secondary school and college.