Pragmatic nationwide master observational trial based on genomic alterations in advanced solid tumors: KOrean Precision Medicine Networking Group Study of MOlecular profiling guided therapy based on genomic alterations in advanced Solid tumors (KOSMOS)-II study protocol KCSG AL-22-09.

BACKGROUND: Next-generation sequencing (NGS) has been introduced to many Korean institutions to support molecular diagnostics in cancer since 2017, when it became eligible for reimbursement by the National Health Insurance Service. However, the uptake of molecularly guided treatment (MGT) based on NGS results has been limited because of stringent regulations regarding prescriptions outside of approved indications, a lack of clinical trial opportunities, and limited access to molecular tumor boards (MTB) at most institutions. The KOSMOS-II study was designed to demonstrate the feasibility and effectiveness of MGT, informed by MTBs, using a nationwide precision medicine platform. METHODS: The KOSMOS-II trial is a large-scale nationwide master observational study. It involves a framework for screening patients with metastatic solid tumors for actionable genetic alterations based on local NGS testing. It recommends MGT through a remote and centralized MTB meeting held biweekly. MGT can include one of the following options: Tier 1, the therapeutic use of investigational drugs targeting genetic alterations such as ALK, EGFR, ERBB2, BRAF, FH, ROS1, and RET, or those with high tumor mutational burden; Tier 2, comprising drugs with approved indications or those permitted for treatment outside of the indications approved by the Health Insurance Review and Assessment Service of Korea; Tier 3, involving clinical trials matching the genetic alterations recommended by the MTB. Given the anticipated proportion of patients receiving MGT in the range of 50% ± 3.25%, this study aims to enroll 1,000 patients. Patients must have progressed to one or more lines of therapy and undergone NGS before enrollment. DISCUSSION: This pragmatic master protocol provides a mass-screening platform for rare genetic alterations and high-quality real-world data. Collateral clinical trials, translational studies, and clinico-genomic databases will contribute to generating evidence for drug repositioning and the development of new biomarkers. TRIAL REGISTRATION: NCT05525858.

Data Resource Profile: The Cancer Public Library Database in South Korea.

This paper provides a comprehensive overview of the Cancer Public Library Database (CPLD), established under the Korean Clinical Data Utilization for Research Excellence project (K-CURE). The CPLD links data from four major population-based public sources: the Korea National Cancer Incidence Database in the Korea Central Cancer Registry, cause-of-death data in Statistics Korea, the National Health Information Database in the National Health Insurance Service, and the National Health Insurance Research Database in the Health Insurance Review & Assessment Service. These databases are linked using an encrypted resident registration number. The CPLD, established in 2022 and updated annually, comprises 1,983,499 men and women newly diagnosed with cancer between 2012 and 2019. It contains data on cancer registration and death, demographics, medical claims, general health checkups, and national cancer screening. The most common cancers among men in the CPLD were stomach (16.1%), lung (14.0%), colorectal (13.3%), prostate (9.6%), and liver (9.3%) cancers. The most common cancers among women were thyroid (20.4%), breast (16.6%), colorectal (9.0%), stomach (7.8%), and lung (6.2%) cancers. Among them, 571,285 died between 2012 and 2020 owing to cancer (89.2%) or other causes (10.8%). Upon approval, the CPLD is accessible to researchers through the K-CURE portal. The CPLD is a unique resource for diverse cancer research to investigate medical use before a cancer diagnosis, during initial diagnosis and treatment, and long-term follow-up. This offers expanded insight into healthcare delivery across the cancer continuum, from screening to end-of-life care.

Cost-Utility Analysis for Colorectal Cancer Screening According to the Initiating Age of National Cancer Screening Program in Korea.

BACKGROUND: This study aimed to identify the most cost-effective strategy for colorectal cancer screening using the fecal immunochemical test (FIT), focusing on screening initiation age in Korea. METHODS: We designed Markov simulation models targeting individuals aged 40 years or older. Twelve strategies combining screening initiation ages (40, 45, or 50 years old), termination ages (80 or no limit), and intervals (1 or 2 years) were modeled, and the most cost-effective strategy was selected. The robustness of the results was confirmed using one-way and probabilistic sensitivity analyses. Furthermore, the cost-effectiveness of the qualitative and quantitative FIT methods was verified using scenario analysis. RESULTS: The 2-year interval strategy with a screening age range of 45-80 years was the most cost-effective (incremental cost-utility ratio = KRW 7,281,646/quality adjusted life years). The most sensitive variables in the results were transition rate from advanced adenoma to local cancer and discount rate. The uncertainty in the model was substantially low. Moreover, strategies starting at the age of 40 years were also cost-effective but considered suboptimal. The scenario analysis showed that there was no significant difference in cost-effectiveness between strategies with various relative screening ratio of quantitative and qualitative method. CONCLUSION: The screening method for advancing the initiation age, as presented in the 2015 revised national screening recommendations, was superior regarding cost-effectiveness. This study provides a new paradigm for the development of a national cancer screening system in Korea, which can be utilized as a scientific basis for economic evaluations.

Cancer screening programs in South-east Asia and Western Pacific.

BACKGROUND: The burden of cancer can be altered by screening. The field of cancer screening is constantly evolving; from the initiation of program for new cancer types as well as exploring innovative screening strategies (e.g. new screening tests). The aim of this study was to perform a landscape analysis of existing cancer screening programs in South-East Asia and the Western Pacific. METHODS: We conducted an overview of cancer screening in the region with the goal of summarizing current designs of cancer screening programs. First, a selective narrative literature review was used as an exploration to identify countries with organized screening programs. Second, representatives of each country with an organized program were approached and asked to provide relevant information on the organizations of their national or regional cancer screening program. RESULTS: There was wide variation in the screening strategies offered in the considered region with only eight programs identified as having an organized design. The majority of these programs did not meet all the essential criteria for being organized screening. The greatest variation was observed in the starting and stopping ages. CONCLUSIONS: Essential criteria of organized screening are missed. Improving organization is crucial to ensure that the beneficial effects of screening are achieved in the long-term. It is strongly recommended to consider a regional cancer screening network.

Strategies to Improve Smoking Cessation for Participants in Lung Cancer Screening Program: Analysis of Factors Associated with Smoking Cessation in Korean Lung Cancer Screening Project (K-LUCAS).

PURPOSE: Smoking cessation intervention is one of the key components of successful lung cancer screening program. We investigated the effectiveness and related factors of smoking cessation services provided to the participants in a population-based lung cancer screening trial. MATERIALS AND METHODS: The Korean Lung Cancer Screening Project (K-LUCAS) is a nationwide, multi-center lung cancer screening trial that evaluates the feasibility of implementing population-based lung cancer screening. All 5,144 current smokers who participated in the K-LUCAS received a mandatory smoking cessation counseling. Changes in smoking status were followed up using a telephone survey in 6 months after lung cancer screening participation. The lung cancer screening's impact on smoking cessation is analyzed by variations in the smoking cessation interventions provided in screening units. RESULTS: Among 4,136 survey responders, participant's motivation to quit smoking increased by 9.4% on average after lung cancer screening. After 6 months from the initial screening, 24.3% of participants stopped smoking, and 10.6% of participants had not smoked continuously for at least 6 months after screening. Over 80% of quitters stated that participation in lung cancer screening motivated them to quit smoking. Low-cost public smoking cessation program combined with lung cancer screening increased the abstinence rates. The smokers were three times more likely to quit smoking when the smoking cessation counseling was provided simultaneously with low-dose computed tomography screening results than when provided separately. CONCLUSION: A mandatory smoking cessation intervention integrated with screening result counselling by a physician after participation in lung cancer screening could be effective for increasing smoking cessation attempts.

Synthetic Tabular Data Based on Generative Adversarial Networks in Health Care: Generation and Validation Using the Divide-and-Conquer Strategy.

BACKGROUND: Synthetic data generation (SDG) based on generative adversarial networks (GANs) is used in health care, but research on preserving data with logical relationships with synthetic tabular data (STD) remains challenging. Filtering methods for SDG can lead to the loss of important information. OBJECTIVE: This study proposed a divide-and-conquer (DC) method to generate STD based on the GAN algorithm, while preserving data with logical relationships. METHODS: The proposed method was evaluated on data from the Korea Association for Lung Cancer Registry (KALC-R) and 2 benchmark data sets (breast cancer and diabetes). The DC-based SDG strategy comprises 3 steps: (1) We used 2 different partitioning methods (the class-specific criterion distinguished between survival and death groups, while the Cramer V criterion identified the highest correlation between columns in the original data); (2) the entire data set was divided into a number of subsets, which were then used as input for the conditional tabular generative adversarial network and the copula generative adversarial network to generate synthetic data; and (3) the generated synthetic data were consolidated into a single entity. For validation, we compared DC-based SDG and conditional sampling (CS)-based SDG through the performances of machine learning models. In addition, we generated imbalanced and balanced synthetic data for each of the 3 data sets and compared their performance using 4 classifiers: decision tree (DT), random forest (RF), Extreme Gradient Boosting (XGBoost), and light gradient-boosting machine (LGBM) models. RESULTS: The synthetic data of the 3 diseases (non-small cell lung cancer [NSCLC], breast cancer, and diabetes) generated by our proposed model outperformed the 4 classifiers (DT, RF, XGBoost, and LGBM). The CS- versus DC-based model performances were compared using the mean area under the curve (SD) values: 74.87 (SD 0.77) versus 63.87 (SD 2.02) for NSCLC, 73.31 (SD 1.11) versus 67.96 (SD 2.15) for breast cancer, and 61.57 (SD 0.09) versus 60.08 (SD 0.17) for diabetes (DT); 85.61 (SD 0.29) versus 79.01 (SD 1.20) for NSCLC, 78.05 (SD 1.59) versus 73.48 (SD 4.73) for breast cancer, and 59.98 (SD 0.24) versus 58.55 (SD 0.17) for diabetes (RF); 85.20 (SD 0.82) versus 76.42 (SD 0.93) for NSCLC, 77.86 (SD 2.27) versus 68.32 (SD 2.37) for breast cancer, and 60.18 (SD 0.20) versus 58.98 (SD 0.29) for diabetes (XGBoost); and 85.14 (SD 0.77) versus 77.62 (SD 1.85) for NSCLC, 78.16 (SD 1.52) versus 70.02 (SD 2.17) for breast cancer, and 61.75 (SD 0.13) versus 61.12 (SD 0.23) for diabetes (LGBM). In addition, we found that balanced synthetic data performed better. CONCLUSIONS: This study is the first attempt to generate and validate STD based on a DC approach and shows improved performance using STD. The necessity for balanced SDG was also demonstrated.

Cluster of lifestyle risk factors for stomach cancer and screening behaviors among Korean adults.

This study aimed to investigate clustering patterns of lifestyle risk factors for stomach cancer and examine the association of risk factor clusters with stomach cancer screening adherence. Data from the 2019 Korean National Cancer Screening Survey, an annual cross-sectional nationwide survey, were used. The study population included 3539 adults aged 40-74 years with no history of cancer. Six stomach cancer risk factors, including smoking, drinking, physical inactivity, obesity, meat intake, and salted food intake, as well as stomach cancer screening behaviors, were assessed. The most frequent risk factor for stomach cancer was physical inactivity, followed by smoking in males and high salted food intake in females. Compared with participants subjects with no risk factors, those with three or more risk factors were less likely to adhere to screening guidelines (males: adjusted odds ratio [aOR] = 0.35, 95% confidence interval [CI] 0.23-0.53; females: aOR = 0.32, 95% CI 0.21-0.48). Our findings indicate a disparity in stomach cancer screening, such that those with more risk factors are less likely to get screened. Increasing public awareness, providing behavioral counseling, and targeting high-risk populations for screening interventions are critical for promoting cancer screening adherence and reducing the disparity in cancer screening.

Socioeconomic inequality in organized and opportunistic screening for gastric cancer: results from the Korean National Cancer Screening Survey 2009-2022.

Objectives: This study aimed to evaluate the socioeconomic inequality in gastric cancer (GC) screening in Korea. Socioeconomic inequality was assessed using both organized and opportunistic screening according to income and educational level. Methods: GC screening data were obtained from the 2009-2022 Korean National Cancer Screening Survey. The final analysis included 47,163 cancer-free men and women. The weighted cancer screening rate was estimated using joinpoint regression. The inequality indices were measured in terms of both the absolute slope index of inequality (SII) and the relative index of inequality (RII) using the Poisson regression model. Results: The organized screening rate for GC increased from 38.2% in 2009 to 70.8% in 2022, whereas the opportunistic screening rate decreased from 18.8 to 4.5%. Regarding educational inequality, a negative SII value was observed [-3.5, 95% confidence interval (CI), -7.63-0.83%] in organized screening, while a positive SII (9.30%; 95% CI, 6.69-11.91%) and RII (1.98%; 95% CI, 1.59-2.46) were observed in opportunistic screening. Furthermore, income inequality was not found in organized GC screening; however, overall SII and RII for opportunistic screening were 7.72% (95% CI, 5.39-10.5) and 1.61 (95% CI, 1.42-1.81), respectively. Conclusion: Organized screening rates have grown gradually over time and account for the majority of GC screenings in South Korea. While no socioeconomic inequalities were found in organized screening, significant socioeconomic inequalities were found in opportunistic screening.

Socioeconomic inequality in organized and opportunistic screening for colorectal cancer: results from the Korean National Cancer Screening Survey, 2009-2021.

OBJECTIVES: This study aimed to investigate socioeconomic status (SES)-based inequality in colorectal cancer (CRC) screening in Korea. We assessed whether the rates of opportunistic and organized CRC screening differed according to income and education levels. METHODS: We analyzed data from the Korean National Cancer Screening Survey of 27,654 cancer-free individuals, aged 50-74 years, from 2009 to 2021. The weighted cancer screening rates with trends were estimated with the average annual percentage change using joinpoint regression. Inequality was calculated in both relative and absolute terms, based on a Poisson regression model. RESULTS: The organized screening rate increased significantly from 22.1% in 2009 to 53.1% in 2020 and 50.6% in 2021, with an average annual change of 8.6% (95% confidence interval [CI], 4.9 to 12.5). In contrast, no significant trend was observed for opportunistic screening. The SES inequality in opportunistic screening uptake was indicated by a slope index of inequality (SII) of 9.74% (95% CI, 6.36 to 13.12), relative index of inequality (RII) of 2.18 (95% CI, 1.75 to 2.70) in terms of education level; and an SII of 7.03% (95% CI, 4.09 to 9.98), RII of 1.81 (95% CI, 1.41 to 2.31) in terms of measured income. Although there was an increasing trend in income inequality, no significant SES inequalities were observed in the overall estimates for organized screening. CONCLUSIONS: Organized CRC screening is effective in improving the participation rate, regardless of SES. However, significant inequalities were found in opportunistic screening, suggesting room for improvement in the overall equity of CRC screening.

Parental intention to vaccinate daughters with the human papillomavirus vaccine in Korea: a nationwide cross-sectional survey.

OBJECTIVES: We aimed to identify and compare the characteristics and factors associated with parental intention to vaccinate daughters under 12 years old against human papillomavirus (HPV), examining data from 2016 and 2020. METHODS: Data were obtained from the Korean National Cancer Screening Survey conducted in 2016 and 2020. The present study included 3,510 parents with daughters under 12 years old. Changes in parental intention-to-vaccinate rates were calculated. To identify factors associated with parental intention to vaccinate their daughters, the chi-square test and logistic regression analysis were used. RESULTS: The percentage of respondents intending to vaccinate their daughters increased from 33.4% in 2016 to 58.9% in 2020, constituting a 25.5 percentage point (%p) increase. Since 2016, the proportion of men expressing positive intention towards HPV vaccination increased by 31.5%p, while that of women demonstrated a 20.9%p increase. Logistic regression analysis indicated that parents with a strong intention to vaccinate their daughters tended to be younger, more educated, and aware of the free vaccination program available, as well as to have a history of HPV vaccination and to have undergone cervical cancer screening within 2 years, compared to those who did not intend to vaccinate. Being a mother with a history of HPV vaccination was the strongest predictor of positive intention to vaccinate a daughter. CONCLUSIONS: The intention among parents to vaccinate daughters remains relatively low, although it is rising. To increase the HPV vaccination rate, strong recommendations and education should be provided to parents and the younger generation.

Impact of health disparities on national breast cancer screening participation rates in South Korea.

Socioeconomic barriers to cancer screening exist at a regional level. The deprivation index is used to estimate socioeconomic gradients and health disparities across different geographical regions. We aimed to examine the impact of deprivation on breast cancer screening participation rates among South Korean women. Municipal breast cancer screening participation rates in women were extracted from the National Cancer Screening Information System and linked to the Korean version of the deprivation index constructed by the Korea Institute for Health and Social Affairs. A generalised linear mixed model was employed to investigate the association between the deprivation index and age-standardised breast cancer screening participation rates in 2005, 2012, and 2018. Participation rates increased gradually across all age groups from 2005 to 2018. Participants in their 60 s consistently had one of the highest participation rates (2005: 30.37%, 2012: 61.57%, 2018: 65.88%). In 2005, the most deprived quintile had a higher estimate of breast cancer screening participation than the least deprived quintile (2nd quintile; estimate: 1.044, p = 0.242, 3rd quintile; estimate: 1.153, p = 0.192, 4th quintile; estimate: 3.517, p = 0.001, 5th quintile; estimate: 6.913, p = < 0.0001). In 2012, the participation rate also increased as the level of deprivation increased. There were no statistically meaningful results in 2018. Regions with high deprivation have a higher participation rate in breast cancer screening. The role of health disparities in determining cancer outcomes among women in Korea requires further examination.

Individual and joint effect of socioeconomic status and lifestyle factors on cancer in Korea.

BACKGROUND: There is limited evidence on the individual and joint effect of socioeconomic status (SES) and unhealthy lifestyle on cancer. Therefore, this study aimed to examine the effects of these factors on cancer incidence and mortality. METHODS: In this population-based cohort study, income was used as the proxy of SES. A combined unhealthy lifestyle score was obtained using data on smoking, alcohol consumption, physical activity, and body mass index. Hazard ratios were estimated using a Cox proportional hazards model. RESULTS: The study included data on 8,353,169 participants (median follow-up period, 17 years). Although the association between low income and cancer incidence varied depending on cancer type, low income consistently increased the risk of cancer-related death with a social gradient. Unhealthy behaviors increased the risk of cancer incidence and mortality, except for thyroid and breast cancer in women and prostate cancer in men. Compared with the wealthiest and healthiest individuals, the poorest and unhealthiest men and women showed 2.1-fold (2.05-2.14) and 1.36-fold (1.31-1.41) higher risk of cancer-related death, respectively. The joint effect was most robust for lung, liver, head, and neck cancers in men and liver and cervical cancers in women; further, the effect was stronger with cancer-specific mortality than with incidence. CONCLUSION: In conclusion, income and combined healthy lifestyle behaviors have individual and joint effects on cancer incidence and mortality. The effect varies by cancer type and sex.

Risk of upper gastrointestinal cancer and death in persons with negative screening results: results from the National Cancer Screening Program in South Korea.

BACKGROUND: The Korea National Cancer Screening Program (KNCSP) offers upper endoscopy or upper gastrointestinal series (UGIS) biannually for people aged ≥ 40 years. This study aimed to assess the effect of negative screening results on the incidence of and mortality from upper gastrointestinal (GI) cancer. METHODS: A population-based retrospective cohort of 15,850,288 men and women was constructed using data from 3 national databases. The participants were followed until the end of 2017 for data on cancer incidence and in 2019 for data on the vital status. Cox proportional hazard model with time-varying exposure was used to assess the association. RESULTS: By the end of the follow-up period, 230,783 upper GI cancer cases and 99,348 upper GI cancer deaths were recorded. Negative gastric cancer screening was significantly associated with a lower risk of upper GI cancer in both UGIS (adjusted hazard ratio [aHR] = 0.81, 95% CI = 0.80-0.82) and upper endoscopy (aHR = 0.67, 95% CI = 0.67-0.68) groups. The HRs for upper GI mortality were 0.55 (95% CI = 0.54-0.56) and 0.21 (95% CI = 0.21-0.22) for the UGIS and upper endoscopy groups, respectively. The most significant reductions in the risk of upper GI cancer (UGIS: aHR = 0.76, 95% CI = 0.74-0.77; upper endoscopy: aHR = 0.60, 95% CI = 0.59-0.61) and death (UGIS: aHR = 0.54, 95% CI = 0.52-0.55; upper endoscopy: aHR = 0.19, 95% CI = 0.19-0.20) were observed among individual aged 60-69 years. CONCLUSION: Negative screening cases, especially in upper endoscopy of the KNCSP, were associated with an overall reduction in the risk of and mortality from upper GI cancer.

Overview of the National Cancer Screening Program for Colorectal Cancer in Korea over 14 Years (2004-2017).

PURPOSE: This study aimed to evaluate the participation and follow-up test compliance rates and key performance indicators of the National Cancer Screening Program (NCSP) for colorectal cancer (CRC) from 2004 to 2017. Materials and Methods: The overall outcomes of the NCSP for CRC were analyzed using the NCSP data collected from 2004 to 2017 and the Korean Central Cancer Registry for CRC from 2005 to 2017. We cross-sectionally analyzed the participation and follow-up test compliance rates and performance indicators for each year. The trend of participation rates as an annual percentage change was assessed, and other statistical analyses were performed. RESULTS: The screening participation rates increased from 7.3% in 2004 to 30.5% in 2017. Additionally, the screening rates were higher among individuals aged 60-69 years and National Health Insurance Service beneficiaries of low-income status. However, the adherence to the follow-up test decreased from 63% in 2004 to 32% in 2017. The follow-up tests using the double-contrast barium enema method decreased from 42.2% in 2004 to 0.3% in 2017. However, follow-up tests by colonoscopy increased from 21.0% in 2004 to 31.8% in 2017. Furthermore, the positivity, false-positive, and interval CRC rates decreased, whereas the specificity increased from 2004 to 2016, indicating improved performance of CRC. CONCLUSION: The participation rates and performance of the NCSP for CRC have steadily improved, whereas adherence to follow-up tests has decreased. Additionally, there is a rapid growth in colonoscopy volume as a follow-up test. Continued efforts are required to improve the follow-up rates.

Estimating Age-Specific Mean Sojourn Time of Breast Cancer and Sensitivity of Mammographic Screening by Breast Density among Korean Women.

PURPOSE: High breast cancer incidence and dense breast prevalence among women in forties are specific to Asian. This study examined the natural history of breast cancer among Korean women. MATERIALS AND METHODS: We applied a three-state Markov model (i.e., healthy, preclinical, and clinical state) to fit the natural history of breast cancer to data in the Korean National Cancer Screening Program. Breast cancer was ascertained by linkage to the Korean Central Cancer Registry. Disease-progression rates (i.e., transition rates between three states), mean sojourn time (MST) and mammographic sensitivity were estimated across 10-year age groups and levels of breast density determined by the Breast Imaging, Reporting and Data System. RESULTS: Overall prevalence of dense breast was 53.9%. Transition rate from healthy to preclinical state, indicating the preclinical incidence of breast cancer, was higher among women in forties (0.0019; 95% confidence interval [CI], 0.0017 to 0.0021) and fifties (0.0020; 95% CI, 0.0017 to 0.0022), than women in sixties (0.0014; 95% CI, 0.0012 to 0.0017). The MSTs, in which the tumor is asymptomatic but detectable by screening, were also fastest among younger age groups, estimated as 1.98 years (95% CI, 1.67 to 2.33), 2.49 years (95% CI, 1.92 to 3.22), and 3.07 years (95% CI, 2.11 to 4.46) for women in forties, fifties, and sixties, respectively. Having dense breasts increased the likelihood of the preclinical cancer risk (1.96 to 2.35 times) and decreased the duration of MST (1.53 to 2.02 times). CONCLUSION: This study estimated Korean-specific natural history parameters of breast cancer that would be utilized for establishing optimal screening strategies in countries with higher dense breast prevalence.

Trends in breast cancer screening rates among Korean women: results from the Korean National Cancer Screening Survey, 2005-2020.

OBJECTIVES: Since 2002, the Korean government has provided breast cancer screening as part of the National Cancer Screening Program. This study reported trends in the screening rate among Korean women from 2005 to 2020, including organized and opportunistic screening for breast cancer. METHODS: Data from the Korean National Cancer Screening Survey, an annual cross-sectional nationwide survey, were collected using a structured questionnaire between 2005 and 2020. The study population included 23,702 women aged 40-74 years with no history of cancer. We estimated the screening rate based on the current recommendation of biennial mammographic screening for breast cancer. In addition, a joinpoint trend analysis was performed for breast cancer screening rates among various subgroups. RESULTS: In 2020, the breast cancer screening rate was 63.5%, reflecting an annual increase of 7.72% (95% confidence interval 5.53 to 9.95) between 2005 and 2012, followed by non-significant trends thereafter. In particular, a significant decrease in the breast cancer screening rate was observed in the subgroups aged 50-59 years old, with 12-15 years of education, and living in rural areas. CONCLUSIONS: Although there has been substantial improvement in breast cancer screening rates in Korean women, the trend has flattened in recent years. Therefore, continual efforts are required to identify subgroups with unmet needs and solve barriers to the uptake of breast cancer screening.

Effect of mammography screening on the long-term survival of breast cancer patients: results from the National Cancer Screening Program in Korea.

OBJECTIVES: This study investigated the effect of mammography screening on the long-term survival of breast cancer (BC) patients aged 40 years or older according to their screening history and duration since screening. METHODS: The study cohort was organized from 3 nationwide databases of the Korean National Cancer Screening Program, the Korean Central Cancer Registry, and death certificates. We included 24,387 women diagnosed with invasive BC or ductal carcinoma in situ in 2008 and 2009 and followed up until December 31, 2019. Cox proportional-hazards regression was used to investigate the effect of BC screening on the risk of death. RESULTS: Overall, 20,916 of 24,387 patients (85.8%) were alive at the end of the follow-up period (median: 10.5 years). The long-term survival rate was significantly lower in the never-screened group (80.3%) than in the screened group (88.9%) (p<0.001). A 35% reduction in the risk of BC death (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.60 to 0.70) from screening was observed. A subgroup analysis according to the cancer stage showed 62%, 36%, and 24% lower risks of BC death for the localized stage, regional stage, and distant stage, respectively. Women aged 40-49 years received the least benefit from BC screening (HR, 0.71; 95% CI, 0.62 to 0.81). CONCLUSIONS: Mammography screening was effective in reducing the risk of BC-specific death in Asian women across all cancer stages. However, this effect was relatively small among women in their 40s, suggesting that more detailed and specialized screening strategies are needed for that age group.

Impact of the COVID-19 Pandemic on Gastric Cancer Screening in South Korea: Results From the Korean National Cancer Screening Survey (2017-2021).

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted cancer screening services worldwide. We aimed to measure the impact of COVID-19 on gastric cancer screening rates based on age, sex, household income, and residential area. MATERIALS AND METHODS: We analyzed data from the Korean National Cancer Screening Survey from 2017 to 2021 for adults aged 40-74 years. We evaluated the gastric cancer screening rate within two years in accordance with the National Cancer Screening Program protocol recommendations and that within the previous year. We compared the trends in the pre- and post-COVID-19 outbreak periods. RESULTS: Before the COVID-19 outbreak, there was little change in the gastric cancer screening rates until 2019. After the COVID-19 outbreak, the screening rate as per recommendation decreased from 70.8% in 2019 to 68.9% in 2020 and that for one year decreased from 32.7% in 2019 to 27.2% in 2020. However, as the COVID-19 pandemic continued after 2020, both gastric cancer screening rates as per recommendations and for one year rebounded. Although a similar trend was observed for the upper endoscopy screening rate, the upper gastrointestinal series screening rate decreased from 7.8% in 2020 to 3.1% in 2021. During the pandemic, the screening rate decreased among younger adults (40-49), those residing in metropolitan regions, and those with high incomes. CONCLUSIONS: Despite a decline in gastric cancer screening rate during the COVID-19 pandemic, the rate surged in 2021. Further studies are needed to estimate the impact of cancer screening delays on future cancer-related mortalities.

Effect of Pap smears on the long-term survival of cervical cancer patients: a nationwide population-based cohort study in Korea.

OBJECTIVES: This study aimed to investigate the effect of cervical cancer screening by Papanicolaou (Pap) smears on the long-term survival of cervical cancer patients. METHODS: We constructed a retrospective cohort of 14,903 women diagnosed with invasive cancer or carcinoma in situ in 2008 and 2009 and followed up until December 31, 2019, by using individual-level data from 3 national databases of the Korean National Cancer Screening Program, the Korean Central Cancer Registry, and death certificates. Cox proportional-hazards regression was used to investigate the effect of cervical cancer screening on mortality. RESULTS: In total, 12,987 out of 14,867 patients (87.4%) were alive at the end of the follow-up period (median: 10.5 years). Screened patients had a 38% lower risk of cervical cancer death than never-screened patients (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.54 to 0.70). Screening was associated with 59% and 35% lower risks of death, respectively, in screened patients with localized and regional stages. Furthermore, lower HRs among women who received screening were observed in all age groups, especially women aged 50-59 years (HR, 0.54; 95% CI, 0.42 to 0.69). The lowest HR for cervical cancer death was reported among patients screened within the past 2 years (HR, 0.54; 95% CI, 0.47 to 0.63), and the HRs increased with increasing time intervals. CONCLUSIONS: Pap smear screening significantly reduced the risk of cervical cancer-specific death in Korean women across all cancer stages.

Association Between Changes in Alcohol Consumption and Cancer Risk.

Importance: Although numerous studies have shown an association between alcohol consumption and cancer, how changes in drinking behavior increase or decrease the incidence of cancer is not well understood. Objective: To investigate the association between the reduction, cessation, or increase of alcohol consumption and the development of alcohol-related cancers and all cancers. Design, Setting, and Participants: This population-based cohort study analyzed adult beneficiaries in the Korean National Health Insurance Service. Participants (aged ≥40 years) included those who underwent a national health screening in both 2009 and 2011 and had available data on their drinking status. Data were analyzed from April 16 to July 6, 2020. Exposures: Alcohol consumption level, which was self-reported by participants in health screening questionnaires, was categorized into none (0 g/d), mild (<15 g/d), moderate (15-29.9 g/d), and heavy (≥30 g/d) drinking. Based on changes in alcohol consumption level from 2009 to 2011, participants were categorized into the following groups: nondrinker, sustainer, increaser, quitter, and reducer. Main Outcomes and Measures: The primary outcome was newly diagnosed alcohol-related cancers (including cancers of the head and neck, esophagus, colorectum, liver, larynx, and female breast), and the secondary outcome was all newly diagnosed cancers (except for thyroid cancer). Results: Among the 4 513 746 participants (mean [SD] age, 53.6 [9.6] years; 2 324 172 [51.5%] men), the incidence rate of cancer was 7.7 per 1000 person-years during a median (IQR) follow-up of 6.4 (6.1-6.6) years. Compared with the sustainer groups at each drinking level, the increaser groups had a higher risk of alcohol-related cancers and all cancers. The increased alcohol-related cancer incidence was associated with dose; those who changed from nondrinking to mild (adjusted hazard ratio [aHR], 1.03; 95% CI, 1.00-1.06), moderate (aHR, 1.10; 95% CI, 1.02-1.18), or heavy (aHR, 1.34; 95% CI, 1.23-1.45) drinking levels had an associated higher risk than those who did not drink. Those with mild drinking levels who quit drinking had a lower risk of alcohol-related cancer (aHR, 0.96; 95% CI, 0.92-0.99) than those who sustained their drinking levels. Those with moderate (aHR, 1.07; 95% CI, 1.03-1.12) or heavy (aHR, 1.07; 95% CI, 1.02-1.12) drinking levels who quit drinking had a higher all cancer incidence than those who sustained their levels, but when quitting was sustained, this increase in risk disappeared. Compared with sustained heavy drinking, reduced heavy drinking levels to moderate levels (alcohol-related cancer: aHR, 0.91 [95% CI, 0.86-0.97]; all cancers: aHR, 0.96 [95% CI, 0.92-0.99]) or mild levels (alcohol-related cancer: aHR, 0.92 [95% CI, 0.86-0.98]; all cancers: aHR, 0.92 [95% CI, 0.89-0.96]) were associated with decreased cancer risk. Conclusions and Relevance: Results of this study showed that increased alcohol consumption was associated with higher risks for alcohol-related and all cancers, whereas sustained quitting and reduced drinking were associated with lower risks of alcohol-related and all cancers. Alcohol cessation and reduction should be reinforced for the prevention of cancer.