Attitudes towards risk-stratified breast cancer screening: a population-based survey among 5,001 Danish women.

BACKGROUND: The individual woman's risk of being diagnosed with breast cancer can now be estimated more precisely, and screening can be stratified accordingly. The risk assessment requires that women are willing to provide a blood test, additional personal information, to know their risk, and alter screening intervals. This study aimed to investigate Danish women's attitudes towards risk-stratified breast cancer screening. METHODS: An online, cross-sectional survey was conducted among Danish women aged 52-67 years. We used logistic regression analyses to assess how personal characteristics were associated with the women's attitudes. RESULTS: 5,001 women completed the survey (response rate 44%) of which 74% approved of risk estimation to potentially alter their screening intervals. However, only 42% would accept an extended screening interval if found to have low breast cancer risk, while 89% would accept a reduced interval if at high risk. The main determinants of these attitudes were age, education, screening participation, history of breast cancer, perceived breast cancer risk and to some extent breast cancer worry. CONCLUSION: This study indicates that women are positive towards risk-stratified breast cancer screening. However, reservations and knowledge among subgroups of women must be carefully considered and addressed before wider implementation of risk-stratified breast cancer screening in a national program.

Breast Cancer Screening Among Women With Intellectual Disability in Denmark.

Importance: Breast cancer-specific mortality is increased among women with intellectual disability (ID), and knowledge about participation in breast cancer screening in this group is needed. Objective: To examine participation in the Danish national breast cancer screening program among women with ID compared with women without ID. Design, Setting, and Participants: This dynamic population-based cohort study assessed participation in the Danish national breast cancer screening program initiated in 2007, targeting women aged 50 to 69 years with a screening interval of 2 years. In all, 6357 women with ID born between 1941 and 1967 and eligible for the screening program were identified in national registers. Women entered the study between January 1, 2007, and December 31, 2017. Subsequently, 273 women were excluded due to a history of carcinoma in situ or breast cancer, and 489 due to registration errors in registers. Each woman was individually age-matched with 10 women without ID (reference group). All women were followed up until March 31, 2021, or censoring (due to death, carcinoma in situ, or breast cancer). Data were analyzed from December 1, 2021, to June 31, 2022. Exposures: Intellectual disability was defined as being registered with an ID diagnosis or a diagnosis most likely leading to ID or residing at an institution for persons with ID. Main Outcomes and Measures: Participation in breast cancer screening (fully, partly, and never). Results: A total of 5595 women with ID and 49 423 age-matched women in the reference group were included in the analysis. Of these, 2747 women with ID (49%) and 24 723 in the reference group (50%) were 50 years of age at study entry; for those older than 50 years, the median age was 51 years (IQR, 50-58 years) in both groups. In all, 1425 women with ID (25%) were fully screened according to guidelines for the Danish breast cancer screening program compared with 30 480 women in the reference group (62%). Women with ID had nearly 5 times higher odds of never being screened compared with the reference group (odds ratio, 4.90 [95% CI, 4.60-5.22]). In all, 2498 women with ID (45%) and 6573 in the reference group (13%) were never screened. The proportion of never-screened women increased with severity of ID, from 834 of 2287 (36%) among women with mild ID to 173 of 212 (82%) among women with profound ID. Conclusions and Relevance: The findings of this cohort study suggest that women with ID are markedly less likely to participate in breast cancer screening compared with women without ID. These findings further suggest a need for tailored guidelines and approaches for breast cancer screening in this group of women.

Young Danish HPV vaccinated women's knowledge, barriers and facilitators towards cervical cancer screening: A qualitative study.

Cervical cancer occurs more often in under-screened women, and participation rates in cervical cancer screening among young women are worryingly low worldwide. In Denmark only about half the women in their twenties participate in cervical cancer screening. 64-80% of women between 20 and 29 have been HPV vaccinated with a vaccine protecting against 70% of all cervical cancers. Thus screening is still an important supplement to HPV vaccination for the next decades. The aim of this study was to investigate knowledge, facilitators and barriers towards cervical cancer screening among young HPV vaccinated women in Denmark. This qualitative study used an anthropological approach, and data was collected using semi structured focus group interviews as this is an effective method for promoting self-disclosure among participants. Eight focus groups were conducted with participation of 49 HPV vaccinated women aged 20-29 years. We identified five main themes providing an understanding of the women's barriers and facilitators towards cervical cancer screening: Lack of knowledge about HPV and cervical cancer, the screening invitation, the GP as gatekeeper, the gynaecological examination and perceived relevance of cervical cancer screening. Former vaccination did not impact the women's reflection about screening attendance. We argue that systematic information and the attitude and tone of the GP are the primary facilitators for filling the knowledge gap we found among young HPV vaccinated women. As an important gatekeeper, the GP can explain, motivate and remind young women about the importance of a regular Pap smear.

Vaccination against HPV: boosting coverage and tackling misinformation.

The availability of human papillomavirus (HPV) vaccines and screening tests has raised the possibility of globally eliminating cervical cancer, which is caused by HPV. Cervical cancer is a very common malignancy worldwide, especially among deprived women. High vaccination coverage is key to the containment and eventual elimination of the infection. Public HPV vaccination programmes in Italy and Denmark were swiftly established and are among the most successful worldwide. Still, in both countries, it has been challenging to achieve and maintain the recommended coverage of > 80% in girls. In a well-studied Italian region, vaccination coverage in girls at age 15 years (World Health Organization's gold standard) reached 76% in 2015 but decreased to 69% in 2018, likely due to work overload in public immunization centres. In Denmark, doubts about safety and efficacy of the HPV vaccine generated a decline in coverage among girls age 12-17, from 80% in 2013 down to 37% in 2015, when remedial actions made it rise again. Insights from these two countries are shared to illustrate the importance of monitoring coverage in a digital vaccine registry and promptly reacting to misinformation about vaccination.

Strategic health communication on social media: Insights from a Danish social media campaign to address HPV vaccination hesitancy.

OBJECTIVE: To evaluate whether the social media strategy developed for the campaign Stop HPV - stop cervical cancer was successful at engaging target groups in communication regarding HPV vaccination. INTRODUCTION: In 2009, the Human Papillomavirus (HPV) vaccine became part of the Danish childhood vaccination program to protect Danish girls from cervical cancer. In 2015, after a period of massive media coverage questioning the safety of the HPV vaccination, a rapid decline in HPV vaccination coverage was observed. An information campaign was therefore launched in May 2017 to address HPV vaccination hesitancy. THE SOCIAL MEDIA STRATEGY: 'Heart-brain communication' combined facts and emotions through varied content. Community management guidelines were worked out to ensure that there was positive dialogue. Key Point Indicators (KPI) for Engagement Rate (ER) and Click Through Rate (CTR) were chosen to uphold engagement and traffic from Facebook to the website. The KPIs were used to measure effectiveness. RESULTS: In January 2019, the social media campaign had reached 8,020,000 people with an average of 127 comments per post. The average ER from May 2017 to halfway through 2018 was 6.07% and the CTR was 2.09%. The content subgroup personal stories was the most effective in creating positive dialogue. One year after the launch of the campaign, the number of positive comments had increased from less than 50% to approximately 75%. CONCLUSION: A comprehensive social media strategy using 'heart-brain communication' proved useful in a campaign for HPV vaccination. The success of the social media strategy was due to meticulous planning prior to launching the campaign, the use of content subgroups, the allocation of adequate resources for community management, the empirical analysis of content, and the use of evaluation results as guidance for the production of new content.

Using Facebook to increase coverage of HPV vaccination among Danish girls: An assessment of a Danish social media campaign.

OBJECTIVES: In this study we assess how different Facebook (FB) posts resonate with parents hesitant about HPV vaccination and how to engage parents in positive dialogues on FB. BACKGROUND: Vaccination against human papillomavirus (HPV) was successfully introduced in the Danish childhood vaccination program in 2009 for 12 year-old girls, with coverage reaching approximately 90%. However, negative public debate questioning the safety of the vaccine coincided with a rapid decline in vaccination coverage from 2015. In May 2017, we launched the national campaign Stop HPV - stop cervical cancer with the aim to rebuild trust in the HPV vaccine and increase vaccination coverage. We used a FB page and a social media strategy to engage the campaign's primary target group: mothers hesitant about HPV vaccination of their daughters. METHODS: We analyzed a variety of posts on the FB page Stop HPV - stop cervical cancer posted from May 2017 to December 2017. We performed analysis documenting post reach, engagement in the posts and sentiment (positive, neutral or negative) of the comments. Focus groups were recruited to provide data about attitudes to the posts and the responses from the FB management team. RESULTS: 84 unique posts were published on the FB page from May 2017 to December 2017 reaching 3,476,023 individual FB profiles. In focus groups, parents requested more in-depth information. However, analyses of FB posts and sentiment of comments showed that personal stories generated higher engagement rates and more positive dialogues compared to factual posts. CONCLUSION: The FB page Stop HPV - stop cervical cancer has successfully reached and engaged FB users in dialogue about HPV vaccination. Personal stories are effective in creating positive dialogues on FB. However, it remains important to provide factual information to parents to enable informed decision making about HPV vaccination.

25-Hydroxyvitamin D at time of breast cancer diagnosis and breast cancer survival.

PURPOSE: Previous studies have shown that low levels of 25-hydroxyvitamin D (25(OH)D) are associated with a poorer breast cancer survival. The relationship between vitamin D status and breast cancer outcomes is however still debated. The aim of the present study was to investigate the association between 25(OH)D blood levels measured at time of diagnosis and event-free survival (EFS) and overall survival (OS) in a large cohort of patients with early-stage primary invasive breast cancer. METHODS: From April 2008 to April 2013, 25(OH)D status was measured at time of diagnosis in all women operated for early stage primary invasive breast cancer at Rigshospitalet, Copenhagen, Denmark. Associations between 25(OH)D and EFS and OS were investigated using a Cox Proportional hazards model, adjusting for age, disease characteristics, time period, and BMI. Differences in survival were evaluated by hazard ratios (HR). RESULTS: In the present study, 2510 women with primary invasive breast cancer were included. Women with the lowest 25(OH)D levels (≤ 52 nmol/L) had an inferior EFS with a HR of 1.63 (95% CI 1.21-2.19) compared to women in the third quartile (76-99 nmol/L). Women with the highest 25(OH)D levels (≥ 99 nmol/L) also had an inferior EFS with a HR of 1.37 (95% CI 1.02-1.83). Plotting 25(OH)D status against EFS, the association was inversely J-shaped. For OS, a similar association with 25(OH)D status was observed. CONCLUSION: We confirmed previous findings suggesting that a low 25(OH)D status is associated with an inferior breast cancer survival, but unlike previous findings, we found an indication of poorer breast cancer survival also among women with high 25(OH)D levels.

Idiopathic pseudoaneurysm in a patient with breast implants.

Aneurysms and pseudoaneurysms of the internal mammary artery (IMA) are rare and the etiology uncertain although iatrogenic causes have been described. A 64-year-old woman suffered hematoma and bleeding from a pseudoaneurysm probably originating from a branch of the right IMA 16 years after breast implant surgery. After clinical assessment, the patient underwent surgery with resection of the aneurysm and ligation of the arterial branch. No early postoperative complications were reported. Pseudoaneurysms in small vessels such as the IMA or its branches are not well described in the literature. Proper diagnosis with imaging is of importance in order to determine treatment as each case is unique. Some cases can be managed conservatively.

Management of central breast tumours with immediate reconstruction of the nipple-areola complex; a suggested guide.

BACKGROUND: Breast conserving surgery (BCS) for central breast tumours with immediate reconstruction of the nipple-areola complex (NAC) is a relatively new addition to the surgical palette of the oncoplastic surgeon. Most oncoplastic techniques presented to date have only been suitable for women with large breasts. METHODS: From 2012 to 2013, a series of eligible women with central breast cancers were treated with BCS and NAC reconstruction. According to breast size and shape, three different procedures were performed. RESULTS: 20 women were operated, 13 by breast reduction techniques and 7 by anterior intercostal perforator flaps (AICAP flaps). Overall cosmetic results were good to excellent for breast shape, symmetry and neo-nipple projection. CONCLUSION: We present a guideline for selecting the best available surgical technique for immediate NAC reconstruction in women with any breast type, size or shape and describe a new replacement technique using a local perforator flap.

Influence of lifestyle aspects on the association of body size and shape with all-cause mortality in middle-aged men and women.

OBJECTIVE: Waist circumference, BMI and hip circumference are differentially associated with mortality. We investigated the potential influence of selected lifestyle aspects such as smoking, alcohol intake, sports activity and education. METHOD: The Danish prospective study 'Diet, Cancer and Health' recruited 27,179 men and 29,875 women from 1993 to 1997. Cox regression models were used to estimate mortality rate ratios. RESULTS: Adjustment for smoking habits attenuated the associations between mortality and the three body size measurements in both sexes. Adjustment for sport activity and, to a lesser extent, alcohol intake weakened the associations further for the men, whereas alcohol intake slightly weakened associations for the women. In the fully adjusted models, mortality increased highly significantly with higher waist circumference and lower hip circumference, and decreased highly significantly with higher BMI for BMI below 25 kg/m(2). This pattern was seen for all levels of the selected lifestyle factor. CONCLUSION: A large waist circumference remained a strong risk indicator for mortality, and a large hip circumference appeared to be protective when smoking habits, alcohol intake and sport activity were accounted for. BMI below 25 kg/m(2) remained a risk factor, but not above 25 kg/m(2) once waist circumference was adjusted for.

Body composition and breast cancer in postmenopausal women: a Danish prospective cohort study.

OBJECTIVE: To assess the importance of body fat mass (BFM) and fat free mass (FFM) for the established positive association between BMI and breast cancer among post-menopausal women. RESEARCH METHODS AND PROCEDURES: A prospective cohort of 23,788 postmenopausal women included in the Danish study Diet, Cancer, and Health during 1993 to 1997 was linked to the Danish Cancer Registry to identify all cases of breast cancer occurring during 1993 to 2002. Breast cancer incidence rate ratios for anthropometric measurements with adjustment for known risk factors for breast cancer were calculated by Cox regression analyses. RESULTS: Among the most commonly used anthropometric measurements, BMI was positively associated with breast cancer among never users of hormone replacement therapy (HRT). By splitting BMI into two indices, BFM index and FFM index, we found that the incidence rate ratio with each 1 kg/m(2) among never users of HRT was 0.98 (95% confidence interval, 0.93 to 1.03) for BFM index and 1.12 (95% confidence interval, 1.00 to 1.26) for FFM index after mutual adjustment. DISCUSSION: The finding for BMI was in accordance with previous findings. Our results indicate that the FFM component of BMI may play a role for development of breast cancer among never users of HRT.

Self-reported and technician-measured waist circumferences differ in middle-aged men and women.

We investigated the agreement between 1) self-reported and technician-measured waist circumference at the level of the umbilicus, 2) circumference measured at the level of the umbilicus and halfway between the lower rib and the iliac crest (the natural waist), and 3) self-reported circumference at the level of the umbilicus and technician-measured circumference at the natural waist. At follow-up in the Danish "Diet, Cancer and Health" study, we recruited 176 men and 240 women for a validation study. Bland-Altman plots were used to evaluate agreement among measurement sites. Multiple regression was used to identify variables explaining the difference between measurements. The participants underestimated their waist circumference; the mean differences were -1.6 cm (95% CI: -2.4 cm, -0.8 cm) in men and -3.0 cm (95% CI: -3.8 cm, -2.3 cm) in women. Limits of agreement were from -11.9 to +8.7 cm among men and -14.9 to +8.9 cm among women. High BMI and large baseline waist circumference were associated with a larger degree of underreporting. Waist circumference measured at the level of the umbilicus was larger than at the natural waist; the mean differences were +0.7 cm (95% CI: +0.4 cm, +1.1 cm) in men and +5.0 cm (95% CI: +4.4 cm, +5.6 cm) in women. The self-reported waist circumference at the level of the umbilicus was correlated with the technician-measured circumference at the natural waist. The circumference at the natural waist was overestimated for women, depending on baseline waist circumference, and slightly underestimated for men, depending on baseline BMI.

Body fat and fat-free mass and all-cause mortality.

OBJECTIVE: To investigate whether the association between BMI and all-cause mortality could be disentangled into opposite effects of body fat and fat-free mass (FFM). RESEARCH METHODS AND PROCEDURES: All-cause mortality was studied in the Danish follow-up study "Diet, Cancer and Health" with 27,178 men and 29,875 women 50 to 64 years old recruited from 1993 to 1997. By the end of year 2001, the median follow-up was 5.8 years, and 1851 had died. Body composition was assessed by bioelectrical impedance. Cox regression models were used to estimate the relationships among body fat mass index (body fat mass divided by height squared), FFM index (FFM divided by height squared), and mortality. All analyses were adjusted for smoking habits. RESULTS: Men and women showed similar associations. J-shaped associations were found between body fat mass index and mortality adjusted for FFM and smoking. The mortality rate ratios in the upper part of body fat mass were 1.12 per kg/m2 (95% confidence interval: 1.07, 1.18) in men and 1.06 per kg/m2 (95% confidence interval: 1.02, 1.10) in women. Reversed J-shaped associations were found between FFM index and mortality with a tendency to level off for high values of FFM. DISCUSSION: Our findings suggest that BMI represents joint but opposite associations of body fat and FFM with mortality. Both high body fat and low FFM are independent predictors of all-cause mortality.

Body size and breast cancer risk: findings from the European Prospective Investigation into Cancer And Nutrition (EPIC).

The evidence for anthropometric factors influencing breast cancer risk is accumulating, but uncertainties remain concerning the role of fat distribution and potential effect modifiers. We used data from 73,542 premenopausal and 103,344 postmenopausal women from 9 European countries, taking part in the EPIC study. RRs from Cox regression models were calculated, using measured height, weight, BMI and waist and hip circumferences; categorized by cohort-wide quintiles; and expressed as continuous variables, adjusted for study center, age and other risk factors. During 4.7 years of follow-up, 1,879 incident invasive breast cancers were identified. In postmenopausal women, current HRT modified the body size-breast cancer association. Among nonusers, weight, BMI and hip circumference were positively associated with breast cancer risk (all ptrend < or = 0.002); obese women (BMI > 30) had a 31% excess risk compared to women with BMI < 25. Among HRT users, body measures were inversely but nonsignificantly associated with breast cancer. Excess breast cancer risk with HRT was particularly evident among lean women. Pooled RRs per height increment of 5 cm were 1.05 (95% CI 1.00-1.16) in premenopausal and 1.10 (95% CI 1.05-1.16) in postmenopausal women. Among premenopausal women, hip circumference was the only other measure significantly related to breast cancer (ptrend = 0.03), after accounting for BMI. In postmenopausal women not taking exogenous hormones, general obesity is a significant predictor of breast cancer, while abdominal fat assessed as waist-hip ratio or waist circumference was not related to excess risk when adjusted for BMI. Among premenopausal women, weight and BMI showed nonsignificant inverse associations with breast cancer.

Waist circumference, BMI, smoking, and mortality in middle-aged men and women.

OBJECTIVE: Measurement of waist circumference alone as a proxy of abdominal fat mass has been suggested as a simple clinical alternative to BMI for detecting adults with possible health risks due to obesity. RESEARCH METHODS AND PROCEDURES: From 1993 to 1997, 27,178 men and 29,875 women, born in Denmark, 50 to 64 years of age, were recruited in the Danish prospective study Diet, Cancer and Health. By the end of the year 2000, 1465 deaths had occurred. We evaluated the relationship between waist circumference and BMI (simultaneously included in the model) and all-cause mortality. We used Cox regression models to estimate the mortality-rate ratios and to consider possible confounding from smoking. RESULTS: Waist circumference among both men and women showed a strong dose-response type of relationship with mortality when adjusted for BMI, whereas the low range of BMI was inversely associated with mortality when adjusted for waist circumference. A 10% larger waist circumference corresponded to a 1.48 (95% confidence interval: 1.36 to 1.61) times higher mortality over the whole range of waist circumference. The associations were independent of age and time since baseline examination. Restriction to never smokers showed a similar pattern, but a weakening of the associations. DISCUSSION: Despite the high correlation between waist circumference and BMI, the combination may be very relevant in clinical practice because waist circumference for given BMI was a strong predictor of all-cause mortality. The inverse association between BMI and mortality for given waist circumference was diminished in never smokers, particularly for high values of BMI.