International variation in management of screen-detected ductal carcinoma in situ of the breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) incidence has grown with the implementation of screening and its detection varies across International Cancer Screening Network (ICSN) countries. The aim of this survey is to describe the management of screen-detected DCIS in ICSN countries and to evaluate the potential for treatment related morbidity. METHODS: We sought screen-detected DCIS data from the ICSN countries identified during 2004-2008. We adopted standardised data collection forms and analysis and explored DCIS diagnosis and treatment processes ranging from pre-operative diagnosis to type of surgery and radiotherapy. RESULTS: Twelve countries contributed data from a total of 15 screening programmes, all from Europe except the United States of America and Japan. Among women aged 50-69 years, 7,176,050 screening tests and 5324 screen-detected DCIS were reported. From 21% to 93% of DCIS had a pre-operative diagnosis (PO); 67-90% of DCIS received breast conservation surgery (BCS), and in 41-100% of the cases this was followed by radiotherapy; 6.4-59% received sentinel lymph node biopsy (SLNB) only and 0.8-49% axillary dissection (ALND) with 0.6% (range by programmes 0-8.1%) being node positive. Among BCS patients 35% received SLNB only and 4.8% received ALND. Starting in 2006, PO and SLNB use increased while ALND remained stable. SLNB and ALND were associated with larger size and higher grade DCIS lesions. CONCLUSIONS: Variation in DCIS management among screened women is wide and includes lymph node surgery beyond what is currently recommended. This indicates the presence of varying levels of overtreatment and the potential for its reduction.

Variation in detection of ductal carcinoma in situ during screening mammography: a survey within the International Cancer Screening Network.

BACKGROUND: There is concern about detection of ductal carcinoma in situ (DCIS) in screening mammography. DCIS accounts for a substantial proportion of screen-detected lesions but its effect on breast cancer mortality is debated. The International Cancer Screening Network conducted a comparative analysis to determine variation in DCIS detection. PATIENTS AND METHODS: Data were collected during 2004-2008 on number of screening examinations, detected breast cancers, DCIS cases and Globocan 2008 breast cancer incidence rates derived from national or regional cancer registers. We calculated screen-detection rates for breast cancers and DCIS. RESULTS: Data were obtained from 15 screening settings in 12 countries; 7,176,050 screening examinations; 29,605 breast cancers and 5324 DCIS cases. The ratio between highest and lowest breast cancer incidence was 2.88 (95% confidence interval (CI) 2.76-3.00); 2.97 (95% CI 2.51-3.51) for detection of breast cancer; and 3.49 (95% CI 2.70-4.51) for detection of DCIS. CONCLUSIONS: Considerable international variation was found in DCIS detection. This variation could not be fully explained by variation in incidence nor in breast cancer detection rates. It suggests the potential for wide discrepancies in management of DCIS resulting in overtreatment of indolent DCIS or undertreatment of potentially curable disease. Comprehensive cancer registration is needed to monitor DCIS detection. Efforts to understand discrepancies and standardise management may improve care.

[Safety of the patient and the Mammography Program in the Grand Duchy of Luxembourg: Care of cancers detected by mammography. Retrospective studies]. / La Sécuritré du Patient et le Programme Mammographie du Grand-Duché de Luxembourg: Prise en charge des cancers détectés par la mammographie. Etudes rétrospectives.

UNLABELLED: In Luxemburg, the national breast cancer mammography screening programme has been running for 18 years. The Coordinating Centre treats approximately 17,000 files a year. The Health Directorate, as promoter of the "Programme Mammographie", is obliged to provide itself with a maximum of guarantees; within the framework of its legal missions, it has to implement all the possible means in order that the whole approach assures minimal adverse effects. The technical quality of the 9 centres is at the level required by the European Guidelines for Quality Assurance in Mammography Screening and Diagnosis, 4th edition. The quality of the readings was already the subject of 2 evaluations of the performance of the readers: the mean accuracy of the first readers to detect cancers is 87%, of the second readers 97%. The mean recall rate for assessment is about 6%. The double reading assures the detection of between 15 and 21% additional cancers, depending on the years. The imaging of diagnostic assessment has been the subject of a retrospective study. Out of 392 cancers, time from assessment to diagnosis was longer then 24 months for 17 women (4%). Examples are described and reasons for negative assessment are listed. The main cause is the multiplicity of the doctors acting in the assessment process, resulting in a default of the examination synthesis and a certain lack of communication and multidisciplinary approach. More convergence in diagnostic breast assessment and a shortening of delays between screening and diagnosis, are desirable. IN CONCLUSION: The evolution towards Specialist Centres for breast cancer care answers an ethical obligation which the initiators of a public health programme have to assume, such as the organization of a high quality breast cancer screening programme.

Communicating with women about mammography.

BACKGROUND/METHODS: We report survey results of the types of tools used to communicate with women about breast cancer screening and the content areas included in each tool for member countries of the International Breast Cancer Screening Network (IBSN). RESULTS: In addition to using pamphlets and invitation letters, new technologies are being used such as the Internet which allows for easy updating of information and can provide interactive modules. Several countries have addressed the needs of specific populations such as indigenous populations or blind women. All countries provide basic information, although they do not provide all the same information. CONCLUSION: More research is needed to understand what women need to make an informed decision about mammography and to learn what the best modalities are to provide this information.

[Evaluation of the national epidemiological program of breast cancer screening in the Grand Duchy of Luxembourg, 1999-2002]. / Evaluation epidémiologique du programme national de dépistage du cancer du sein au Grand-Duché de Luxembourg, 1999-2002.

In 1992 a national breast cancer screening programme was launched in Luxembourg with following characteristics; invitation at 2-yearly interval, 2 views, double reading for women aged between 50 and 64 and since 2001, those aged 65-69 are as well included. From the beginning on, one of the main concern was to respect a rigorous methodology, in accordance with the recommendations of the European Commission. This paper presents the early performance indicators of the years 1999-2002 of the "Programme Mammographie". Almost all histopathological results were obtained, because only one national pathology laboratory exists in Luxembourg, where also the national tumor's register is located. In ten years, a total of 91.432 mammograms were performed. The results of the early performance indicators are in agreement with the European Recommendations. A 36% detection rate of small size cancers, < or = 10 mm, and since 2000, more then 70% of node negative cancers are observed among women aged 50-64 attending the Programme. The cancer rate with a good prognostic factor for the patients is high. Despite good results, the rate of interval cancers is still too high, and two conclusions can be drown: the women's participation at screening has to be steady in time without trespassing a two years intervals, and after the detection of small cancer a high quality assessment should be followed by an adequate treatment, leading to a reduction of mortality and also to a decrease of morbidity by treatment.

A breast cancer screening programme operating in a liberal health care system: the Luxembourg Mammography Programme, 1992-1997.

The national breast cancer screening programme in Luxembourg, the Mammography Programme (MP), was launched in 1992. Its primary goal was to set up an organised breast cancer screening with biennial invitation-reinvitation of women 50-64 years, 2-view mammography, technical quality assurance, double-reading procedures and close monitoring of performance. In 1994, the decision was taken by health authorities to only reimburse screening mammograms done within the MP. We evaluated the performance of 3 screening rounds that took place in 1992-1997. In 1992, 4,815 women had opportunistic screening and 4,790 attended the MP. In 1997, 861 women had opportunistic screening and 8,603 attended the MP. In 1997, the participation rate in the MP reached 50%. The referral rate in the MP was 10% for initial screening and 5% for subsequent screening. Echographic examinations accounted for 71% of referrals. Per 1,000 screened women, biopsy and cancer rates were 18.0 and 8.0 for initial screening and 10.3 and 5.8 for subsequent screening. Twenty-one percent of the breast cancers diagnosed in screened women were interval cancers. The age-adjusted proportion of tumours >20 mm was 56.1% before 1992, 45.1% for women not (yet) screened by the MP, 27.0% for interval cancers, 26.6% for initial screening and 12.0% for subsequent screenings. Tumour size distribution was similar to that observed in the Dutch Breast Cancer Screening Programme, 1990-1993, except that in the latter programme, no difference was observed between initial and subsequent screening. The Luxembourg experience shows that in a liberal health care system, a policy of organising the screening process by reimbursing only those mammograms done within the context of the organised screening programme can drastically reduce opportunistic screening. Further efforts in the Mammography Programme will aim at increasing participation and look at ways to decrease referrals to echography.