Measures of benefit for breast screening from the pathology database for Scotland, 1991-2001.

AIMS: To examine pathology characteristics of breast cancers detected by mammography screening over 10 years in Scotland, and compare the nature of cancer yields after different levels of very small invasive cancer at prevalence detection. METHODS: A pathology database of cancers from mammography screening of women aged 50-64 years invited every three years was used to assess the variation over time in annual yield of different invasive cancer sizes. Screening centres were compared for incidence screen yields, according to sizes, histological type, grade, and node status. RESULTS: There was a significant trend over time for increased detection of < 15 mm cancers among 2353 prevalence cancers, and a significant trend for increase in all size groups, < 10, 10-14, < 15, and >or= 15 mm, among 2245 incidence cancers. Based on individual screening centres, there was a significant negative relation between proportions of very small (< 10 mm) cancers at prevalence screens and of large (>or= 15 mm) cancers at incidence screens of the same "cohort" three years later. There was no significant relation on the same centre basis for worse pathology characteristics (histological no special type, high grade, and positive node status) in cancers detected in the same "cohort" three years later. CONCLUSIONS: Sensitive mammography screening has a significant effect on the nature of yields at subsequent screens. Length of screening interval and consistency in pathologist opinions are factors that account for lack of effect on incidence cancer qualitative pathology characteristics. These issues are relevant to the use of such characteristics as surrogate measures of service screening performance.

Symptomatic women with normal screening mammograms: is assessment by the breast screening programme justifiable?

Since the commencement of screening in 1988, the West of Scotland Breast Screening Programme has invited women with symptoms, but normal screening mammograms, for assessment. This paper reviews the results of 344 such assessments. Malignancy was detected in three patients; two had invasive carcinoma and one Paget's disease of the nipple. One woman underwent a benign excision biopsy. Three women returned to routine recall were subsequently diagnosed with breast cancer; one had Paget's disease, a second developed a true interval cancer, and a third a screen detected cancer six years later. Cancer detection rate in this group of women was approximately 1% in those assessed. The two women with invasive breast carcinomas had dense breasts and one view only was taken on screening. No cancers were detected in women complaining of lumps or dimpling who had normal fatty or mixed density mammograms.

Tailored written invitations for second round breast cancer screening: a randomised controlled trial.

OBJECTIVES: Firstly, to determine if attendance for second round mammography screening in those sent a tailored letter (that is, making reference to their screening history) is increased compared with those sent a standard letter; secondly, to investigate the acceptability of tailored letters. SETTING: North West Glasgow Breast Screening Centre. METHODS: A randomised controlled trial. RESULTS: Overall attendance was unrelated to whether the women were sent a tailored or standard letter; 60% of those sent the standard letter attended (922/1531) compared with 62% of those sent the tailored letter (956/1552) (chi 2 = 0.61, P = 0.4) (difference 2%; 95% confidence interval -2% to 5%). There were no significant differences in percentage attendance within each of the study subgroups: women who attended previously and received an all clear result, women who attended previously and received a false positive result, women who were invited previously and failed to attend, and women who were previously too young to be invited for screening. However, there was a statistically significant difference in percentage attendance between these four groups, independent of letter type (chi 2 = 510, P < 0.00001). Although women found the letters acceptable and understandable, they did not seem to pay close attention to the content. CONCLUSIONS: Tailoring invitation letters does not have a significant effect on uptake rates for breast screening and does not justify the additional workload required.

The effect of ascorbic acid on the seasonal variations in serum cholesterol levels.

One gram of ascorbic acid (Vitamin C) administered randomly to a group of healthy young people (aged 29 +/- 5 years) produced a significant mean fall in serum cholesterol of 16 per cent within two months. A similar supplement to a group of healthy older people (aged 58 +/- 3 years) produced a significant mean fall in serum cholesterol of 14 per cent but required six to 12 months' administration. Serial observations on a mixed age group of healthy people (aged 38 +/- 12 years) over one calendar year revealed a seasonal fluctuation in serum cholesterol, the lowest levels being in summer (June 5.5 +/- 0.7 mmols/l) and the highest levels in winter (January 6.4 +/- 0.8 mmols/l), a significant rise of 16 per cent. These changes showed an inverse relationship with the leucocyte and serum ascorbic acid levels which also revealed a seasonal fluctuation, the months April/September being higher than the months October/March. The administration of 1g of ascorbic acid per day throughout the year abolished the winter rise in serum cholesterol levels. These results are discussed in the light of the relationship between cholesterol and vascular disease and the observations by Sir Richard Doll that lowering the cholesterol level, whether achieved by drugs or diet, results in a reduction in morbidity from myocardial infarction.

Preliminary examination of integrated vector management in a tropical rainforest area of Cameroon.

In the tropical rainforest area of Cameroon, people are affected by blackflies (Simulium spp.) and mosquitoes (Anopheles spp). Use of insecticide-treated bed nets (ITNs) has been promoted to protect vulnerable groups from mosquito bites, whereas historically indoor residual spraying (IRS) was the primary intervention. In a malaria-endemic area, a pilot study examined different mosquito control interventions applied to entire villages to assess their impact on vectors, malaria incidence and the quality of life of the communities. The Sanaga River near these villages was treated with insecticide to kill blackfly larvae. A medical survey of the six villages had shown that 20% of the population suffered from malaria, while 50% were infected with onchocerciasis and 5% with Loa loa. IRS+ITN using ICON CS (lambda-cyhalothrin capsule suspension formulation) or improved screening of houses combined with outdoor misting reduced the numbers of mosquitoes collected from exit traps compared to the other treatments. More sporozoites were detected in mosquitoes sampled in exit traps in the untreated village than in the treated villages. Malaria incidence several months after treatments was not significantly different from pre-treatment levels. Blackfly adult populations were reduced for several weeks following larvicide application but recovered when treatment was halted.

Follow-up for screen-detected ductal carcinoma in situ: results of a survey of UK centres participating in the Sloane project.

AIMS: To investigate the variations in follow-up practice for screen-detected ductal carcinoma in situ (DCIS) in the UK. METHODS: A questionnaire enquiring about follow-up practice and the perceived value of clinical follow-up after surgery for screen-detected DCIS was sent to the 74 UK screening centres participating in the Sloane Project. RESULTS: Responses were received from 66 hospitals serving 54 screening centres. These demonstrate wide variations in practice. Clinical follow-up duration ranges from 1 year to indefinite, with the frequency of visits from three-monthly to annually. Formal mammographic follow-up duration ranges from none to indefinite. Mammographic frequency ranges from 1 to 2 years. Follow-up varies according to factors such as size and grade of disease and margin status in 23 units and according to whether adjuvant therapy is given in 23. Seven hospitals perform mammography of reconstructed breasts. Thirty-one centres consider clinical follow-up of DCIS to be of value or limited value whereas 28 consider it to be of little or no value. CONCLUSIONS: There is no consensus with regard to the duration and frequency of follow-up for screen-detected DCIS, the contribution of predictive and treatment factors, the use of mammography of the reconstructed breast or the perceived value of clinical follow-up. Published guidelines show no consensus. Multidisciplinary teams involved in the care of women with screen-detected non-invasive cancer should contribute to audits such as the Sloane Project in order to determine the most effective and efficient ways to treat and follow up these patients.

Balloon catheter dilatation of an ileocolic stricture.

This case report describes the technique of balloon catheter dilatation of an ileocolic anastomotic stricture in a patient with Crohn's disease. The technique has an established role in the management of oesophageal strictures, and recently has been adapted by both radiologists and endoscopists in the management of gastric surgical stenosis. Isolated reports of its use in the colon are now emerging. Balloon catheter dilatation may be of value in selected patients with gastrointestinal strictures.

How accessible is the breast screening assessment centre for Lanarkshire women?

The National Breast Screening Programme in Lanarkshire utilises a mobile screening unit to facilitate access for the catchment population. However, women who require further investigation (8% of the total) have to travel to a regional Assessment Centre in Glasgow. This Centre in Glasgow may be difficult to access by some Lanarkshire residents, especially those who need to use public transport. The objective of this study was to assess the accessibility of the Assessment Centre for a Breast Screening Programme in terms of travelling and social cost. This study was based on systematic samples of patients (n = 109) attending the Assessment Centre in a 12 month period, using a self-completion questionnaire. The sample formed 11.9% of attenders. The cost of attending the Centre is high because of the long distance (average return journey 21.5 miles, range 14-46 miles), long travel time (mean 1.73 hours, range 0.5 to 5.5 hours), multiple journeys (2-6 journeys) and high actual cost (mean 6.08 pounds, range 1 pound to 14.40 pounds). Regional Assessment Centres are necessary to maintain the appropriate level of expertise and quality of the Programme, but Assessment Centres should be sensitive to, and monitor the difficulties faced by women in attending. More generally, costs to patients to obtain a service are not usually taken into account by the service providers. Purchasers of health services should take a societal standpoint when assessing the cost effectiveness of services so that it is not at the expense of individual patients.