Cost-effectiveness of the Norwegian breast cancer screening program.

The Norwegian Breast Cancer Screening Programme (NBCSP) has a nation-wide coverage since 2005. All women aged 50-69 years are invited biennially for mammography screening. We evaluated breast cancer mortality reduction and performed a cost-effectiveness analysis, using our microsimulation model, calibrated to most recent data. The microsimulation model allows for the comparison of mortality and costs between a (hypothetical) situation without screening and a situation with screening. Breast cancer incidence in Norway had a steep increase in the early 1990s. We calibrated the model to simulate this increase and included recent costs for screening, diagnosis and treatment of breast cancer and travel and productivity loss. We estimate a 16% breast cancer mortality reduction for a cohort of women, invited to screening, followed over their complete lifetime. Cost-effectiveness is estimated at NOK 112,162 per QALY gained, when taking only direct medical costs into account (the cost of the buses, examinations, and invitations). We used a 3.5% annual discount rate. Cost-effectiveness estimates are substantially below the threshold of NOK 1,926,366 as recommended by the WHO guidelines. For the Norwegian population, which has been gradually exposed to screening, breast cancer mortality reduction for women exposed to screening is increasing and is estimated to rise to ∼30% in 2020 for women aged 55-80 years. The NBCSP is a highly cost-effective measure to reduce breast cancer specific mortality. We estimate a breast cancer specific mortality reduction of 16-30%, at the cost of 112,162 NOK per QALY gained.

The distribution of ductal carcinoma in situ (DCIS) grade in 4232 women and its impact on overdiagnosis in breast cancer screening.

BACKGROUND: The incidence of ductal carcinoma in situ (DCIS) has rapidly increased over time. The malignant potential of DCIS is dependent on its differentiation grade. METHODS: Our aim is to determine the distribution of different grades of DCIS among women screened in the mass screening programme, and women not screened in the mass screening programme, and to estimate the amount of overdiagnosis by grade of DCIS. We retrospectively included a population-based sample of 4232 women with a diagnosis of DCIS in the years 2007-2009 from the Nationwide network and registry of histopathology and cytopathology in the Netherlands. Excluded were women with concurrent invasive breast cancer, lobular carcinoma in situ and no DCIS, women recently treated for invasive breast cancer, no grade mentioned in the record, inconclusive record on invasion, and prevalent DCIS. The screening status was obtained via the screening organisations. The distribution of grades was incorporated in the well-established and validated microsimulation model MISCAN. RESULTS: Overall, 17.7 % of DCIS were low grade, 31.4 % intermediate grade, and 50.9 % high grade. This distribution did not differ by screening status, but did vary by age. Older women were more likely to have low-grade DCIS than younger women. Overdiagnosis as a proportion of all cancers in women of the screening age was 61 % for low-grade, 57 % for intermediate-grade, 45 % for high-grade DCIS. For women age 50-60 years with a high-grade DCIS this overdiagnosis rate was 21-29 %, compared to 50-66 % in women age 60-75 years with high-grade DCIS. CONCLUSIONS: Amongst the rapidly increasing numbers of DCIS diagnosed each year is a significant number of overdiagnosed cases. Tailoring treatment to the probability of progression is the next step to preventing overtreatment. The basis of this tailoring could be DCIS grade and age.

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study.

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.