http://repub.eur.nl/res/aut/16906/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/38870/ 2012-11-01T00:00:00Z Objective: To determine the level of informed choice in women invited for breast cancer screening for the first time. Methods: To determine the content of decision-relevant knowledge, 16 experts were asked to judge whether each of 51 topics represented essential information to enable informed choices. To assess the level of informed choices, a questionnaire was then sent to all 460 invited women in the south-western part of the Netherlands who turned 50 in August 2008. Results: Of all 229 respondents, 95% were deemed to have sufficient knowledge as they answered at least 8 out of 13 items correctly. In 90% there was consistency between intention (not) to participate and attitude. As a result, 88% made an informed choice. Sixty-eight percent of women responded correctly on the item of over-diagnosis. Even if all non-respondents were assumed to have no knowledge, 50% of the total group invited to participate still had sufficient knowledge. Conclusions: Women were deemed to have sufficient relevant knowledge of the benefits and harms if they answered at least half of the items correctly. Practice implications: To further increase informed choices in breast cancer screening, information on some of the possible harms merits further attention. http://repub.eur.nl/res/pub/34721/ 2012-01-01T00:00:00Z Background: Because the efficacy of mammography screening had been shown in randomized controlled trials, the focus has turned on its effectiveness within the daily practice. Using individual data of women invited to screening, we conducted a case-control study to assess the effectiveness of the Dutch population-based program of mammography screening. Methods: Cases were women who died from breast cancer between 1995 and 2003 and were closely matched to five controls on year of birth, year of first invitation, and number of invitations before case's diagnosis. ORs and 95% confidence intervals (CI) for the association between attending either of three screening examinations prior to diagnosis and the risk of breast cancer death were calculated using conditional logistic regression and corrected for self-selection bias. Results: We included 755 cases and 3,739 matched controls. Among the cases, 29.8% was screen-detected, 34.3% interval-detected, and 35.9% never-screened. About 29.5% of the never-screened cases had stage IV tumor compared with 5.3% of the screen-detected and 15.1% of the interval-detected cases. The OR (95% CIs), all ages (49-75 years), was 0.51 (0.40-0.66) and for the age groups 50-69, 50-75, and 70-75 years were 0.61 (0.47-0.79), 0.52 (CI 0.41-0.67), and 0.16 (0.09-0.29), respectively. Conclusion: The study provides evidence for a beneficial effect of early detection by mammography screening in reducing the risk of breast cancer death among women invited to and who attended the screening. Impact: This is the first case-control study that accurately accounts for equal screening opportunity for both cases and matched controls by number of invitations before case's diagnosis. http://repub.eur.nl/res/pub/30994/ 2011-09-08T00:00:00Z We retrospectively determined the effect of analogue two-view mammography versus single-view mammography at subsequent screens on breast cancer detection and determined financial consequences for a current digital mammography setting. Two screening radiologists reviewed the mammograms of 536 screen detected cancers (SDCs) and 171 interval cancers (ICs) with single-view mammography (medio-lateral-oblique view) at the last but one screen (SDCs) or latest screen (ICs). They determined whether two-view mammography at the last (but one) screen could have increased the cancer detection rate at that screening round. For subsequent screens, the radiologists also assessed the percentage of SDCs and ICs that had been missed at previous two-view screening mammography (SDC) or latest two-view screening (IC), respectively. Additional personnel and digital storage costs for standard two-view mammography at subsequent screening were calculated for digital screening. Two-view mammography could have facilitated earlier cancer detection in 40.9% (219/536) of SDCs and 39.8% (68/171) of ICs. For two-view screens, 24.4% of SDCs (213/871) were missed at previous two-view screening and 29.3% of ICs (110/375) were missed at the latest screen. Overall costs increase € 1.03/screen after implementation of digital two-view mammography. Standard two-view mammography at subsequent screening may modestly increase cancer detection at an earlier stage, whereas additional screening costs are limited. http://repub.eur.nl/res/pub/33305/ 2011-09-01T00:00:00Z Objective: Digital mammography has been shown to increase the detection of ductal carcinoma. in situ (DCIS) compared to screen-film mammography. The benefits and risks of such an increase were assessed. Methods: Breast cancer detection rates were compared between 502,574 screen-film and 83,976 digital mammograms performed between 2004 and 2006 among Dutch screening participants. The detection rates were then modeled using a baseline model and two extreme models that respectively assumed a high rate of progression and no progression of preclinical DCIS to invasive cancer. With these models, breast cancer mortality and overdiagnosis were predicted. Results: The DCIS detection rate was significantly higher at digital mammography (1.2 per 1000 mammograms (95% C.I. 1.0-1.5)) than at screen-film mammography (0.7 per 1000 mammograms (95% C.I. 0.6-0.7)). Consequently, 287 (range progressive- non progressive model: 1-598) extra breast cancer deaths per 1,000,000 women (a 4.4% increase) were predicted to be prevented. An extra 401 (range: 165-2271) cancers would be overdiagnosed (a 21% increase). Conclusion: Modeling predicted that digital mammography screening would further reduce breast cancer mortality by 4.4%, at a 21% increased overdiagnosis rate. The consequences of digital screening, however, are sensitive to underlying assumptions on the natural history of DCIS. http://repub.eur.nl/res/pub/33664/ 2011-07-01T00:00:00Z Estimates of overdiagnosis in mammography screening range from 1% to 54%. This review explains such variations using gradual implementation of mammography screening in the Netherlands as an example. Breast cancer incidence without screening was predicted with a micro-simulation model. Observed breast cancer incidence (including ductal carcinoma in situ and invasive breast cancer) was modeled and compared with predicted incidence without screening during various phases of screening program implementation. Overdiagnosis was calculated as the difference between the modeled number of breast cancers with and the predicted number of breast cancers without screening. Estimating overdiagnosis annually between 1990 and 2006 illustrated the importance of the time at which overdiagnosis is measured. Overdiagnosis was also calculated using several estimators identified from the literature. The estimated overdiagnosis rate peaked during the implementation phase of screening, at 11.4% of all predicted cancers in women aged 0-100 years in the absence of screening. At steady-state screening, in 2006, this estimate had decreased to 2.8%. When different estimators were used, the overdiagnosis rate in 2006 ranged from 3.6% (screening age or older) to 9.7% (screening age only). The authors concluded that the estimated overdiagnosis rate in 2006 could vary by a factor of 3.5 when different denominators were used. Calculations based on earlier screening program phases may overestimate overdiagnosis by a factor 4. Sufficient follow-up and agreement regarding the chosen estimator are needed to obtain reliable estimates. http://repub.eur.nl/res/pub/27582/ 2010-02-01T00:00:00Z BACKGROUND: Screening can lead to earlier detection of breast cancer and thus to an improvement in survival. The authors studied the life expectancy of women with screen-detected invasive breast cancer (patients) compared with women invited to the breast cancer screening program in Nijmegen, the Netherlands (comparison group). METHODS: Each patient diagnosed between 1975 and 2006 was randomly age-matched with a woman invited in the same calendar year and free from breast cancer at the time of diagnosis of the patient. Survival analyses were performed to study differences in life expectancy. RESULTS: The life expectancy for 858 patients was 6 years shorter than for the comparison group. However, for 360 patients with small (<15 mm) invasive breast cancer, life expectancy was similar to that of the comparison group. In contrast, for patients detected with larger tumors (≥15 mm) the life expectancy was 6 to 12 years shorter, depending on tumor size. Furthermore, life expectancy was modified by screening history. For patients who had a negative screening examination 2 years before the detection of their breast cancer, the difference in life expectancy from the comparison group became smaller for the larger tumor sizes (≥15 mm). CONCLUSIONS: In conclusion, about 40% (360 of 858) of all women with invasive screen-detected breast cancer have the same life expectancy as women from the comparison group (reflecting the general population). For women diagnosed with larger tumors at diagnosis, life expectancy diminishes with increasing tumor size and is modified by screening history. http://repub.eur.nl/res/pub/26515/ 2009-12-01T00:00:00Z Introduction: The last detailed report from the National Evaluation Team for Breast cancer screening (NETB) on the Dutch breast cancer screening programme appeared in 2005. It presented the screening results up until the end of 2003 which, however, were incomplete for some regions. The same applies to the two brief interim reports that were released in 2006 and 2007. The new evaluation report adds four reporting years to the entire evaluation period, i.e. those from 2004- 2007. The fact that this 12th report by the NETB is based on complete nationwide data on the screening activities of all nine screening regions is particularly good news. This is thanks to the additional efforts made by the two regions that had had a backlog of screened women’s follow-up data for years, enabling the backlog to be eliminated by spring 2009. It also enabled the optimum analysis of 18 years of national population research, and the presentation of the results without qualification. Unfortunately, this does not apply to the data on interval cancers which, subsequent to 1999, are far from being fully available at national level.... http://repub.eur.nl/res/pub/25387/ 2009-09-01T00:00:00Z Objective: To compare interval breast cancer rates (ICR) between a biennial organized screening programme in Norway and annual opportunistic screening in North Carolina (NC) for different conceptualizations of interval cancer. Setting: Two regions with different screening practices and performance. Methods: 620,145 subsequent screens (1996-2002) performed in women aged 50-69 and 1280 interval cancers were analysed. Various definitions and quantification methods for interval cancers were compared. Results: ICR for one year follow-up were lower in Norway compared with NC both when the rate was based on all screens (0.54 versus 1.29 per 1000 screens), negative final assessments (0.54 versus 1.29 per 1000 screens), and negative screening assessments (0.53 versus 1.28 per 1000 screens). The rate of ductal carcinoma in situ was significantly lower in Norway than in NC for cases diagnosed in both the first and second year after screening. The distributions of histopathological tumour size and lymph node involvement in invasive cases did not differ between the two regions for interval cancers diagnosed during the first year after screening. In contrast, in the second year after screening, tumour characteristics remained stable in Norway but became prognostically more favorable in NC. Conclusion: Even when applying a common set of definitions of interval cancer, the ICR was lower in Norway than in NC. Different definitions of interval cancer did not influence the ICR within Norway or NC. Organization of screening and screening performance might be major contributors to the differences in ICR between Norway and NC. http://repub.eur.nl/res/pub/16354/ 2009-07-31T00:00:00Z http://repub.eur.nl/res/pub/18033/ 2009-03-24T00:00:00Z We prospectively determined the variability in radiologists' interpretation of screening mammograms and assessed the influence of type and number of readers on screening outcome. Twenty-one screening mammography radiographers and eight screening radiologists participated. A total of 106 093 screening mammograms were double-read by two radiographers and, in turn, by two radiologists. Initially, radiologists were blinded to the referral opinion of the radiographers. A woman was referred if she was considered positive at radiologist double-reading with consensus interpretation or referred after radiologist review of positive cases at radiographer double-reading. During 2-year follow-up, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result from any reader. Single radiologist reading (I) resulted in a mean cancer detection rate of 4.64 per 1000 screens (95% confidence intervals (CI)=4.23-5.05) with individual variations from 3.44 (95% CI=2.30-4.58) to 5.04 (95% CI=3.81-6.27), and a sensitivity of 63.9% (95% CI=60.5-67.3), ranging from 51.5% (95% CI=39.6-63.3) to 75.0% (95% CI=65.3-84.7). Sensitivity at non-blinded, radiologist double-reading (II), radiologist double-reading followed by radiologist review of positive cases at radiographer double-reading (III), triple reading by one radiologist and two radiographers with referral of all positive readings (IV) and quadruple reading by two radiologists and two radiographers with referral of all positive readings (V) were as follows: 68.6% (95% CI=65.3-71.9) (II); 73.2% (95% CI=70.1-76.4) (III); 75.2% (95% CI=72.1-78.2) (IV), and 76.9% (95% CI=73.9-79.9) (V). We conclude that screener performance significantly varied at single-reading. Double-reading increased sensitivity by a relative 7.3%. When there is a shortage of screening radiologists, triple reading by one radiologist and two radiographers may replace radiologist double-reading. http://repub.eur.nl/res/pub/14787/ 2008-10-15T00:00:00Z The aim of this study was to assess changes in the trends in breast cancer mortality and incidence from 1975 to 2006 among Dutch women, in relation to the implementation of the national breast cancer screening programme. Screening started in 1989 for women aged 50-69 and was extended to women aged 70-75 years in 1998 (attendance rate approximately >80%). A joinpoint Poisson regression analysis was used to identify significant changes in rates over time. Breast cancer mortality rates increased until 1994 (age group 35-84), but thereafter showed a marked decline of 2.3-2.8% per annum for the age groups 55-64 and 65-74 years, respectively. For the age group of 75-84 years, a decrease started in the year 2001. In women aged 45-54, an early decline in breast cancer mortality rates was noted (1971-1980), which is ongoing from 1992. For all ages, breast cancer incidence rates showed an increase between 1989 and 1993, mainly caused by the age group 50-69, and thereafter, a moderate increase caused by age group 70-74 years. This increase can partly be explained by the introduction of screening. The results indicate an impressive decrease in breast cancer mortality in the age group invited for breast cancer screening, starting to show quite soon after implementation. http://repub.eur.nl/res/pub/29973/ 2008-06-01T00:00:00Z Purpose: To determine the effect of introducing radiographer double reading, in addition to standard radiologist double reading, on screening mammography outcome. Methods: In period A, 66,225 mammograms were read by two screening radiologists. In period B, 78,325 mammograms were read by two radiographers in addition and radiologists were blinded to the referral opinion of the radiographers. Mammograms, for which only radiographers had suggested referral, (i.e. cases that would only be referred by technologists) were re-evaluated by the screening radiologists. Women were referred if at least one radiologist considered this necessary, and diagnostic costs of these additional referrals were estimated. Results: In period A, 322 cancers were diagnosed after referral of 678 women. During period B, radiologists initially referred 1122 patients and 411 cancers were detected. Radiologists' referral rate was higher in period B than in period A (1.43% versus 1.02%, p < 0.001), as well as the cancer detection rate per 1000 women screened (CDR) (5.25 versus 4.86, p = 0.3). The positive predictive value of referral (PPV) was 36.6% versus 47.5% (p < 0.001). In period B, radiologist review of 544 additional positive radiographer readings led to 102 extra referrals, with 29 additional cancers detected, resulting in an overall referral rate of 1.56% (compared to period A, p < 0.001), an overall CDR of 5.62 (p = 0.048) and an overall PPV of 35.9% (p < 0.001). Workup expenses of the 102 additional referrals were €60,274. Conclusion: Additional radiographer double reading detected cancers that would have been missed by radiologists. Mean expenses for diagnostic confirmation of these extra cancers was €2078 per cancer. http://repub.eur.nl/res/pub/14580/ 2008-05-20T00:00:00Z We prospectively assessed trends in utilization and costs of diagnostic services of screen-positive women in a biennial breast cancer screening program for women aged 50-75 years. All 2,062 women with suspicious findings at screening mammography in the southern region of the Netherlands between 1 January 2000 and 1 July 2005 (158,997 screens) were included. Data were collected on any diagnostic examinations, interventional procedures, and surgical consultations with two-year follow-up. We used national reimbursement rates to estimate imaging costs and percutaneous biopsy costs. Cost prices, charged by hospitals, were used to estimate open surgical biopsy costs and surgical consultation costs. The largest increase in utilization of diagnostic procedures per 100 referrals was observed for axillary ultrasound (from 3.9 in 2000 to 33.5 in 2005) and for stereotactic core biopsy (from 2.1 in 2000 to 26.8 in 2005). Per 100 referrals, the open surgical biopsy rate decreased from 34.7 (2000) to 4.6 (2005) and the number of outpatient surgical consultations fluctuated between 269.8 (2000) and 309.7 (2004). Mean costs for the diagnosis of one cancer were €1,501 and ranged from €1,223 (2002) to €1,647 (2003). Surgical biopsies comprised 54.1% of total diagnostic costs for women screened in 2000, but decreased to 9.9% for women screened in 2005. Imaging costs increased from 23.7 to 43.8%, percutaneous biopsy costs from 9.9 to 27.2%, and consultation costs from 12.3 to 19.1%. We conclude that diagnostic costs per screen-detected cancer remained fairly stable through the years, although huge changes in the use of different diagnostic procedures were observed. http://repub.eur.nl/res/pub/36849/ 2007-12-01T00:00:00Z Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in women worldwide. Elderly individuals make up a large part of the breast cancer population, and there are important specific considerations for this population. The International Society of Geriatric Oncology created a task force to assess the available evidence on breast cancer in elderly individuals, and to provide evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. A review of the published work was done with the results of a search on Medline for English-language articles published between 1990 and 2007 and of abstracts from key international conferences. Recommendations are given on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy, and metastatic disease. Since large randomised trials in elderly patients with breast cancer are scarce, there is little level I evidence for the treatment of such patients. The available evidence was reviewed and synthesised to provide consensus recommendations regarding the care of breast cancer in older adults. http://repub.eur.nl/res/pub/35702/ 2007-11-01T00:00:00Z Purpose: In a prospective, multi-institutional follow-up study we describe the trends in the preoperative pathologic confirmation of breast cancer of women who underwent breast cancer screening between 1995 and 2005. Methods: We included all women aged 50-75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between February 13, 1995 and December 22, 2004. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result. Follow-up lasted through the next biennial screening examination and was approximately two years for all referred women. Results: Of 258,900 mammographic screening examinations, 3,064 (1.2%) were positive screens. The majority of women (92%) were analyzed in four regional hospitals and workup yielded breast cancer in 1,332 women. From 1995 to 2005, the percentage of breast cancer cases that underwent percutaneous biopsy prior to surgery, increased from 42.4 to 100%. The proportion of cancers with a preoperative diagnosis of malignancy by percutaneous biopsy, increased from 27.1% in 1995 to 92.7% in 2004. Preoperative breast cancer confirmation by fine needle aspiration cytology (FNAC) gradually decreased from 91.3% to 14.5%, whereas preoperative confirmation by ultrasound guided core biopsy (USCB) or stereotactic core needle biopsy (SCNB) increased from 8.7% to 69.1% and from 0 to 17.4% respectively. Conclusions: A preoperative diagnosis of breast cancer is currently obtained in more than 90% of breast cancer patients. The increase in preoperative breast cancer diagnosis through 1995-2004 is correlated with the introduction of SNCB and increased use of USCB at the expense of FNAC. http://repub.eur.nl/res/pub/35713/ 2007-11-01T00:00:00Z Background: After a systematic mass mammography breast cancer screening programme was implemented between 1991 and 1996 (attendance 80%), we evaluated its impact on survival according to socioeconomic status (SES). Methods: We studied survival rates up to 1-1-2005 for all consecutive breast cancer patients aged 50-69 and diagnosed in the period 1983-2002 in the area of the Eindhoven Cancer Registry (n = 4939). Multivariate analyses were performed using Cox regression analysis. Results: The proportion of breast cancer patients with a low SES decreased from 22% in 1983-1990 to 14% in 1997-2002 when attendance was 85%. The proportion of newly diagnosed patients with stage III or IV disease in 1997-2002 was only 10% compared to 14% in 1991-1996 and 26% in 1983-1989 (P < 0.0001). Stage distribution improved for all socio-economic groups (P = 0.01). Survival was similar for all socio-economic groups in 1983-1990, but after the introduction of the screening programme women with low SES had lower age- and stage-adjusted survival rates (HR 2.0, 95%CI: 1.3-3.0). Survival was better for patients diagnosed in 1997-2002 compared to 1983-1990 for all socioeconomic strata; it was substantially better for the high SES group (HR 0.36, 0.2-0.5) compared to the lowest SES (HR 0.77, 0.6-1.1). Conclusion: Although survival improved for women from each of the socio-economic strata, related to the high participation rate of the screening programme, women from lower socio-economic strata clearly benefited less from the breast cancer screening programme. That is also related to the higher prevalence of comorbidity and possibly suboptimal treatment. http://repub.eur.nl/res/pub/35281/ 2007-08-01T00:00:00Z Background: Studies have shown that having mammography technologists review screening mammograms in addition to radiologist review may increase the number of breast cancers that are detected at screening mammography. We prospectively examined the effects on screening performance of adding independent double reading of screening mammograms by technologists to standard double reading by radiologists. Methods: Twenty-one screening mammography technologists and eight certified screening radiologists participated in this study. From January 1, 2003, to January 1, 2005, all 61251 screening mammograms obtained at two mammography screening units in The Netherlands were independently read (although the second reader was not blinded to the first reader's interpretation) by two technologists and, in turn, by two radiologists. Radiologists were blinded to the referral opinion of the technologists. During a 2-year follow-up period, we collected clinical data, breast imaging reports, biopsy results, and breast surgery reports of all women with a positive screening result (i.e., those that required additional imaging) from any reader. The distributions of categorical variables between subgroups were compared using chi-square or Fisher's exact tests. Differences in referral and detection by radiologists and technologists were assessed using McNemar's test. All statistical tests were two-sided. Results: The radiologists referred 905 women (referral rate = 1.48%, 95% confidence interval [CI] = 1.38% to 1.57%), of whom 323 had breast cancer, corresponding to a positive predictive value of referral (PPV) of 35.7% (95% CI = 32.6% to 38.8%). Review of 446 additional technologist-positive readings led to another 80 referrals, resulting in the detection of 22 additional cancers. These extra referrals increased the initial referral rate from 1.48% to 1.61% (difference = 0.13%; 95% CI = 0.10% to 0.16%) and the cancer detection rate (CDR) from 5.27 to 5.63 cancers per 1000 women screened (difference = 0.36 cancers per 1000 women screened; 95% CI = 0.24 to 0.55). With technologist double reading only, 829 women would have been referred (referral rate = 1.35%, 95% CI = 1.26% to 1.45%); among these women, 286 cancers were diagnosed (PPV = 34.5%, 95% CI = 31.3% to 37.7%; CDR = 4.67 cancers per 1000 women screened, 95% CI = 4.13 to 5.21). Referral of all 1351 radiologist- and/ or technologist-positive readings would have led to 362 cancers found at screening. The cancer detection rate for radiologist double reading would have increased from 5.27 to 5.91 cancers per 1000 women screened (relative increase = 12.1%, 95% CI = 8.8% to 16.5%; difference = 0.64 cancers per 1000 women screened, 95% CI = 0.47 to 0.87). Conclusion: A referral strategy that includes all technologist-positive readings, which would have increased the cancer detection rate while maintaining a low referral rate, should be considered. http://repub.eur.nl/res/pub/35818/ 2007-04-01T00:00:00Z In mammography screening with double reading, different strategies can be used when the readers give discordant recommendations for referral. We investigated whether the results of the Dutch breast cancer screening programme can be optimised by replacing the standard referral strategy by consensus. Twenty-six screening radiologists independently and blinded to outcome read a test set consisting of previous screening mammograms of 250 cases (screen-detected and interval cancers) and 250 controls. Their referral recommendations were paired and, in case of discrepancy, re-read according to three referral strategies: (1) decision by one of the readers; (2) arbitration by a third reader; (3) referral if both readers agree (consensus). Data allowed studying other referral strategies, including referral if any reader suggests, as well. Double reading with referral if any reader suggests resulted in a 1.03 times higher sensitivity (76.6%) and a 1.31 times higher referral rate (1.26%) than double reading with consensus. To estimate the cost-effectiveness, the outcomes were used in a microsimulation model. Even if double reading with referral if any reader suggests results in four times as high referral rates and an accompanying increase of biopsies or other invasive procedures, the cost-effectiveness of €4,190 per life-year gained may well be in the range of acceptable cost-effectiveness for Dutch health care programmes.