A cross-sectional study on informed choice in the mammography screening programme in Germany (InEMa): a study protocol

The efficacy of mammography screening in reducing breast cancer mortality has been demonstrated in randomized trials. However, treatment options - and hence prognosis - for advanced tumor stages as well as mammography techniques have considerably improved since completion of these trials. Consequently, the effectiveness of mammography screening under current conditions is unclear and controversial. The German mammography screening program (MSP), an organized population-based screening program, was gradually introduced between 2005 and 2008 and achieved nation-wide coverage in 2009. We describe in detail a study protocol for investigating the effectiveness of the German MSP in reducing breast cancer mortality in women aged 50 to 69 years based on health claims data. Specifically, the proposed study aims at estimating per-protocol effects of several screening strategies on cumulative breast cancer mortality. The first analysis will be conducted once 10-year follow-up data are available. We will use claims data from five statutory health insurance providers in Germany, covering approximately 37.6 million individuals. To estimate the effectiveness of the MSP, hypothetical target trials will be emulated across time, an approach that has been demonstrated to minimize design-related biases. Specifically, the primary contrast will be in terms of the cumulative breast cancer mortality comparing the screening strategies of "never screen" versus "regular screening as intended by the MSP". In Germany, the utilization of data from health insurances for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the responsible authorities approved the use of the health claims data for this study. The Ethics Committee of the University of Bremen determined that studies based on claims data are exempt from institutional review. The findings of the proposed study will be published in peer-reviewed journals.

Socioeconomic inequalities in breast and thyroid cancer screening in Korea: A nationwide cross-sectional study

BackgroundHigh participation in mammographic screening is essential for its effectiveness to detect breast cancers early and thereby, improve breast cancer outcomes. Breast density is a strong predictor of breast cancer risk and significantly reduces the sensitivity of mammography to detect the disease. There are increasing mandates for routine breast density notification within mammographic screening programs. It is unknown if breast density notification impacts the likelihood of women returning to screening when next due (i.e. rescreening rates). This study investigates the association between breast density notification and rescreening rates using individual-level data from BreastScreen Western Australia (WA), a population-based mammographic screening program.MethodsWe examined 981,705 screening events from 311,656 women aged 40+ who attended BreastScreen WA between 2008 and 2017. Mixed effect logistic regression was used to investigate the association between rescreening and breast density notification status.ResultsResults were stratified by age (younger, targeted, older) and screening round (first, second, third+). Targeted women screening for the first time were more likely to return to screening if notified as having dense breasts (Percentunadjusted notified vs. not-notified: 57.8% vs. 56.1%; Padjusted = 0.016). Younger women were less likely to rescreen if notified, regardless of screening round (all P < 0.001). There was no association between notification and rescreening in older women (all P > 0.72).ConclusionsBreast density notification does not deter women in the targeted age range from rescreening but could potentially deter younger women from rescreening. These results suggest that all breast density notification messaging should include information regarding the importance of regular mammographic screening to manage breast cancer risk, particularly for younger women. These results will directly inform BreastScreen programs in Australia as well as other population-based screening providers outside Australia who notify women about breast density or are considering implementing breast density notification.

Successful screening mammography programs aim to screen large numbers of women efficiently and inexpensively. Development of an effective screening mammography program requires skilled personnel, solid infrastructure, and a robust computer system. A group of physicians, technologists, computer support personnel, and administrators carefully analyzed a growing screening mammography program as a series of steps, starting with the request for the examination and ending with the receipt of a hard-copy consultation. The analysis involved a detailed examination of every step and every possible outcome in the screening process. The information gained through process mapping may be used for identification of systemic and personnel problems, allocation of resources, modification of workplace architecture, and design of computer networks. Process mapping is helpful for those involved in designing and improving screening mammography programs. Viewing a process (i.e., obtaining a screening mammogram) as a series of steps may allow for the identification of inefficient components that may limit growth.

The purpose of this study was to predict intention to obtain a mammogram on a mobile medical van, using Ajzen and Fishbein's theory of reasoned action. Verification of intention through behavior follow-up was conducted on 199 women ages 40 and older through use of a medical center's mobile medical van. Using regression equations, the results showed that (a) the model failed to predict intention when using the mobile van for screening breast cancer, yet (b) intention was significantly predicted in regard to obtaining a mammogram within the next two years. Attitude was a significant predictor of intention over and above subjective norm, whereas subjective norm was not a significant predictor of intention over and above attitude. The test for interaction between attitude and subjective norm was a significant predictor of intention. In view of this, the attitudinal component should receive greater emphasis with regard to designing health promotion activities aimed toward encouraging women to participate in mammography screenings.

BackgroundThe Bahçeşehir population-based mammography screening program (BMSP) is an example of Türkiye’s first population-based screening program. This study aims to reveal the successful implementation of population-based secreening program in one of the low- and middle-income countries, Türkiye and long-term results of patients diagnosed with breast cancer during BMSP.MethodsThis study was conducted between 2009 and 2019, in the Bahçeşehir county of Istanbul. Women between the ages of 40 and 69 living in this region were invited every two years to undergo clinical breast examination (CBE) and mammography screening. All data was recorded in a dedicated software program. Women diagnosed with breast cancer were followed as a separate cohort.ResultsDuring the 10-year screening period, 8,825 women were screened and 146 (1.7%) breast cancers were detected. The median age at diagnosis for these patients was 52.9 years (40–69). The risk of breast cancer was 1.39 times higher (95% CI: 1.01–1.93) in women aged ≥ 50 compared to those less than 50 years (p = 0.045). The Cox regression analysis revealed that age at first birth, and number of births were significant predictors of breast cancer risk (p < 0.001, and p = 0.011). The breast cancer rate tends to increase as the breast density category progresses from A to D (p < 0.001). The median follow-up time for 146 breast cancer patients was 95.3 months. The 10-year breast cancer specific survival rate was 85%.ConclusionsThis study demonstrates that with a committed team and sufficient infrastructure, screening mammography can be effectively carried out in Türkiye, leading to early detection and lower mortality rates. The recommended age to commence screening is 40 years old.

BackgroundTriggered by the successive implementation of organized mammography screening programs (MSPs) throughout western European countries over the last decades, there is an ongoing debate questioning their effectiveness. Since it is difficult to assess the effect of MSPs on a population level, we rather aim to assess the impact of the implementation itself on breast cancer mortality rates utilizing an ecological study design.MethodsWe analyzed age group-specific (50–59, 60–69 and 70–79 years) female breast cancer mortality rates in 14 western European countries between 1980 and 2017 using Joinpoint regression, interrupted time series (ITS) regression and multivariable Poisson regression.ResultsThe Joinpoint analysis demonstrated decreasing trends resulting in annual percentage changes ranging from − 1.5% to − 5.4% (50–59), − 0.2% to − 8.1% (60–69) and 0% to − 7.1% (70–79) depending on the country within 3 years after MSP implementation. The ITS analysis results in highly significant interaction terms (calendar year * binary MSP indicator) for all age groups. The multivariable regression using “calendar year”, “year of MSP implementation” and “years with MSP” as independent variables yielded a significant yearly decrease for “years with MSP” ranging from 0.9 to 1.2%.ConclusionsThe results of this study suggest a positive association between the implementation of MSPs and the (accelerated) reduction of breast cancer mortality rates. Measuring and quantifying the isolated effect of MSPs on a population level will require additional studies using individual data.

BackgroundThe population-based mammography screening program (MSP) was implemented by the end of 2005 in Germany, and all women between 50 and 69 years are actively invited to a free biennial screening examination. However, despite the expected benefits, the overall participation rates range only between 50 and 55 %. There is also increasing evidence that belonging to a vulnerable population, such as ethnic minorities or low income groups, is associated with a decreased likelihood of participating in screening programs. This study aimed to analyze in more detail the intra-urban variation of MSP uptake at the neighborhood level (i.e. statistical districts) for the city of Dortmund in northwest Germany and to identify demographic and socioeconomic risk factors that contribute to non-response to screening invitations.MethodsThe numbers of participants by statistical district were aggregated over the three periods 2007/2008, 2009/2010, and 2011/2012. Participation rates were calculated as numbers of participants per female resident population averaged over each 2-year period. Bayesian hierarchical spatial models extended with a temporal and spatio-temporal interaction effect were used to analyze the participation rates applying integrated nested Laplace approximations (INLA). The model included explanatory covariates taken from the atlas of social structure of Dortmund.ResultsGenerally, participation rates rose for all districts over the time periods. However, participation was persistently lowest in the inner city of Dortmund. Multivariable regression analysis showed that migrant status and long-term unemployment were associated with significant increases of non-attendance in the MSP.ConclusionLow income groups and immigrant populations are clustered in the inner city of Dortmund and the observed spatial pattern of persistently low participation in the city center is likely linked to the underlying socioeconomic gradient. This corresponds with the findings of the ecological regression analysis manifesting socioeconomically deprived neighborhoods as risk factors for low attendance in the MSP. Spatio-temporal surveillance of participation in cancer screening programs may be used to identify spatial inequalities in screening uptake and plan spatially focused interventions.

Background: Breast cancer screening is effective in reducing breast cancer mortality, but there is increasing concern that it may also lead to overdiagnosis; the detection and treatment of a cancer that would never have presented symptomatically during the woman's lifetime. Conservative management of low-risk breast cancer may reduce the harm of overdiagnosis resulting from mammographic screening programs, yet little is known about how such strategies might impact upon quality of life. Aim: To quantify women's preferences for managing low risk breast cancers identified by breast cancer screening. Methods: Utilities (measures of preference) were obtained from women with and without a history of breast cancer for seven health states reflecting low risk screen detected ductal carcinoma in situ (DCIS) using standard gambles. Demographics and a history of prior screening participation or breast cancer diagnosis were examined as predictors of screening and treatment pathway preferences. Results: Utilities were lower for breast cancers treated with mastectomy or invasive adjuvant treatment. The impact of active monitoring on quality of life was comparable to breast conserving surgery, although women in both patient and general population groups rated active monitoring more favorably as the risk of disease spread was decreased. There was some variation in ratings across patients suggesting that individual risk aversion does affect preferences for the type of conservative management valued. Conclusion: Overdiagnosis remains a challenge for improving the current breast cancer screening program. Active monitoring of low risk ductal carcinoma in situ may provide an acceptable solution for reducing the impact of overdiagnosis and overtreatment resulting from breast cancer screening on quality of life.

Physicians play a key role in motivating women to undergo mammography screening. In 1998 we assessed Swiss physicians' attitudes to mammography screening and their prescription behaviour in this regard. All female physicians and every second male physician aged 50-69 who were either not board-certified or board-certified in general practice, internal medicine, or obstetrics/gynaecology were sent a questionnaire. The response rate was 50% and thus 738 questionnaires were included in this study. Of the study population 39% were female and 61% male physicians. The distribution of professional backgrounds was: 27% board-certified general practitioners; 23% board-certified internists; 11% board-certified gynaecologists; 39% not board-certified. 55% of all study participants were in favour of a mammography screening programme for women aged over 50 in Switzerland, but breast self-examination and clinical breast examination were judged to have a more positive impact on breast cancer survival. Among clinically practising physicians, 22% reported generally prescribing biannual screening mammographies for women aged 50-69. Irrespective of other determinants, physicians from the Italian- and French-speaking parts of Switzerland prescribed screening mammographies more often than their colleagues from the German-speaking part (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5-4.2). Clinical practice in obstetrics/gynaecology (OR 2.4; CI 1.3-4.2) and a self-reported high level of knowledge concerning mammography screening (OR 1.9; CI 1.1-3.2) were also positively associated with the prescription of screening mammography. Since mammography screening programmes exist in only three French-speaking cantons of Switzerland (VS; VD; GE), the gap in prescription of screening mammographies between French/Italian- and German-speaking regions must be narrowed to prevent a higher prevalence of side effects from opportunistic screening among German-speaking women. There is a need to educate physicians and the political community regarding the risks and benefits of mammography screening.

Physicians play a key role in motivating women to undergo mammography screening. In 1998 we assessed Swiss physicians' attitudes to mammography screening and their prescription behaviour in this regard. All female physicians and every second male physician aged 50-69 who were either not board-certified or board-certified in general practice, internal medicine, or obstetrics/gynaecology were sent a questionnaire. The response rate was 50% and thus 738 questionnaires were included in this study. Of the study population 39% were female and 61% male physicians. The distribution of professional backgrounds was: 27% board-certified general practitioners; 23% board-certified internists; 11% board-certified gynaecologists; 39% not board-certified. 55% of all study participants were in favour of a mammography screening programme for women aged over 50 in Switzerland, but breast self-examination and clinical breast examination were judged to have a more positive impact on breast cancer survival. Among clinically practising physicians, 22% reported generally prescribing biannual screening mammographies for women aged 50-69. Irrespective of other determinants, physicians from the Italian- and French-speaking parts of Switzerland prescribed screening mammographies more often than their colleagues from the German-speaking part (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5-4.2). Clinical practice in obstetrics/gynaecology (OR 2.4; CI 1.3-4.2) and a self-reported high level of knowledge concerning mammography screening (OR 1.9; CI 1.1-3.2) were also positively associated with the prescription of screening mammography. Since mammography screening programmes exist in only three French-speaking cantons of Switzerland (VS; VD; GE), the gap in prescription of screening mammographies between French/Italian- and German-speaking regions must be narrowed to prevent a higher prevalence of side effects from opportunistic screening among German-speaking women. There is a need to educate physicians and the political community regarding the risks and benefits of mammography screening.

The screening mammography paradox: better when found, perhaps better not to find

BackgroundThe reduced mortality rate from breast carcinoma among women offered screening mammography is demonstrated after 15–20 years of follow-up. However, the assessment of 5-year overall and event-free survival could represent an earlier measure of the efficacy of mammography screening program (MSP).MethodsAll cases of breast cancer diagnosed in the Province of Modena between years 1996 and 2000 in women aged 50 to 69 years, were identified through the Modena Cancer Registry (MCR). Stage of disease and treatment information were obtained from clinical records. All the events occurring up to June 30, 2003 were retrieved by experienced monitors. Five-year overall and event-free survival were the principal end-points of the study.ResultsDuring a 5-year period, 587 primary breast cancers were detected by the MSP and 471 primary breast cancers were diagnosed out of the MSP. The screen-detected breast cancers were smaller, more likely node negative, with low histological grade, low proliferative activity and positive receptors status. Furthermore, the breast cancer diagnosed through the MSP more frequently received a conservative surgery. The 5-year survival rate was 94% in the screen-detected group, versus 84% in the other group (p = 0.0001). The rate of 5-year event-free survival was 89% and 75% for the MSP participants and not participants, respectively (p = 0.0001).ConclusionsOur data confirm a favourable outcome of screen-detected breast cancers in terms of five-year overall and event-free survival, which reflect the good quality assurance parameters of the MSP. Finally, a cancer registry should be implemented in every area covered by screening programs.

Differences in mammography screening attendance among non-Western immigrants in Denmark, Finland, Iceland and Norway

To investigate the impact of population mammography screening on breast cancer incidence trends in New Zealand. Trends in age-specific rates of invasive breast cancer incidence (1994-2014) were assessed in relation to screening in women aged 50-64 from 1999 and 45-69 following the programme age extension in mid-2004. Breast cancer incidence increased significantly by 18% in women aged 50-64 compared with 1994-98 (p<0.0001), coinciding with the 1999 introduction of mammography screening, and remained elevated for four years, before declining to pre-screening levels. Increases over 1994-99 incidence occurred in the 45-49 (21%) and 65-69 (19%) age groups following the 2004 age extension (p<0.0001). Following establishment of screening (2006-10), elevated incidence in the screening target age groups was compensated for by lower incidence in the post-screening ⩾70 age groups than in 1994-98. Incidence in women aged ⩾45 was not significantly higher (+5%) after 2006 than in 1994-98. The cumulated risk of breast cancer in women aged 45-84 for 1994-98 was 10.7% compared with 10.8% in 2006-10. Increases in breast cancer incidence following introduction of mammography screening in women aged 50-64 did not persist. Incidence inflation also occurred after introduction of screening for age groups 45-49 and 65-69. The cumulated incidence for women aged 45-84 over 2006-10 after screening was well established, compared with 1994-98 prior to screening, shows no increase in diagnosis. Over-diagnosis is not inevitable in population mammography screening programmes.