The aim of this study was to quantify the impact of organised mammography screening on breast cancer mortality across European regions. Therefore, a systematic review was performed including ...different types of studies from all European regions and stringently used clearly defined quality appraisal to summarise the best evidence.
Six databases were searched including Embase, Medline and Web of Science from inception to March 2018. To identify all eligible studies which assessed the effect of organised screening on breast cancer mortality, two reviewers independently applied predefined inclusion and exclusion criteria. Original studies in English with a minimum follow-up of five years that were randomised controlled trials (RCTs) or observational studies were included. The Cochrane risk of bias instrument and the Newcastle–Ottawa Scale were used to assess the risk of bias.
Of the 5015 references initially retrieved, 60 were included in the final analysis. Those comprised 36 cohort studies, 17 case–control studies and 7 RCTs. None were from Eastern Europe. The quality of the included studies varied: Nineteen of these studies were of very good or good quality. Of those, the reduction in breast cancer mortality in attenders versus non-attenders ranged between 33% and 43% (Northern Europe), 43%–45% (Southern Europe) and 12%–58% (Western Europe). The estimates ranged between 4% and 31% in invited versus non-invited.
This systematic review provides evidence that organised screening reduces breast cancer mortality in all European regions where screening was implemented and monitored, while quantification is still lacking for Eastern Europe. The wide range of estimates indicates large differences in the evaluation designs between studies, rather than in the effectiveness of screening.
•Study summarises current evidence of mortality reduction due to mammography screening.•Includes different types of studies, using a methodologically sound quality appraisal.•Impact ranges between 12% and 58% in screening attenders versus non-attenders.•Impact ranges between 4% and 31% in invited versus non-invited women.•Quantification of the actual effects is still lacking for Eastern Europe.•Results fortify that mammography screening reduces mortality from breast cancer.
Harms and benefits of cancer screening depend on age and comorbid conditions, but reliable estimates are lacking.
To estimate the harms and benefits of cancer screening by age and comorbid conditions ...to inform decisions about screening cessation.
Collaborative modeling with 7 cancer simulation models and common data on average and comorbid condition level-specific life expectancy.
U.S. population.
U.S. cohorts aged 66 to 90 years in 2010 with average health or 1 of 4 comorbid condition levels: none, mild, moderate, or severe.
Mammography, prostate-specific antigen testing, or fecal immunochemical testing.
Lifetime cancer deaths prevented and life-years gained (benefits); false-positive test results and overdiagnosed cancer cases (harms). For each comorbid condition level, the age at which harms and benefits of screening were similar to that for persons with average health having screening at age 74 years.
Screening 1000 women with average life expectancy at age 74 years for breast cancer resulted in 79 to 96 (range across models) false-positive results, 0.5 to 0.8 overdiagnosed cancer cases, and 0.7 to 0.9 prevented cancer deaths. Although absolute numbers of harms and benefits differed across cancer sites, the ages at which to cease screening were consistent across models and cancer sites. For persons with no, mild, moderate, and severe comorbid conditions, screening until ages 76, 74, 72, and 66 years, respectively, resulted in harms and benefits similar to average-health persons.
Comorbid conditions influenced only life expectancy.
Comorbid conditions are an important determinant of harms and benefits of screening. Estimates of screening benefits and harms by comorbid condition can inform discussions between providers and patients about personalizing screening cessation decisions.
National Cancer Institute and Centers for Disease Control and Prevention.
Many breast, cervical, and colorectal cancer screening programmes were disrupted due to the COVID-19 pandemic. This study aimed to estimate the effects of five restart strategies after the disruption ...on required screening capacity and cancer burden.
Microsimulation models simulated five restart strategies for breast, cervical, and colorectal cancer screening. The models estimated required screening capacity, cancer incidence, and cancer-specific mortality after a disruption of 6 months. The restart strategies varied in whether screens were caught up or not and, if so, immediately or delayed, and whether the upper age limit was increased.
The disruption in screening programmes without catch-up of missed screens led to an increase of 2.0, 0.3, and 2.5 cancer deaths per 100 000 individuals in 10 years in breast, cervical, and colorectal cancer, respectively. Immediately catching-up missed screens minimised the impact of the disruption but required a surge in screening capacity. Delaying screening, but still offering all screening rounds gave the best balance between required capacity, incidence, and mortality.
Strategies with the smallest loss in health effects were also the most burdensome for the screening organisations. Which strategy is preferred depends on the organisation and available capacity in a country.
Quality-of-Life Effects of PSA Screening
PSA screening of men between the ages of 55 and 69 years resulted in a reduction in deaths from prostate cancer. However, when overdiagnosis and treatment ...sequelae were considered, the number of quality-adjusted life-years gained through screening was also reduced.
After a median follow-up of 9 years, the initial results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) showed a significant relative reduction of 20% in prostate-cancer mortality among men undergoing prostate-specific antigen (PSA) screening, with a reduction of 27% after adjustment for selection bias.
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In recently updated results at 11 years, the relative reduction in prostate-cancer mortality in the screening group was 29% after adjustment for selection bias.
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At the Gothenburg center in the ERSPC, there was a reduction of 44% in prostate-cancer mortality after a median follow-up of 14 years among all men (including those . . .
The ERSPC (European Randomized Study of Screening for Prostate Cancer) found that screening reduced prostate cancer mortality, but the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening ...Trial) found no reduction.
To evaluate whether effects of screening on prostate cancer mortality relative to no screening differed between the ERSPC and PLCO.
Cox regression of prostate cancer death in each trial group, adjusted for age and trial. Extended analyses accounted for increased incidence due to screening and diagnostic work-up in each group via mean lead times (MLTs), which were estimated empirically and using analytic or microsimulation models.
Randomized controlled trials in Europe and the United States.
Men aged 55 to 69 (ERSPC) or 55 to 74 (PLCO) years at randomization.
Prostate cancer screening.
Prostate cancer incidence and survival from randomization; prostate cancer incidence in the United States before screening began.
Estimated MLTs were similar in the ERSPC and PLCO intervention groups but were longer in the PLCO control group than the ERSPC control group. Extended analyses found no evidence that effects of screening differed between trials (P = 0.37 to 0.47 range across MLT estimation approaches) but strong evidence that benefit increased with MLT (P = 0.0027 to 0.0032). Screening was estimated to confer a 7% to 9% reduction in the risk for prostate cancer death per year of MLT. This translated into estimates of 25% to 31% and 27% to 32% lower risk for prostate cancer death with screening as performed in the ERSPC and PLCO intervention groups, respectively, compared with no screening.
The MLT is a simple metric of screening and diagnostic work-up.
After differences in implementation and settings are accounted for, the ERSPC and PLCO provide compatible evidence that screening reduces prostate cancer mortality.
National Cancer Institute.
Molecular characterization of breast cancer allows subtype-directed interventions. Estrogen receptor (ER) is the longest-established molecular marker.
We used six established population models with ...ER-specific input parameters on age-specific incidence, disease natural history, mammography characteristics, and treatment effects to quantify the impact of screening and adjuvant therapy on age-adjusted US breast cancer mortality by ER status from 1975 to 2000. Outcomes included stage-shifts and absolute and relative reductions in mortality; sensitivity analyses evaluated the impact of varying screening frequency or accuracy.
In the year 2000, actual screening and adjuvant treatment reduced breast cancer mortality by a median of 17 per 100000 women (model range = 13-21) and 5 per 100000 women (model range = 3-6) for ER-positive and ER-negative cases, respectively, relative to no screening and no adjuvant treatment. For ER-positive cases, adjuvant treatment made a higher relative contribution to breast cancer mortality reduction than screening, whereas for ER-negative cases the relative contributions were similar for screening and adjuvant treatment. ER-negative cases were less likely to be screen-detected than ER-positive cases (35.1% vs 51.2%), but when screen-detected yielded a greater survival gain (five-year breast cancer survival = 35.6% vs 30.7%). Screening biennially would have captured a lower proportion of mortality reduction than annual screening for ER-negative vs ER-positive cases (model range = 80.2%-87.8% vs 85.7%-96.5%).
As advances in risk assessment facilitate identification of women with increased risk of ER-negative breast cancer, additional mortality reductions could be realized through more frequent targeted screening, provided these benefits are balanced against screening harms.
Prostate cancer screening depends on a careful balance of benefits, in terms of reduced prostate cancer mortality, and harms, in terms of overdiagnosis and overtreatment. We aimed to estimate the ...effect on overdiagnosis of restricting prostate specific antigen (PSA) testing by age and baseline PSA.
Estimates of the effects of age on overdiagnosis were based on population based incidence data from the US Surveillance, Epidemiology and End Results database. To investigate the relationship between PSA and overdiagnosis, we used two separate cohorts subject to PSA testing in clinical trials (n = 1,577 and n = 1,197) and a population-based cohort of Swedish men not subject to PSA-screening followed for 25 years (n = 1,162).
If PSA testing had been restricted to younger men, the number of excess cases associated with the introduction of PSA in the US would have been reduced by 85%, 68% and 42% for age cut-offs of 60, 65 and 70, respectively. The risk that a man with screen-detected cancer at age 60 would not subsequently lead to prostate cancer morbidity or mortality decreased exponentially as PSA approached conventional biopsy thresholds. For PSAs below 1 ng/ml, the risk of a positive biopsy is 65 (95% CI 18.2, 72.9) times greater than subsequent prostate cancer mortality.
Prostate cancer overdiagnosis has a strong relationship to age and PSA level. Restricting screening in men over 60 to those with PSA above median (>1 ng/ml) and screening men over 70 only in selected circumstances would importantly reduce overdiagnosis and change the ratio of benefits to harms of PSA-screening.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose To critically evaluate and confirm previous results regarding the diagnostic accuracy of digital mammography screening (DM), compared to screen-film mammography (SFM) in the whole ...Dutch screening programme, in the period of 2004–2010, during which a full transition from SFM to DM was made. Materials and methods 1.5 million DM and 4.6 million SFM were read in the Dutch national breast cancer screening programme in the period of 2004–2010. We evaluated recall rate, detection rate, positive predictive value and tumour-size distribution for younger and older women, for first time participants and women having a timely subsequent screen. We compared DM screens read by radiologists reading DM and SFM (DM-group) to SFM screens read by these radiologists (SFM-group) and to SFM screens read by radiologists reading only SFM (SFMonly-group). Results Recall rate was 2.0% (95% confidence interval (C.I.): 2.0; 2.1) in the DM-group, compared to 1.6% (95% C.I.: 1.6; 1.6) in the SFM-group and 1.6% (95% C.I.: 1.5; 1.6) in the SFM only-group. The overall detection rates were 5.9/1000 screens (95% C.I.: 5.7; 6.0) in the DM-group, 5.1/1000 screens (95% C.I.: 5.0; 5.2) in the SFM-group and 5.0/1000 screens (95% C.I.: 5.0; 5.1) in the SFM only-group. Detection rate rose most markedly in younger women (age 49–54) from 4.0/1000 screens to 5.1/1000 screens ( p -value < 0.001). Positive predictive value (PPV) in DM rose from 18.4% (95% C.I.: 14.6; 23.1) in 2004 to 32.5% (95% C.I.: 31.7; 33.2) in 2010. Detection rate rose in SFM-group from 5.0/1000 screens (95% C.I.: 4.7; 5.3) in 2004 to 5.5/1000 screens (95% C.I.: 5.2; 5.7) in 2010. Detection rate in DM-group rose mostly due to ductal carcinoma in situ (DCIS) detection especially in younger women/first screens. The proportion of T1a tumours was significantly higher in DM-group; otherwise size distribution did not change significantly for invasive carcinoma. Recall rates were variable between different screening regions. Conclusion In accordance to previous, smaller, studies, we can confirm that DM has a higher detection rate compared to SFM, at the cost of a higher recall rate and lower PPV. More DCIS and a higher fraction of very small tumours were detected with DM, which has positive consequences for the stage shift as a result of mass screening.
The benefit of prostate cancer screening is counterbalanced by the risk of overdiagnosis and overtreatment. The use of a multi-parametric magnetic resonance imaging (mpMRI) test after a positive ...prostate-specific antigen (PSA) test followed by magnetic resonance imaging-guided biopsy (MRIGB) may reduce these harms. The aim of this study was to determine the effects of mpMRI and MRIGB vs the regular screening pathway in a population-based prostate cancer screening setting. A micro-simulation model was used to predict the effects of regular PSA screening (men with elevated PSA followed by TRUSGB) and MRI based screening (men with elevated PSA followed by mpMRI and MRIGB). We predicted reduction of overdiagnosis, harm-benefit ratio (overdiagnosis per cancer death averted), reduction in number of biopsies, detection of clinically significant cancer, prostate cancer death averted, life-years gained (LYG), and quality adjusted life years (QALYs) gained for both strategies. A univariate sensitivity analysis and threshold analysis were performed to assess uncertainty around the test sensitivity parameters used in the MRI strategy.In the MRI pathway, we predicted a 43% reduction in the risk of overdiagnosis, compared to the regular pathway. Similarly a lower harm-benefit ratio (overdiagnosis per cancer death averted) was predicted for this strategy compared to the regular screening pathway (1.0 vs 1.8 respectively). Prostate cancer mortality reduction, LY and QALYs gained were also slightly increased in the MRI pathway than the regular screening pathway. Furthermore, 30% of men with a positive PSA test could avoid a biopsy as compared to the regular screening pathway. Compared to regular PSA screening, the use of mpMRI as a triage test followed by MRIGB can substantially reduce the risk of overdiagnosis and improve the harm-benefit balance, while maximizing prostate cancer mortality reduction and QALYs gained.
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