Cariddi A

Independent Double Reading of Screening Mammograms

Objective — To evaluate the cost effectiveness of independent double reading of screening mammograms. Setting — Prospective study of 18817 women undergoing first or repeat screening in a population based programme in the Florence district. Methods — Mammograms were independently double read by experienced radiologists. Subjects with mammographic abnormalities reported by at least one reader were recalled for diagnostic assessment. The mean increase in recall rate, cancer detection rate, and screening costs attributable to double reading was calculated. Results — Eleven of 125 cancers were detected by only one reader. The mean increase in cancer detection rate attributable to double reading compared with single reading was 4·6% (95% confidence interval (CI) 1·1 to 8·9). From a total of 748 cases referred for diagnostic assessment, 196 subjects were referred by one reader only. The mean increase in referral rate attributable to double reading compared with single reading was 15·1% (CI 12·3 to 17·8). Double reading caused a marked increase in the cost for each woman screened −8·5% at the first screening and 6·2% at repeat screening and a more limited increase in the cost for each cancer detected −3·5% at the first screening and 2·7% at repeat screening. Cancers detected by only one screener were at an earlier stage than those detected by both screeners (P = 0·6, not significant). Conclusions — Independent double reading results in only a modest increase in the detection of cancers and therefore may not be cost effective.

LONG-TERM SEQUELAE OF BREAST CANCER SURGERY

Background Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986. Patients and Methods The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed. Results Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88). Conclusions The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Intensive diagnostic follow-up after treatment of primary breast cancer: A randomised trial

Objective.\p=m-\Toevaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients. Design.\p=m-\Randomizedclinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years. Setting.\p=m-\Twelvebreast clinics (referral centers) in different areas in Italy. Patients.\p=m-\Atotal of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics. Intervention.\p=m-\Patientsin both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months. Main Outcome Measures.\p=m-\Vitalstatus at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed. Results.\p=m-\Overall,393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups. Conclusions.\p=m-\Periodicchest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy.

Histopathologic Classification of Breast Cancer in Sweden and Italy: A Comparison between two Pathologists

Two large series of breast cancers (BC), identified in the Pathology Departments of Malmö (Sweden) and Florence (Italy), were independently reviewed by two experienced pathologists, one from each department. Overall, comparison of diagnoses of 372 BCs according to a simplified WHO histologic classification system (in four combined categories) revealed agreement for 74 % of the cases. Concordance, as measured by the kappa statistic, was relatively good (0.53 overall). Kappa values for specific categories were also acceptable, being highest for « invasive lobular » BC (0.63) and lowest for « other types » (0.45). The kappa value for « noninvasive » versus all other categories of invasive BC was 0.53. Some BCs were systematically classified as « noninvasive » by one pathologist and as « invasive ductal with a predominant intraductal component » by the other. Invasive lobular BCs were also diagnosed more frequently by one pathologist. These findings suggest that when planning geographical or temporal comparisons of distribution for BC histologic categories, standardization of classification and a centralized review may play an important role.