E.J. Roebuck

Early experience in breast cancer screening: emphasis on development of protocols for triple assessment

Abstract The early experience of the Nottingham Breast Screening Service participating in the prevalent round of the UK National Health Service Breast Screening Programme is presented. Over a 3-year-period management protocols have been developed and refined. These protocols are based on the principle of multidisciplinary triple assessment, including imaging, clinical evaluation and fine needle aspiration cytology (FNAC). Throughout this period screening performance indicators well within the national guidelines were achieved. In addition, recall for assessment rates fell from 12% to 3.4%, the benign-to-malignant biopsy ratio falling from 1:1 to 0.3:1, while the cancer detection rate of 7 per 1000 women screened was maintained. A progressive increase in diagnostic specificity was achieved while retaining cancer detection sensitivity. Overall, 60% of carcinomas were diagnosed by FNAC. Using the Nottingham Prognostic Index, 47% of cancers were in the good prognostic group, previously shown to correlate with a 10 year survival of 83%. These results are encouraging and suggest that a significant mortality benefit can be predicted for screen detected breast cancers. The adoption of a multidisciplinary triple assessment increases the specificity of the screening test without compromising sensitivity.

Mammography in the pre-operative assessment and post-operative surveillance of patients treated by excision and radiotherapy for primary breast cancer.

To evaluate the place of mammography in the selection of patients for excision and radiotherapy for primary breast cancer a detailed analysis of pre-operative mammograms was performed in (i) a study group of 37 patients who developed local recurrence; (ii) a matched control group with a median local recurrence free survival of 57 months. There were significantly more multifocal tumours in the study group. Tumours were significantly larger (P = 0.02) and closer to the nipple (P = 0.008) in the study group compared to the control group. Regular follow-up mammograms were available in 26 of the study group. Twenty-one patients had mammographic evidence of either residual or recurrent tumour. We conclude that pre-operative mammography is essential in the selection of patients for excision and radiotherapy. Following treatment, mammography is useful in detecting residual or recurrent disease.

Double contrast knee arthrography. Some new points of technique including the use of Dimer X.

A short review of the development of techniques in knee arthrography is given, together with a full account of the authors technique, including the use of a specially designed pad and a frame to facilitate radiography and a new method to demonstrate the cruciate ligaments. Side effects in a group of patients examined using Dimer X as the positive contrast medium are compared with those in a group of patients who were examined using Urografin 60%. Comparason of the radiological advantages of Dimer X examinations with Urografin 60% examinations has been made. A possible method to distinguish normal from damaged or degenerate tissues is suggested. The author concludes that Dimer X is the positive contrast medium of choice at the present time.

An evaluation of transmission spectroscopy (lightscanning) in the diagnosis of symptomatic breast lesions.

A prospective study of transmission spectroscopy (lightscanning) has been performed on 285 women presenting with symptomatic breast disease to one outpatient clinic. Of the 41 patients with histologically confirmed breast cancer lightscanning detected 36 (87.8%). In the study group 164 patients had both lightscans and mammography performed and, of the 30 biopsy-proven carcinomas in this group, lightscanning detected 26 (87%) and mammography 25 (83%). Lightscanning was positive in five of the six non-invasive breast cancers and in 13 of the 15 invasive carcinomas 2 cm or less in diameter. No carcinoma was misdiagnosed as benign when the results of both investigations were combined.

The subcutaneous reaction: A useful mammographic sign

The appearance of a subcutaneous reaction which may be observed on a mammogram in the presence of underlying pathology is described. When this sign was used as the sole indicator of malignancy in a series of 273 consecutive biopsied cases, a specificity of 96% and a positive predictive value of 89% was observed. Non-malignant cases, not in the series, are also presented and it is concluded that, in cases not investigated by Tru-cut needle biopsy or cyst aspiration and in the absence of infection or lymphoedema, malignancy should be considered a highly likely cause of a subcutaneous reaction.

Brian Stewart Worthington. 9 June 1938 — 9 December 2007

Brian Worthington was born into modest circumstances in Oldham and attended the local primary school, from which he moved to Hulme Grammar School, where he studied until he was 18 years of age. He was academically talented and attained the standard to enter university and indeed medical school with a scholarship to Guy’s Hospital in London. He graduated in physiology and medicine and was drawn towards radiology and in particular neuroradiology. He became a consultant for the Nottingham and Derby hospitals, but followed that with a university career as a Professor of Diagnostic Radiology at the University of Nottingham. He was a pioneer in clinical magnetic resonance imaging, for which he was honoured in many ways. Moreover, Brian Worthington was fascinated in all things Icelandic and became a fluent speaker in that language. With his wife Margaret and two sons, Andrew and Stuart, he maintained a close family relationship with his parents.

A personal view of the approach to breast cancer screening in the UK

emerged from these schemes probably mainly due to difficulties in case follow-up. This is an inevitable consequence when women with a suspected abnormal mammogram are referred elsewhere for assessment. Some of the schemes were well controlled, high-quality services, but others were far from this, with abysmal standards of mammography, and mammographic interpretation which was in some instances so poor as to be positively dangerous to the users of the schemes, with high numbers of false positives and, with possibly even worse effects, false negatives. One suspects that financial reward was a major objective of some of the organisations and individuals who initiated some of these early breast screening schemes. The NHS activity at this stage was limited to a few centres undertaking mammography of symptomatic women with only a handful of these involved with trials of breast screening. A multi-centre UK trial of early detection had been in progress since 1979, designed to test the relative values of various screening methods,’ but a report on the preliminary findings was not due until 1988. The public, lead by women’s organisations and supported by a sprinkling of enthusiastic professionals, was beginning to press for breast cancer screening as a part of the NHS. The health ministers, however, were rightly cautious. They, perhaps more than anyone, were aware of the less than optimal service which had resulted from the over-hasty, largely uncontrolled development of the Cervical Cancer Screening Programme, initiated on a wave of political enthusiasm as a result of women’s pressure groups.