Erik Thurfjell

Effect of estrogen and estrogen-progestin replacement regimens on mammographic breast parenchymal density.

PURPOSE Hormone replacement therapy (HRT) may increase the mammographic density with a possible reduction in the sensitivity or specificity. If so, the benefit of mammographic screening in women using HRT could be compromised. We evaluated the hypothesis that HRT regimens have differential effects on the mammographic density depending on treatment regimens or on age. PATIENTS AND METHODS Among 31,498 Swedish women who received mammographic screening, we selected 554 women who started HRT after the first examination and who were current users at the second, and 554 age-matched women who had never received HRT. Mammograms were examined in a blinded review. The changes in density between the two examinations, graded as moderate or weak reduction, no change, or weak, moderate, or substantial increase, were assessed. We studied four HRT regimens-estradiol compounds only, estradiol compounds cyclically or continuously combined with progestins, and weak estrogens-and used descriptive statistics and logistic regression to analyze the association between HRT and density change. RESULTS Density increased in 10% and 28% of women who received estradiol compounds with cyclically or continuously combined progestins, respectively, but in only 3% of unexposed women. Logistic regression analyses showed an elevated risk of a density increase (relative risk [RR] = 3.6; 95% confidence interval [CI], 1.6 to 7.7) in women who received cyclically combined regimens or continuously combined regimens (RR = 12.4; 95% CI, 6.3 to 24.4) compared with unexposed women. Women > or = 50 years of age had even stronger associations; RRs in women on estradiol only, the cyclically combined and the continuously combined regimens were 32.2 (95% CI, 3.9 to 267.5), 21.9 (95% CI, 1.9 to 251.5), and 176.9 (95% CI, 22.8 to 1,372.7), respectively. CONCLUSION HRT with estradiol-progestin regimens, especially continuously combined, may increase the mammographic density in a substantial proportion of women.

Sociodemographic predictors of non-attendance at invitational mammography screening: a population-based register study (Sweden)

Objective: To investigate the role of sociodemographic factors in predicting mammography uptake in an outreach screening program. Methods: Linkage of data from a regional population-based mammography program with four Swedish nationwide registers: the Population and Housing Census of 1990, the Fertility Register, the Cancer Register, and the Cause of Death Register. We computed odds ratios (OR) and 95% confidence intervals (CI) for non-attendance by sociodemographic factors. Non-attendance was defined as failure to attend in response to the two most recent invitations. Results: Multivariate analyses among 4198 non-attenders and 38,972 attenders revealed that both childless and high-parity women were more likely to be non-attenders (OR = 1.8, 95% CI: 1.6–2.0 and OR = 2.2, 95% CI: 1.8–2.7, respectively). Women living without a partner were less likely to attend (OR = 1.7, 95% CI: 1.5–1.9), as were non-employed women (OR = 2.1, 95% CI: 1.9–2.3). Those renting an apartment were more likely to be non-attenders compared with home-owners (OR = 1.8, 95% CI: 1.6–2.0), and immigrants from non-Nordic countries were more than twice as likely to be non-attenders compared with Swedish-born women (OR = 2.4, 95% CI: 2.0–2.8). Conclusions: There are identifiable subgroups in which mammography utilization can be increased. Special attention should be paid to women who have never attended, childless women, and non-Nordic immigrants.

Predictors of non-attendance in a population-based mammography screening programme; socio-demographic factors and aspects of health behaviour

The aim of this study was to identify predictors of non-attendance in a population-based mammography-screening programme in central Sweden, on the basis of telephone interviews with 434 non-attendees and 515 attendees identified in a mammography register. Non-attendance was studied in relation to socio-demographic factors, indicators of general health behaviour, self-rated health and experience of cancer in others and own cancer or breast problems. Being single or being non-employed were the only important socio-demographic predictors of non-attendance. Non-attendance was more likely among women who never visited a dentist, had not visited a doctor in 5 years, had never used oral contraceptives or hormone replacement therapy, had never had cervical smear tests, never drank alcohol, smoked regularly, reported no breast cancer in family or friends or own breast problems. We conclude that socio-demographic factors alone do not appear to constitute strong predictors of non-attendance. General health behaviour and previous experience of cancer and breast disease seem to be more important factors. Our results suggest that in the setting of population-based outreach mammography programmes, previous contacts with the health care system and encouragement from health professionals represent determinants of attendance.

Hormone replacement therapy and the risk of breast cancer. Nested case‐control study in a cohort of Swedish women attending mammography screening

There is concern that hormone replacement therapy (HRT) increases the risk of breast cancer. We undertook a case‐control study of this risk relationship within a cohort of 40‐ to 74‐year‐old women in Uppsala County, Sweden, who participated in mammography screening. Incident cases of breast cancer were ascertained during 5 years of follow‐up. In all, 435 cases (87% invasive, 13% in situ cancers) were detected, 313 through screening and 122 through clinical diagnosis. As controls, 1,740 women were selected randomly. Information on risk factors and use of HRT was obtained through interviews before the start of follow‐up. Multivariate analyses revealed an increased risk among users of any type of HRT for more than 10 years, the odds ratio (OR) being 2.1 (95% confidence interval [CI] 1.1–4.0), as well as when restricting analyses to cases diagnosed through mammography screening. After stratification for compound type, risk estimates were apparently higher among women reporting estradiol–progestin combined treatment vs. estradiol or conjugated estrogens alone, with ORs for more than 10 years of intake being 2.4 (95% CI 0.7–8.6) and 1.3 (95% CI 0.5–3.7), respectively. Analyses through a model including both compound type and length of hormone intake confirmed a significant excess risk linked to treatment for more than 10 years, OR = 2.6 (95% CI 1.3–5.1). Our results indicate a moderately increased risk of breast cancer after many years of HRT and, hypothetically, a further enhancement of the risk with added progestins. Int. J. Cancer 72:758–761, 1997.

Sensitivity and specificity of computer-assisted breast cancer detection in mammography screening.

Purpose: To evaluate a system of computer-assisted diagnosis (CAD) in mammography. Material and Methods: A sample of 120 sets of two-view mammograms was examined by an expert screener, a screening radiologist, a clinical radiologist, and a CAD system. The screening and clinical radiologists examined the mammograms twice, first without and then with the help of CAD. The sample consisted of first-round screening films from a two-round population-based screening, and comprised: 32 women in whom breast cancer was detected at the first screening; 10 with cancer detected during the screening interval; 32 with cancer detected at the second screening; and 46 with normal mammograms at both screenings. Results: The expert screener, the screening radiologist, the clinical radiologist, and the CAD system detected respectively 44, 41, 34 and 37 cancers. Their respective specificities were 80%, 83%, 100% and 22%. With the help of CAD, the screening radiologist detected 1 additional cancer and the clinical radiologist detected 3; their respective specificities were 80% and 100%. Conclusion: The sensitivity of the CAD system was satisfactory. The two radiologists helped by CAD achieved a modest increase in sensitivity with unaffected specificity. However, the CAD system by itself had a very low specificity and it needs improvement before it can be useful in mammographic screening.

Mammographic finding as predictor of survival in 1-9 mm invasive breast cancers. worse prognosis for cases presenting as calcifications alone.

AbstractPurpose. To investigate breast cancer survival in small invasive breast cancers in relation to mammographic findings. Materials and methods. We investigated a consecutive series of 96 cases of 1–9mm small invasive breast cancers diagnosed 1988–1994. Median follow-up of the survivors was 7 years (range: 4.5–10.5). Mammographic findings were classified into rounded masses, spiculated masses, calcifications (casting or pleomorphic) and masses combined with calcifications. Lymph node status and histological malignancy grade were also evaluated. Eight year survival rate in breast cancer was estimated with the Kaplan–Meier method and risk of death with proportional-hazards regression. Results. 6/96 women died from breast cancer. 3/14 had calcifications alone, 2/56 with spiculated masses, 1/12 with rounded masses. 5/78 who died were node-negative cancers and 1/4 was node-positive. The survival rate for the whole group was 93%: 77% for the calcifications alone group, 95% for spiculated masses and 91% for rounded masses. The survival rate for the node-negative cancers was 92% compared to 75% for node-positive cancers. Calcifications alone (p=0.01) and node positivity (p=0.03) had each independent significant higher risk of death taking finding, node status and grade into account. Conclusion. Small invasive breast cancers mammographically presenting as casting or pleomorphic calcifications alone have a significantly worse prognosis than other types.

Local breast cancer recurrence caused by mammographically guided punctures.

PURPOSE To evaluate the risk of needle track seeding or tumor cell implantation as the cause of locally recurrent breast cancer after breast conserving surgery. MATERIAL AND METHODS We reviewed recurrences from a consecutive series of 303 clinically nonpalpable breast cancers treated with breast conserving surgery after pre-operative localization. The median mammographic follow-up was 5.4 years. The suspicion of seeding or implantation was based on the location of the recurrent lesion in comparison with the needle path in two orthogonal mammographic projections. Pre-operative percutaneous biopsies had been done in 71% (214/303) of the cases. Postoperative radiotherapy was administered to 82% (194/238) of the invasive cancers and to 28% (18/65) of the ductal cancers in situ (DCIS). RESULTS Locally recurrent cancer occurred in 11% (33/303) of the cases. Radiotherapy demonstrated a protective effect from relapse among invasive cancers but not for DCIS. Seeding or implantation was suspected in 3 recurrent invasive cancers which had not been subject to radiotherapy. The histopathological diagnosis of the primary cancer and the recurrent cancer were the same in these cases: adenoid cystic, mucinous and tubuloductal cancer. CONCLUSION Seeding or implantation was suspected as the cause of local recurrence in 7% (3/44) of the invasive cancers which did not receive radiotherapy.

Mammographically-Guided Fine Needle Aspiration in Differential Diagnosis of Cystic Versus Solid Rounded Masses Smaller than 2 cm Detected at Mammographic Screening

AbstractPurpose. To evaluate mammographically-guided fine needle aspiration (FNA) in the differential diagnosis of smaller cystic and solid rounded masses, detected at screening. Materials and methods. All mammographically-guided FNAs performed in a consecutive series of 5013 women recalled in a population-based screening programme were reviewed. FNA was done with a perforated compression plate in 369 masses and stereotactically in 259 masses. More than 3 years of mammographic follow-up were available for 267 cysts. Results from ultrasound examinations were available for a subset of 69 cysts. Results. A total of 344 rounded masses were diagnosed as benign cysts and 284 as solid masses. Surgical biopsy was performed in 75 masses. Two surgically biopsied masses proved to be cysts, one where the aspirate was misinterpreted as suspicious for mucinous cancer, and one where FNA failed to prove a cyst. In another case initially regarded as cyst, a rounded ductal cancer in situ was diagnosed 2 years later in the same location. Thus, among 267 masses diagnosed as benign cysts and followed up for 3 years, only one proved to be malignant. Ultrasound failed to visualise 35% (24/69) of smaller cysts. Conclusion. Mammographically-guided FNA is a valuable method to differentiate smaller cysts from solid rounded masses and hence to avoid unnecessary surgical biopsies.

Pneumocystography in nonpalpable breast cysts: effect on remission rate.

The purpose of the study was to evaluate the effect on remission rate after pneumocystography among nonpalpable cysts. A series of 206 nonpalpable cysts aspirated using the perforated compression plate technique was reviewed. The effect on remission was evaluated on mammograms obtained 1-3 years after the cyst aspiration. Logistic regression was used to compare the effect between those examined with pneumocystography (n=62) and those aspirated alone (n=144). The ratio of complete remission was 52% (32/62) with pneumocystography compared to 53% (76/144) without. In univariate analysis there was no association between pneumocystography and complete remission. However, complete emptying of the cyst was significantly associated with complete remission (OR = 1.85, 95%CI = 1.05-3.25). In a multivariate model, complete emptying without pneumocystography was significantly associated with complete remission (OR = 2.40, 95%CI = 1.14-5.02) but not complete emptying in combination with pneumocystography (OR = 0.84, 95%CI = 0.24-2.89). Pneumocystography showed a close to two-fold association with complete remission. However, this association was not statistically significant (OR = 1.92, 95%CI = 0.52-7.05). In conclusion, complete emptying of a nonpalpable cyst significantly increased the chance of complete remission when pneumocystography was not performed. Pneumocystography showed no significant effect on remission rate.

Book Review: Percutaneous Breast BiopsyPercutaneous Breast Biopsy. Edited by ParkerS. H. & JobeW. E.. Raven Press, New York1993. ISBN 07817-0010-8. Price: USD 94.50.

been performed. A 34% rate of gallbladder opacification in this study indicates that significant extrarenal excretion of ioxaglate takes place soon after the administration of contrast medium in patients with normal renal function, and that this phenomenon is of no pathologic importance. Our findings indicate that the contrast material is excreted into the hepatobiliary tract immediately after intraarterial administration of ioxaglate.