Francesc Macià

Cumulative false positive recall rate and association with participant related factors in a population based breast cancer screening programme

Study objective: To investigate the cumulative false positive recall rate throughout the period of participation in a population based breast cancer screening programme and to examine its association with women related factors. Design: Analysis of a database to estimate the cumulative false positive recall rate after 10 biennial mammograms in a cohort of women. Cumulative risk after 10 rounds was calculated by projecting forward the information available on the four rounds. Logistic regression was used to evaluate the association between the cumulative risk of false positive recall and women related factors. Setting: Population based breast cancer screening programme in Barcelona City (Spain). Participants: 8502 women aged 50–69 years who participated in four consecutive screening rounds. Eligible women had received a mammogram in the first screening round between 1 December 1995 and 31 December 1996. Main results: The false positive recall rate in the first screening for women who entered the screening programme at the age of 50–51 years was assessed at 10.6% (95% CI 8.9, 12.3). In the second screening this risk decreased to 3.8% (95% CI 2.7, 4.9) and remained almost constant in subsequent rounds. After 10 mammograms, the cumulative false positive recall rate was estimated at 32.4% (95% CI 29.7, 35.1). The factors associated with a higher cumulative risk of false positive recall were: previous benign breast disease (OR = 8.48; CI 7.39, 9.73), perimenopausal status (OR = 1.62; CI 1.12, 2.34), body mass index above 27.3 (OR = 1.17; CI 1.02, 1.34), and age 50–54 years (OR = 1.15; CI 1.00, 1.31). Conclusions: One third of women could have at least one false positive recall over 10 biennial screens. Women participating in screening programmes should be informed about this risk, especially those with associated factors.

Implementation of Digital Mammography in a Population-based Breast Cancer Screening Program: Effect of Screening Round on Recall Rate and Cancer Detection

PURPOSE To compare the effect of the introduction of digital mammography on the recall rate, detection rate, false-positive rate, and rates of invasive procedures performed in the first and successive rounds of a population-based breast cancer screening program with double reading in Barcelona, Spain. MATERIALS AND METHODS The study was approved by the ethics committee; informed consent was not required. Data were compared from 12,958 women aged 50-69 years old who participated in a screening round before the introduction of digital mammography (screen-film mammography group) with data from 6074 women who participated in another screening round after the introduction of digital mammography (digital mammography group). Groups were compared for recall rate and detection rate stratified according to first or successive screening rounds, and logistic regression analysis was performed. RESULTS Overall recall rates for screen-film and digital mammography groups were 5.5% and 4.2%, respectively (P < .001). The recall rate was higher in the first screening round (11.5% and 11.1% in the screen-film mammography and digital mammography groups, respectively; P = .68) than in successive screening rounds (3.6% and 2.4% in the screen-film mammography and digital mammography groups, respectively; P < .001). The main factors related to the risk of recall were screen-film mammography group (odds ratio = 1.28), first screening round (odds ratio = 3.53), menopausal status (odds ratio = 0.62), and history of personal benign breast disease (odds ratio = 2.26). No significant differences were found in the cancer detection rate between groups. In the first screening round, this rate was higher in the digital than in the screen-film mammography group (1.1% and 0.4%, respectively; P = .009). The invasive test rate was 2.6% and 1.3% in the screen-film and digital mammography groups, respectively (P < .001) and was lower with digital mammography than with screen-film mammography in both the first and successive screening rounds. CONCLUSION Digital mammography may reduce the adverse effects of screening programs if this technique is confirmed to have the same diagnostic accuracy as screen-film mammography.

Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer

BackgroundColorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment.MethodsThis is a cross-sectional study of all incident cases of symptomatic CRC during 2006–2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients’ interviews and reviews of primary care and hospital clinical records. Measurements: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables.ResultsSymptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment.ConclusionsResults show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.

Trends in hormone therapy use before and after publication of the Women's Health Initiative trial: 10 years of follow-up

Objective: The aim of this study was to assess the impact of the scientific evidence reported by Womens Health Initiative (WHI) trial on hormone therapy (HT) use in a 10-year follow-up retrospective cohort of women participating in a breast cancer screening program. Methods: Between 1998 and 2007, a retrospective cohort of participants in a population-based breast cancer screening program in the city of Barcelona (Catalonia, Spain) was assessed. The study population consisted of 50,918 women. Trends in current HT use and the annual rate of new users were analyzed by age group. Results: From 1998, successive annual increases were found in the prevalence levels of HT use in all age groups. In 2002, the prevalence peaked at 11% in 50- to 54-year-olds and at 10.1% in 55- to 59-year-olds, followed by a sudden reversal and a progressive decrease. In 2007, 5 years after the publication of the WHI trial, the HT use decreased by 89.1% in 50- to 54-year-olds, 87.5% in 55- to 59-year-olds, 84.6% in 60- to 64-year-olds, and 66.0% in 65- to 69-year-olds. The percentage of new users also fell substantially after 2002. Conclusions: HT use decreased during the 5 years after the publication of the WHI. This reduction was especially marked in the first 2 years, when the decrease in new treatments exceeded the number of continuations. In the following 3 years, the decrease was approximately equal in both groups.

Multiple independent primary cancers do not adversely affect survival of the lung cancer patient

OBJECTIVE Diagnosis of multiple independent primary cancers is increasing in many settings. Objectives of this study were to analyze clinical characteristics, organ location, and prognosis associated with the presentation of multiple independent primaries when a lung cancer is involved. METHODS We analyzed all patients with a histology-proven diagnosis of lung cancer registered from January 1990 to December 2004 at the Tumor Registry of the Hospital del Mar, Barcelona. We compared 1686 patients presenting a lung cancer as unique primary versus 228 patients presenting a lung cancer and another independent primary. Cofactors included age, sex, smoking habit, lung cancer histology and stage, type and intention of treatment, organ location of the other cancer, and survival from the date of lung cancer diagnosis. RESULTS Seventy percent of the other cancers were tobacco-related. Independent risk factors of cancer multiplicity were smoking (OR: 3.99; 95% CI: 1.4-11.2), lung cancer stages I (OR: 1.84; 95% CI: 1.2-2.9) and II (OR: 3.25; 95% CI: 1.7-6.3), and older age (OR: 3.11; 95% CI: 1.9-5.1). Once adjusted by age and sex, the main determinant of survival was lung cancer stage rather than cancer multiplicity. However, patients with multiple cancers presented a slightly better survival than patients with a lung cancer as unique primary. When analyzed by subgroups, survival was higher in patients with the lung cancer first (HR: 0.44; 95% CI: 0.24-0.80), and in patients with the other cancer first (HR: 0.80; 95% CI: 0.65-0.99), but it was not different in the patients with a lung cancer and a synchronous other cancer (HR: 0.80; 95% CI: 0.52-1.15). CONCLUSIONS The risk of developing a second independent cancer was strongly associated with tobacco smoking. Cancer multiplicity was not associated with a worse prognosis. As a consequence, when a first primary tobacco-related cancer is treated with curative intention, patients should be closely followed up for an early diagnosis of a possible new independent cancer; and if diagnosed, treatment to cure should be considered as the first option.

Participation in a colorectal cancer screening programme: influence of the method of contacting the target population

We assessed the effect of two different methods of contacting the target population on the rate of participation in a colorectal cancer screening programme. All individuals aged between 50 and 74 years enlisted in one primary health care centre in Barcelona (Spain) were included in a prospective randomized controlled trial. An invitation letter signed by a doctor together with two containers for faecal sample collection were sent by post to subjects in the ‘standard’ group (n  = 1060), while subjects in the ‘study’ group (direct contact, n  = 965) were visited by a trained non-health professional who supplied them with the same documentation as the standard group. The screening test consisted of an immunological method for the detection of faecal blood which does not require any prior specific dietary measures. Specimens were collected on two successive days. A significantly higher participation was observed in the study group (557/965, 57.7%) compared with the standard group (388/1060, 36.5%, P  < 0.005). Specimen collection correctness was also higher in the study group (419/557, 75.1%) compared with the standard group (262/388, 67.5%, P  < 0.014). There were no differences in terms of either age group or sex for the participation, nor for degree of correctness of specimen collection. Participation and specimen collection can be raised in colorectal cancer screening programmes by means of an invitation made through direct contact by a suitably trained non-health professional.

Effect of false-positive results on reattendance at breast cancer screening programmes in Spain.

BACKGROUND Mammography is the only breast screening method, we are aware of today, which is able to reduce mortality from breast cancer. Nevertheless, this procedure carries an inherent risk of false-positive screening mammogram. The association between these results and reattendance at the next scheduled screening mammogram is controversial. The aim of this study was to examine the effect of a false-positive screening mammogram and womens characteristics on reattendance in eight regional population-based breast cancer screening programmes in Spain. METHODS This study included 1 383 032 women aged 44-67 years who were initially screened for breast cancer between 1990 and 2004. To investigate factors associated with reattendance, logistic regression models were used. RESULTS The mean age of women at first screening was 53.6 years (SD = 6.1 years). Of 120 800 women with a false-positive screening mammogram, 78.3% returned for a subsequent screening mammogram compared with 81.9% of those with a negative result (P < 0.001). Multivariate analysis showed that women with a false-positive result at first screening mammogram were less likely to reattend (OR = 0.71; 95% CI 0.70-0.73) and that the likelihood was lower in those who had undergone invasive additional tests (OR = 0.56; 95% CI 0.53-0.59). CONCLUSION A false-positive screening mammogram in the first screening negatively affected attendance at the subsequent screening. The results of this study could be useful to improve the screening process and to increase womens compliance.

Cost-effectiveness of early detection of breast cancer in Catalonia (Spain)

BackgroundBreast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Early detection has contributed to the observed decline in BC mortality. However, there is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, follow-up and advanced care.MethodsWe used a probabilistic model to estimate the effect and costs over time of each scenario. The effect was measured as years of life (YL), quality-adjusted life years (QALY), and lives extended (LE). Costs of screening and treatment were obtained from the Early Detection Program and hospital databases of the IMAS-Hospital del Mar in Barcelona. The incremental cost-effectiveness ratio (ICER) was used to compare the relative costs and outcomes of different scenarios.ResultsStrategies that start at ages 40 or 45 and end at 69 predominate when the effect is measured as YL or QALYs. Biennial strategies 50-69, 45-69 or annual 45-69, 40-69 and 40-74 were selected as cost-effective for both effect measures (YL or QALYs). The ICER increases considerably when moving from biennial to annual scenarios. Moving from no screening to biennial 50-69 years represented an ICER of 4,469€ per QALY.ConclusionsA reduced number of screening strategies have been selected for consideration by researchers, decision makers and policy planners. Mathematical models are useful to assess the impact and costs of BC screening in a specific geographical area.

Utilization of screening mammography as a preventive practice prior to initiating a population-based breast cancer screening program

Factors associated with the level of utilization of screening mammography as a preventive practice were analyzed prior to initiating a population-based breast cancer screening program. A questionnaire was used to collect information about screening mammography utilization during the last 4 years among women invited to enroll in the program. Sociodemographic and health factors, and health services utilization were studied. A screening mammography in the last 4 years had been performed on 59.3% of the 8867 women interviewed. The utilization of mammography was higher among women who were younger, had a higher education level, or had previous visits to a physician (P < 0.001). The variables more strongly associated with use of screening mammography were: visit to a gynecologist and performance of a pap smear. Also associated with the utilization of screening mammography were: personal history of breast pathology, family history of breast cancer, breast self-examination, and recent visit to a general practitioner. Self-perceived health presented an inverse relation with screening mammography use (P < 0.001). The use of screening mammography appears to have increased in recent years, although inequalities persist which the breast cancer screening programs help to modulate. Mammographic frequency only would be deemed appropriate by the European guidelines in fewer than one-half of the cases.

Age differences in presentation, diagnosis pathway and management of colorectal cancer

BACKGROUND The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.