Lisa Kan

EFFECTS OF SOCIAL RELATIONSHIPS ON SURVIVAL FOR WOMEN WITH BREAST CANCER :A PROSPECTIVE STUDY

In this study we examine the relationship between a womans social contexts at the time of diagnosis and her chances of having survived breast cancer four years later. A cohort of 133 women were followed prospectively after initial diagnosis and treatment and data were obtained from a questionnaire mailed soon after diagnosis and from hospital charts. Using multivariate methods to examine predictors of survival, two clinical factors, pathologic nodal status and clinical stage of disease, were significantly associated with survival. In addition we found significant and independent effects on survival of: number of supportive friends, number of supportive persons, whether the woman worked, whether she was unmarried, the extent of contact with friends and the size of her social network. Thus, the womans social context, particularly contexts of friendship and work outside the home, are statistically important for survival. Using existing literature, further data analyses and interviews with some survivors, we speculate on the ways in which social contexts may influence survival and suggest research methods suitable to this question.

The prognostic significance of psychosocial factors in women with breast cancer

One hundred and thirty three recently diagnosed breast cancer patients completed a self-administered questionnaire which measured 16 psychosocial variables. After 4 years, three variables (expressive activities at home, extroversion, low anger) were significant prognostic factors for overall survival independent of clinical and other psychosocial factors; likewise three variables (expressive activities at home, expressive activities away from home, low cognitive disturbance) were significant independent prognostic factors for disease-free survival. These findings support the prognostic importance of the social emotional network.

Influence of delay to diagnosis on prognostic indicators of screen‐detected breast carcinoma

Although delay to diagnosis after a breast screening abnormality causes anxiety, its effect on prognosis is unknown.

Breast cancer mortality after screening mammography in British Columbia women

Mammographic screening is a proven method for the early detection of breast cancer. The authors analyzed the impact of service mammographic screening on breast cancer mortality among British Columbia women who volunteered to be screened by the Screening Mammography Program of British Columbia. A cohort of women having at least one mammographic screen by Screening Mammography Program of British Columbia between the ages of 40 and 79 in the period 1988–2003 was identified. All cases and deaths from breast cancer occurring in British Columbia were identified from the British Columbia Cancer Registry and linked to the screening cohort. Expected deaths from breast cancer in the cohort were calculated using incidence and survival rates for British Columbia women not in the cohort. Adjustment was made for age and socioeconomic status of their area of residence at time of diagnosis. The breast cancer mortality ratio was calculated by dividing observed by expected breast cancer deaths. The mortality ratio (95% confidence interval) was 0.60 (0.55, 0.65) for all ages combined (p < 0.0001). The mortality ratio in women aged 40–49 at first screening was 0.61 (0.52, 0.71), similar to that in women over 50 (p = 0.90). Exclusion of mortality associated with breast cancers diagnosed after age 50 in women starting screening in their 40s increased the mortality ratio to 0.63 (0.52, 0.77), but it remained statistically significant. Correction for self‐selection bias using estimates from the literature increased the mortality ratio for all ages to 0.76. Mammographic screening at all ages between 40 and 79 reduced subsequent mortality rates from breast cancer.

Primary cervical cancer screening with HPV testing compared with liquid-based cytology: results of round 1 of a randomised controlled trial – the HPV FOCAL Study

Background:Round 1 data of human papillomavirus (HPV) FOCAL, a three-arm, randomised trial, which aims to establish the efficacy of HPV DNA testing as a primary screen for cervical cancer, are presented.Methods:The three arms are: Control arm – liquid based cytology with atypical squamous cells of unknown significance (ASC-US) triage with hrHPV testing; Intervention Arm – hrHPV at entry with liquid-based cytology (LBC) triage of hrHPV positives, with exit screen at 4 years; Safety check arm – hrHPV at entry with LBC triage of hrHPV positives with exit screen at 2 years.Results:A total of 6154 women were randomised to the control arm and 12 494 to the HPV arms (intervention and safety check). In the HPV arm, the baseline cervical intraepithelial neoplasia (CIN)2+ and CIN3+ rate was 9.2/1000 (95%CI; 7.4, 10.9) and 4.8/1000 (95%CI; 3.6, 6.1), which increased to 16.1/1000 (95%CI 13.2, 18.9) for CIN2+ and to 8.0/1000 (95%CI; 5.9, 10.0) for CIN3+ after subsequent screening of HPV-DNA-positive/cytology-negative women. Detection rate in the control arm remained unchanged after subsequent screening of ASC-US-positive/hrHPV DNA-negative women at 11.0/1000 for CIN2+ and 5.0/1000 for CIN3+.Conclusion:After subsequent screening of women who were either hrHPV positive/cytology negative or ASC-US positive/HPV negative, women randomised to the HPV arms had increased CIN2+ detection compared with women randomised to the cytology arm.

A randomized controlled trial of Human Papillomavirus (HPV) testing for cervical cancer screening: trial design and preliminary results (HPV FOCAL Trial)

BackgroundIn the HPV FOCAL trial, we will establish the efficacy of hr-HPV DNA testing as a stand-alone screening test followed by liquid based cytology (LBC) triage of hr-HPV-positive women compared to LBC followed by hr-HPV triage with ≥ CIN3 as the outcome.Methods/DesignHPV-FOCAL is a randomized, controlled, three-armed study over a four year period conducted in British Columbia. It will recruit 33,000 women aged 25-65 through the provinces population based cervical cancer screening program. Control arm: LBC at entry and two years, and combined LBC and hr-HPV at four years among those with initial negative results and hr-HPV triage of ASCUS cases; Two Year Safety Check arm: hr-HPV at entry and LBC at two years in those with initial negative results with LBC triage of hr-HPV positives; Four Year Intervention Arm: hr-HPV at entry and combined hr-HPV and LBC at four years among those with initial negative results with LBC triage of hr-HPV positive casesDiscussionTo date, 6150 participants have a completed sample and epidemiologic questionnaire. Of the 2019 women enrolled in the control arm, 1908 (94.5%) were cytology negative. Women aged 25-29 had the highest rates of HSIL (1.4%). In the safety arm 92.2% of women were hr-HPV negative, with the highest rate of hr-HPV positivity found in 25-29 year old women (23.5%). Similar results were obtained in the intervention arm HPV FOCAL is the first randomized trial in North America to examine hr-HPV testing as the primary screen for cervical cancer within a population-based cervical cancer screening program.Trial RegistrationInternational Standard Randomised Controlled Trial Number Register, ISRCTN79347302

Prognosis, treatment, and recurrence of breast cancer for women attending or not attending the Screening Mammography Program of British Columbia

Breast cancer screening programs have been initiated in many countries in the past decade. To determine the impact of the Screening Mammography Program of British Columbia (SMPBC), disease and treatment outcomes for women with breast cancer diagnosed in BC between 1989 and 1996 were compared on the basis of attendance at the SMPBC. An SMPBC attender was a women diagnosed with breast cancer within three years of an SMPBC screen, regardless whether the cancer was detected as a result of that screen. Of the 13,636 women aged 40–89 years diagnosed with breast cancer in BC during the study period, 2,647 (19.4%) were SMPBC attenders. 73.5% of SMPBC attenders (N=1,946) and 74.2% of non-attenders (N=8,149) were referred to the BC Cancer Agency and had pathology, staging, treatment, and outcome information available. SMPBC attenders compared with non-attenders were more likely to have in situ disease alone, and those with invasive cancers had smaller tumors which were less likely to have grade III histology and less likely to have spread to axillary lymph nodes (all P<0.001). SMPBC attenders were more likely to be treated with breast conservation and less likely to receive adjuvant chemotherapy or tamoxifen (P < 0.001). Log-rank tests showed local (P = 0.017), distant (P < 0.001), and overall (P < 0.001) disease-free survival were better for SMPBC attenders. These favorable surrogate endpoints suggest that the benefits of breast screening as demonstrated by randomized trials can be translated into community practice by an organized breast screening program.

Ten years of breast screening in the Screening Mammography Program of British Columbia, 1988–97

Objectives To evaluate 10 year outcomes of the Screening Mammography Program of British Columbia (SMPBC) and determine if breast screening targets were being achieved among women aged 40–80+ years. Setting Organised breast screening programme in British Columbia, Canada. Methods Rates of participation, abnormal referral, cancer detection, and interval cancer were calculated for asymptomatic women receiving an SMPBC mammography from 1988–97. Results 895 849 screening mammographies were provided to 335 433 women. 51.3% of women were age 50–69 years. Abnormalities were identified on 57 454 screens (6.4%) from which 3304 cancers were detected. Abnormal call rates were higher on first (9.8%), compared with subsequent screens (4.4%) and declined with age: 7.7% at age < 40 to 5.4% for age 70–79 years. Cancer detection rates were higher on first (5.0 per 1000) compared with subsequent screens (2.8 per 1000) and increased smoothly with age from 1.4 to 8.2 per 1000 from age < 40 to age 80 years and older. Twenty per cent of cancers were non-invasive. The median size of invasive cancers was 14 mm and 81% had no axillary lymph node metastases. The 12 month interval cancer rate was 0.6 per 1000 and did not vary significantly with age or screening history. The prevalence to expected incidence ratio was 3.1 for women age 50–79 years. Conclusion Across a broad range of ages, surrogate indices of screening mammography success have been achieved in a population based, North American, organised breast cancer screening programme.

Screening mammography in British Columbia: 1988–1993

Breast carcinoma continues to be the most common cause of death due to malignancy for women in Canada. The Screening Mammography Program of British Columbia, the first provincial screening program in Canada, was established in 1988 with funding from the Ministry of Health to diagnose the disease as early as possible. The program has grown rapidly, increasing from 7,100 examinations in a pilot project in 1988 to 89,390 examinations between April 1, 1992 and March 31, 1993 for a cumulative total of 201,937 examinations of 128,325 women, and it now offers free screening mammography throughout the province. The program has maintained quality control standards and low cost per mammogram while developing different operational models for the differing requirements of the various areas of the province. Similar proportions of women older or younger than age 50 have favourable characteristics such as small size of tumor (median: 15 to 16 mm) and negative lymph nodes (86% to 89%).

Risk of invasive cervical cancer after pap smears: the protective effect of multiple negatives

Objective: To determine the relationship between the number of initial negative Pap smears and risk of subsequent cervical cancer. Design: A cohort study was conducted using data from the British Columbia Cervical Cancer Screening Program and British Columbia CancerRegistry. The analysis used a random sample (1%) of women aged 20–69 with Pap smears and all cases of invasive cervical cancer diagnosed between 1994 and 1999. Each negative screen defined the beginning of a screening interval and intervals longer than five years were truncated. Thefollowing variables were created for each interval: age at the beginning of the interval, interval length, previous cytological abnormality, previous cervical procedure and number of preceding consecutive negative screens. The relationship between these variables and risk of squamous cervicalcancer was determined using survival analysis methods. Results: A total of 388 cases of invasive cervical cancer (252 squamous) were included in the study from a study population of over 3.3 million Pap smears. The risk of invasive squamous cancer increased with time since the lastnegative screen, history of cytological abnormality and history of cervical therapeutic procedure. Risk was not significantly related to age (P=0.2) but was highest in women aged 30–49. Multiple consecutive negative pap smears were associated with reduced risk in women with ahistory of moderate atypia (P<0.0001), but not in women without a history (P=0.4). Conclusions: Multiple consecutive negative cytology was not associated with reduced risk of invasive cervical cancer in women with no history of cytological abnormality.