Sirpa Heinävaara

Organised mammography screening reduces breast cancer mortality : A cohort study from Finland

We evaluated the effectiveness and the efficacy of population‐based mammography programme in Finland, and explored associations between the screening performance and the screening efficacy. The main outcome, incidence‐based mortality from breast cancer, was estimated by invitation, participation, age at death, and screening centres categorised by recall rates. The study was based on an individual followup of screening invitees and participants from 1992 to 2003. The coverage of screening invitations was 95% among 50–59 years old women, and 20–40% among women aged 60–69 years. We compared observed deaths from breast cancer to expected breast cancer deaths without screening in ages 50–69 at death. The observed deaths were obtained from a cohort of individual invitees (n = 361,848). The expected deaths were defined by modelling breast cancer mortality from 1974 to 1985 and 1992 to 2003 at population level. The population data were derived from the same municipalities (n = 260) that were incorporated into the cohort. The breast cancer mortality among the invited women was reduced by 22% (relative risk 0.78, 95% confidence interval 0.70–0.87). After adjusting for the self‐selection, the efficacy among the participants was 28% (0.72,0.56–0.88). No clear association between the recall rates and the screening efficacy was observed. The organised mammography screening in Finland is effective. The relationship between the estimates of process and outcome of mammography is not yet straightforward: effectiveness and efficacy remain the best estimates for evaluating the success of mammography screening.

Effects of different phases of an invitational screening program on breast cancer incidence

The aim of this study was to quantify the effects of separate phases of an invitational screening program on breast cancer incidence at different ages. Our database included detailed municipality‐specific information about invitations for mass‐screening for breast cancer in 267 Finnish municipalities from time period 1987–2001. The age range was 50–74. For this study, the program was divided into 7 separate phases, and those that had not been invited served as a baseline. The incidence rate was modeled using Poisson regression. To study the differences between age groups within each program phase, an interaction term between age group and phase of screening was included in the model. The modeling was done separately for localized breast cancers, nonlocalized breast cancers and all stages combined. For localized cancers, the risk compared to the noninvited increased during the first years of the 2‐year screening rounds in all age groups, and declined below the baseline during the second years. This effect was larger during the first round compared to the subsequent ones. In nonlocalized cancers, a clear incidence peak was detected only during the first year of the first round. A decreasing post screening effect was detected in nonlocalized cancers in women aged 60–69, but not in localized cancers. Cumulating over ages 50–74, extra incidence caused by regular screening in localized cancers was 5.2% if the program was continued up to age 59, and 28.0% if it continued up to age 69. Corresponding figures for nonlocalized cancers were decreases of 19.8% and 20.9%, respectively.

Adverse Obstetric Outcomes Among Early-Onset Cancer Survivors in Finland.

OBJECTIVE: To evaluate risk of adverse obstetric outcomes and operative deliveries in female cancer survivors (diagnosed younger than 35 years of age) compared with female siblings of survivors. METHODS: Nationwide cancer and birth registries were merged to identify 1,800 first postdiagnosis deliveries of female cancer survivors and 7,137 first deliveries of female siblings between January 1987 and December 2013. Multiple unconditional logistic regression models were used to estimate the risk for adverse obstetric outcomes and operative deliveries adjusting for maternal age, year of delivery, gestational age, and smoking. RESULTS: We found a significantly elevated risk for induction of labor, 19.1% in survivors and 15.6% in siblings (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.02–1.35) and cesarean delivery, 23.6% in survivors and 18.6% in siblings (OR 1.15, 95% CI 1.01–1.31) among cancer survivors compared with female siblings. The risks of instrumental vaginal delivery, malpresentation, placental pathologies, and postpartum hemorrhage were not, however, elevated among cancer survivors. The highest risks of adverse obstetric outcomes were seen among women treated in their childhood (aged 0–14 years). CONCLUSION: Cancer survivors have a small but statistically increased risk for induction of labor and cesarean delivery compared with siblings without a history of cancer. Our findings indicate that pregnancies in cancer survivors are typically uncomplicated and cancer survivors should not be discouraged to have children after their cancer is cured. LEVEL OF EVIDENCE: II

Impact of organized and opportunistic Pap testing on the risk of cervical cancer in young women – A case-control study from Finland

OBJECTIVEnEffectiveness of organized cervical cancer screening has been shown in several studies. However, screening among women aged <25years has been suggested to have little or no impact on the risk of cervical cancer. Also the significance of opportunistic testing in preventing cervical cancer is unclear. The aim of this study was to clarify the effect of opportunistic testing and organized screening on the risk of cervical cancer among young Finnish women.nnnMETHODSnIn the Finnish Cancer Registry there were 284 cervical cancer cases diagnosed and tested below the age of 40 in 2004-2009. Screening histories and data on opportunistic testing for these women and their 1698 age-matched controls were derived from databases of the Mass Screening Registry and The National Institute for Health and Welfare from 1997 onward. ORs and 95% CIs for the association of cervical cancer diagnosis and participation in organized screening and opportunistic testing were estimated using unconditional logistic regression. Results were corrected for self-selection bias and attendance rate.nnnRESULTSnAmong women aged under 25, OR of cervical cancer for any Pap test taken 0.5-5.5years before diagnosis was 1.25 (95% CI 0.46-3.43). Attending only organized screening at age 25-39 resulted in OR 0.52 (0.36-0.77), attending only opportunistic testing in OR 0.86 (0.60-1.25) and attending both in OR 0.48 (0.29-0.79).nnnCONCLUSIONnOpportunistic testing showed no clear additional benefit on preventing cervical cancer. The study also supports findings on a smaller effect of screening in younger age groups.

Lifestyle in population-based colorectal cancer screening over 2-year follow-up

BackgroundnColorectal cancer (CRC) screening may cause changes in health-related lifestyle. In 2010, Finnish Mass Screening Registry began a study on psychosocial effects of CRC screening. This article examines whether there are differential developments in self-reported lifestyle at ages 59-61 years among CRC screening invitees and non-contacted controls.nnnMethodsnA population-based random sample of 10 648 Finnish adults born in 1951 and living in the municipalities voluntary involved in the CRC screening programme were sent a lifestyle questionnaire in 2010. In 2011, the cohort was randomised (1 : 1) for their first ever CRC screening at age 60 or for controls. The questionnaires were repeated in 2012 for all. From both survey rounds, 2508 pairs of completed questionnaires were available for analysis from the screening group and 2387 from the control group. The outcome was 2-year change in total lifestyle index of CRC risk factors (diet, physical activity, body mass index, alcohol consumption and smoking).nnnResultsnTotal lifestyle index decreased throughout the follow-up in both the screening group [odds ratio (OR) = 0.80, 95% confidence interval (CI) 0.72-0.90] and in the control group (OR = 0.80, CI 0.71-0.90) indicating no difference in lifestyle changes between groups. There was also no significant difference by screening participation: the change in score was similar in those participating screening (OR 0.81, CI 0.72-0.92) and in those invited, but not participating (OR 0.75, CI 0.55-1.03).nnnConclusionnPresent study found no unfavourable changes in total lifestyle in the studied age group due to CRC screening. Results are reassuring from the point of view of CRC screening evaluation.

Risk factors for preterm delivery among early onset cancer survivors: A Finnish register-based study: Pregnancy Related Risks in Cancer Survivors

Previous studies have shown an elevated risk for preterm delivery among early onset cancer survivors. Whether the preterm delivery starts spontaneously, due to possible uterine damage because of cancer treatment, or is induced due to maternal conditions is unclear. Our aim was to assess pregnancy related conditions in female cancer survivors possibly underlying the elevated risk for preterm labor. Nationwide cancer and birth registries were merged to identify 1,753 first deliveries of cancer survivors (diagnosed below 40 years of age) and 5,123 first deliveries of matched female comparison subjects between January 1991 and December 2013. Conditional logistic regression models were used to estimate the risk for pregnancy related conditions adjusting for maternal age, gestational age and smoking. We found an overall increased risk for hospitalization during pregnancy (OR 1.45, 95% CI 1.25–1.68), intrahepatic cholestasis (OR 2.86, 95% CI 1.09–7.49), fear of childbirth (OR 2.25, 95% CI 1.31–3.85) and mental disorders and diseases of the nervous system complicating pregnancy and labor (OR 5.89, 95% CI 2.31–15.00). Among survivors, 129 (7.4%) delivered preterm compared to 268 (5.2%) comparisons subjects (p = 0.004). We found a statistically significant increased risk for preterm delivery among cancer survivors with vaginal bleeding (OR 1.35, 95% CI 1.07–1.71) and pre‐eclampsia (1.35, 95% CI 1.06–1.72) compared to comparison subjects with the same condition. Health professionals treating these women should be aware of these risks. In general, however, our results are reassuring when it comes to pregnancies among cancer survivors.

The effect of colorectal cancer screening on health status in a survey study

Abstract Background: Colorectal cancer (CRC) screening has been found to reduce mortality from CRC but it may have adverse effects on other aspects of health. Our aim was to evaluate the effect of CRC screening on overall health status among men and women within a randomized health-services study in Finland. Material and methods: A random sample of 10,648 men and women born in 1951 received a questionnaire on health and lifestyle. They were randomized for CRC screening or controls (1:1) in 2011 (Nu2009=u200910,271). The current study population consisted of those who responded to the questionnaire both before and after screening (nu2009=u20094895). Self-rated health (SRH), perceived healthiness of diet and perceived physical fitness were used to determine health status, and assessed with logistic and ordered logistic models using calendar time (2010, 2012), screening randomization and demographic characteristics as covariates. Results: SRH, healthiness of diet and physical fitness improved over time (OR 1.32, CI 1.17–1.48, OR 1.23, CI 1.08–1.41 and OR 1.44, CI 1.28–1.60, respectively). Compared to non-invited controls, CRC screening invitation had no effect on these measures (OR 0.91, CI 0.74–1.12, OR 0.95, CI 0.75–1.20, and OR 1.09, CI 0.87–1.37, respectively). Women reported better health status than men. However, among those who attended screening, women reported weaker, and men better health status than the respective controls. Conclusions: CRC screening did not have any effect on health status measured using self-rated health, healthiness of diet, and physical fitness. Thus, screening for colorectal cancer can be recommended as a health policy.

Lifestyle effects of colorectal cancer screening. Population-based survey study in FinlandSanni Helander

S Helander, S Heinävaara, T Sarkeala, N Malila Finnish Cancer Registry, Helsinki, Finland Contact: sanni.helander@cancer.fi Background The European cancer screening guidelines recommend colorectal cancer (CRC) screening for 50-74-year-olds. CRC mortality can be reduced with screening, but it is yet unclear if CRC screening affects various lifestyle related factors. Due to population-level nature of screening, even minor adverse effects in health related lifestyle might have relevance for public health. A national programme for CRC screening with repeated faecal occult blood (FOB) testing followed by colonoscopy for test positives has been running in Finland since 2004. Our aim is to clarify, if screening is introducing harmful effects on colorectal cancer risk related life style, thus reducing the potential benefit of an otherwise feasible screening programme. Methods A population-based random sample of 10648 Finnish adults born in 1951 living in the municipalities voluntary involved in CRC screening programme were sent a lifestyle questionnaire in 2010. In 2011, the 60-year old cohort was independently randomised (1:1) for their first ever CRC screening (invited) or control group (not contacted). The questionnaires were repeated in 2012 for all. From both survey rounds, 2508 pairs of completed questionnaires were available for analysis from the screening group and 2387 from the control group. The outcome was 2-year change in total lifestyle score of CRC risk related lifestyle factors (smoking, alcohol consumption, physical activity, diet and BMI). Results Preliminary results indicate that total lifestyle scores improved likewise in the screening group and in controls suggesting favourable changes for CRC risk in both groups. There was no difference by participation, either: the change in score did not differ in those participating screening compared to those invited, but not participated screening. Conclusions Present study found no unfavourable changes in total lifestyle in the studied age group after CRC screening. However, life style counselling could be included in screening setting.