is the best approach to reducing mortality and mor- bidity. Like many jurisdictions, Quebec has estab- lished a structured cancerscreeningprogram. The program, started in 1998, is known as the Programme québécois de dépistage du cancer du sein (Quebecbreastcancerscreeningprogram [QBCSP]). This pro- gram is supported by a specific computer system for invitation and reminder letters, data collection, and mammography reports. Women aged 50 to 69 years are invited for systematic screening mammograms every 2 years; names and contact information are provided by the Quebec public health insurance plan. Mammography is done in designated screening cen- tres; following abnormal results, additional investi- gations are provided by designated screening centres or designated referral centres that must meet quality control standards. The program aims to reach and maintain a 70% participation rate. 2 However, since
We observed some intriguing associations with HER2- positive breastcancer. The effect of pregnancies and age at first birth were similar for the HER2-positive subtype and luminal cancer. Also, age at menopause was strongly associated with increased risk only of the HER2-positive subtype. Further, we observed a positive trend of associ- ation between age at menopause and the luminal B-like HER2-positive subtype. These results might imply that there are hormonal mechanisms involved in the expres- sion of the HER2 protein. On the other hand, exogenous hormone use (EPT) was not associated with this sub- type, suggesting that perhaps only some hormonal mechanisms play a role in HER2-positive subtypes. The contrasting results between the luminal-like subtypes and triple-negative breastcancer are also consistent with previous literature. Hormonal factors have a stronger ef- fect on ER+ PR+ tumors, which suggests that the etiology of triple-negative cancer is different from that of the luminal subtypes. Specifically, this suggests that triple-negative tumors may not be as easily prevented hormonally.
Organized breastcancerscreening programs ensure that eligible women have regular access to high quality mammography screening in accordance with Canadian guidelines. Since 2008, the New Brunswick BreastCancerScreening Services (NBBCSS) program has been under the leadership of the New Brunswick Cancer Network (NBCN). The monitoring and evaluation of the NBBCSS program provides an opportunity for stakeholders to understand the impact of early detection on reducing morbidity and mortality from breastcancer. This report provides an overview of how well the program is achieving these goals, as well as identifying potential areas of opportunity for program enhancement. In this report, the recommended performance indicators have been analyzed at both Provincial and Health Zone levels. The Geographic Information Systems (GIS) has also been used to interpret and visualize the results across different geographic areas in the province.
The Best Chance Network (BCN), one of the first funded programs through NBCCEDP, was established in SC in 1991. The program provides health resources and services to all 46 counties in SC. Screening services offered through the BCN include mammograms, clinical breast exams, pap tests, pelvic exams, and human papillomavirus tests. Other services include diagnostic testing for women with abnormal screening results, support services with patient navigation, referral for treatment, and community education on breast and cervical cancer. Since the BCN’s inception, the program has provided breast and cervical cancer screenings to more than 11,755 women and 178,162 mammograms (South Carolina Department of Health and Environmental Control, 2016). In addition, the BCN program has diagnosed more than 1,800 breast cancers and 3,400 cervical cancers since 1991 (South Carolina Department of Health and Environmental Control, 2017). The appropriation of additional funding from the SC State Legislature in years 2015 and 2016 has enabled BCN to increase services and expand eligibility criteria, which allows more women to be screened (South Carolina Department of Health and Environmental Control, 2017). Best Chance is a resonant resource that moderates the financial barrier to early detection and partners with organizations to extend assistance to address low-income populations.
Some measures of screeningprogram performance are important for quality control, but are not direct measures of the effectiveness of the program. For example, overall program sensitivity is an important indicator of screening test sensitivity and of outcomes The proposed framework assesses screening effectiveness in the era of personalised medicine, allows review of multiple factors that may together warrant change, and gives full, evidence-based consideration of the benefits, harms and costs of various approaches to breastcancerscreening. To be effective, the framework requires a coordinated approach to generating the evidence required for policy makers, with time to prepare appropriate health services.
In addition to barriers such as geography, reasons for lower adherence to cancerscreening for First Nations populations may include less knowledge about cancerscreening, unfavorable attitudes and behaviors toward the healthcare system and a lack of integrated cancerscreening recruitment in existing health care . Integrating better cancerscreening education into existing healthcare services to increase recruitment and participation in cancerscreening among First Nations people may be a helpful solution to increase cancerscreening participation as a whole . Ontario has organized cancerscreening programs for breast, cervical and colorectal cancers. In Northwestern Ontario a mobile coach travels throughout the region, providing all three screening modalities, therefore minimizing travel for many clients. However, it cannot reach all First Nations communities. While access to convenient screening is not the only relevant factor affecting screening rates, it is a factor that could be modified.
to other literature, especially international data. This is due to the NHS’s unique current mammography regime of screening every 3 years and the fact that some other developed coun- tries are yet to implement a breastcancerscreeningprogram. Overall, results are consistent with the existing published data; however, the most robust economic analysis data from the UK were used to conduct the analysis, meaning results were likely to be similar to these studies, making comparison weak. Five systematic reviews of economic evaluations were analyzed for their congruence to the results in this report from Organization for Economic Cooperation and Development (OECD) countries. One key article described a systematic review of all current economic evaluations for breastcancerscreening. Although it focused on annual mammography, ICERs calculated in this report are congruent with this review’s results. However, higher thresholds were utilized to conduct analysis (USD100,000/£71,000), and wide-ranging ICER results were also obtained. It is important to highlight that this review focused on an annual mammography screen- ing program in a private health care system, meaning both financial costs and QALY data may be significantly different.
Despite these improvements, a major problem that arises if the case-control study is conducted within the context of a population screeningprogram is that women who do not participate in screening generally have a poorer outcome [14-17] for reasons that are not related to screening, thus inducing an observed lesser exposure to screening among the cases . A growing number of data documents that, compared with women participating in screening mammography, non-participating women have characteristics associated with a higher risk of dying from breastcancer, such as higher rates of obesity and lower compliance to treatments, and the influence of these characteristics on the risk of breastcancer death exists in the absence of screening [19-21]. So, although a number of non-participants die from breastcancer for reasons unrelated to screening, results of case-control studies may suggest that these deaths are due to not having been screened. This bias in results has been termed the ‘ self- selection bias ’ . As the International Agency for Research on Cancer (IARC) Handbook on BreastCancerScreening concluded, ‘ Observational studies of screening, such as cohort and case-control studies, may give biased measures
Dr Kadaoui is a fifth-year resident in the public health and preventive medicine program and a candidate for the Master of Public Health program at Université de Sherbrooke in Quebec. Dr Guay, Dr Baron, and Dr St-Cerny are associates of the Department of Public Health at Hôpital Charles LeMoyne and medical consultants to the Public Health Department of Agence de la santé et des ser- vices sociaux de la Montérégie in Longueuil, Que. Dr Guay is also a medical consultant to the Institut national de santé publique du Québec, a member of the Québec Immunization Committee, Associate Researcher at Hôpital Charles LeMoyne, Longueuil, and Associate Professor in the Faculty of Medicine and Health Sciences at Université de Sherbrooke. Dr Baron and Dr St-Cerny are, respectively, Assistant Professor and Professor of Clinical Instruction in the Department of Community Health of the Faculty of Medicine at Université de Sherbrooke. Dr Lemaire is Associate Professor in the School of Nursing of the Faculty of Medicine and Health Sciences at Université de Sherbrooke.
This study expands on the existing literature to look at women of varying functional health literacy levels who have already entered a screeningprogram, despite the barriers, with a particular emphasis on Spanish-speaking Latinas. In the screeningprogram studied, 38% of primary Spanish-speaking participants had inadequate or marginal health literacy in Spanish, with a full 10% of the women studied not able to read any words in Spanish (TOFHLA-S score of 0). The women studied in this analysis are facing competing health concerns and lack of continuity of care or health insurance outside the screening setting, challenges that were signiﬁ cantly more prevalent among those with lower functional health literacy. Patients with inadequate health literacy were also signiﬁ cantly more likely to lack access to health information through the Internet, work-based
calendar year of diagnosis, not to exaggerate the effect of implementation of multidisciplinary breastcancer care. It is impossible to reliably attribute the observed survival ben- efit to any specific component of optimal clinical management. New surgical treatments, such as breast-conserving surgery, combined with radiation therapy, sentinel node techniques, and axillary node dissection do not improve the survival rate of patients with breastcancer [20-22]. However, several studies have shown a positive association between surgical experi- ence (measured in number of procedures performed) and sur- vival [23-25]. The proportion of patients treated with chemotherapy across all age groups is stable throughout the study period. However, it is conceivable that such treatment was given more systematically to patients who benefited most when they were managed by multidisciplinary team work. Not surprisingly, we found that women who did not have surgery had poorer outcomes.
Overall 58.7% of the women in this study were asymptomatic and three (1.5%) could not answer questions regarding their symptoms. Among those from the BCH ScreeningProgram, 69.5% were asymptomatic, compared with 55% from the private and 45.8% public systems. Among asymptomatic women participating in the BCH ScreeningProgram, 70.8% had CS 0–I disease in comparison with 58.1% in the private and 50% in the public systems. Detection of early breastcancer (CS 0–I) was more frequent among the asymptomatic women (p<0.001) and is associated with the diagnostic method (p<0.001). The distribution of staged lesions according to age, diagnostic methods, and symptoms is shown (Table 4).
The pure benefits and harms of mammography remain heterogeneous. BCS trials are highly diverse in their protocol designs, adherence and evaluations; combining the outcomes of the RCTs into meta-analyses generates the expectations, but does not predict the outcomes of a specific program (which can either fail or succeed reaching higher effectiveness than meta-synthesised efficacy). Differences between reviews in quality assessment comprise not only identification of bias but also the assignment of overall quality scores, leading to variation in inclusion of RCTs. Subsequently, results of the reviews vary and conclusion were inconsistent. In general, the assessed reviews of RCTs have greater similarity in included studies but larger variability in quality assessment while reviews on observational studies show an opposite trend. If this overview will include only reviews incorporated the qual- ity of studies in their conclusions, the disagreements among the reviews would remain. The impact of screening mammog- raphy on stage shift – the most potent intermediate predictor of screening efficacy – was positive for stage III+ breast can- cer. BCM increases with progressing tumour stage, 51 and therefore reduction of advanced tumours should improve patients’ survival. Tabar et al. (2015) calculated that BCM reduction was reaching 28% in the trials achieving 20% or more reduction in advance cancers. 52 Since BCS programs are long-term planned and costly, detection of advanced cancers should serve as an early indicator of the possible success of the pilot BCS program.
Women with a lifetime risk of >25% were offered 18 monthly screenings in addition to their three yearly screenings from age 51 to 60, which is normally covered by the National Health Service BreastScreeningProgram. Study participants were initially screened with single-view mammography until 1999 and two-view mammography thereafter. Clinical breast examination was performed on all women by specialized nursing staff before mammography, and breast self-examination instruction was offered to all women. Participants were encouraged to return if they detected any worrisome changes or findings on breast self-exam. Earlier screening resulted in the detection of 165 breast cancers, 106 of which were in
The strengths of the DKMS include a large sample size that increases every year and detailed registration of the qual- ity indicators with regular quality assessment. Breastcancerscreening is free of charge and all Danish women between 50 and 69 years of age are invited to participate, which reduces potential selection bias. In addition, we are able to obtain nearly complete follow-up for the main outcomes: invasive breast tumors, node negative cancers, small cancers, breast conserving therapy, and mortality from nationwide registries. Thus, women who decline participation in the screeningprogram or drop out after a few screening rounds can be compared to women who stay in the program in regards to breastcancer-specific morbidity and mortality.
An ethically approved retrospective review of 200 consecutive newly diagnosed breastcancer patients, present- ing to the Symptomatic Breast Unit of Letterkenny Hospital between January 2010 and September 2012, was undertaken. Patients with a known previous diagnosis of breastcancer were excluded from the study (n = 17). Letterkenny Hospital is a designated provider of multidisciplinary breastcancer care under the Irish National Cancer Control Program (NCCP, 2007), working as a satellite centre of its parent cancer centre at University College Hospital Galway . Breastscreening in Ireland commenced in 2000 in Dublin and spread nationally throughout the country having arrived in the North West (where this study took place) in October 2009 . Open access or family doctor referral for non-screening mammography is not available for asymptomatic wom- en.
Due to a limited agreement for the use of data, women screened in other screening regions than the BOB, and therefore do not have a complete screening history, are left out of the analysis (N=18,730, 16.0% of all women 70 years and older and screened in the BOB region). Reasons to be left out of the analysis can be: women moving to a different region and resume the screeningprogram there, or moving into the northern region after being screened in one of the other regions. Another reason can be that women are treated in a hospital that is in the northern region so the tumour will be registered as diagnosed in the northern region, but she was screened in another region. This means that it is possible that women, even though they were screened at least four times, are left out of the analysis. It is unknown if these 18.730 women were diagnosed with breastcancer or not, and therefore it is difficult to indicate how much this has influenced the results. For example, leaving these women out of the analyses could have led to an underestimation of the effect of regular participation in the screeningprogram.
The BreastScreen Australia program was introduced between 1991 and 1995, targeting women aged 50–69 as the group most likely to benefit. It was extended to the 70–74-year-old age group in 2013. There was an initial pronounced rise in the incidence of breastcancer because of the detection of earlier lesions, but that stabilised once the program was fully established, and any further increases in incidence should be attributed to other causes. Over the 20 years since implementation of the program, breastcancer mortality has decreased at a population level (all ages) by about 32%. 21-23 Some of this would be due to
The NBCSP started in 1996 and expanded gradually to become nationwide in 2005 13 . Women aged 50-69 years are invited biennially to two-view mammography, including craniocaudal (CC) and mediolateral oblique (MLO) views. About 300,000 women were invited in 2015. The program includes 26 stationary and four mobile mammography machines administered by 16 breast centres. The breast centres cover different geographical areas corresponding to the counties. The Cancer Registry of Norway is responsible for
that the difference in risk of ipsilateral invasive breast can- cer between screen-detected and non-screening-related DCIS was somewhat larger than in our study (annual ab- solute risk 0.43% vs. 0.65%; HR = 0.32, P value <0.0001), possibly because of variation in selection criteria. Our study only included women who were eligible for partici- pation in the population-based screeningprogram based on age, whereas Cheung et al. analyzed all women, and thus also included younger women (<50 years) who have a higher risk of invasive breastcancer compared to older women . Falk et al.  (n = 3163 subjects, median fol- low up 5.2 years) reported a lower risk of ipsilateral inva- sive breastcancer in screen-detected DCIS, which was comparable to our results (HR = 0.7, 95% CI = 0.4–1.1), but did not report absolute risk estimates for groups ac- cording to different methods of detection.