Application of Breast Ultrasound in a Mammography-Based Chinese Breast Screening Study

We evaluated the clinical significance of the combined use of mammography + ultrasound as a new breast screening strategy. The inclusion criteria were: (1) females aged >40yrs; (2) breast cancer diagnosis by the breast image screening personnel at FUSCC; (3) screening by both ultrasound and mammography; (4) mammographic/sonographic images analyzed independently by different radiologists; and (5) follow-up for at least 1 year. Fifty-four women were enrolled. The analysis included diagnostic sensitivity of mammography, ultrasound, and mammography + ultrasound. The sensitivities of mammography and mammography + ultrasound were compared overall as well as among different age groups/breast densities. The screening sensitivity of mammography, ultrasound, and mammography + ultrasound was 79.6, 57.4, and 92.6 %, respectively. The difference between mammography and mammography + ultrasound was significant (P < 0.05). The benefit of including ultrasound with mammography as a new breast image screening strategy was found statistically significant in patients with dense breast on mammogram while it was non-significant in younger (<50 years) women. We, therefore, concluded that mammography + ultrasound increased the diagnostic sensitivity of breast screening; hence it was more desirable for women with dense breast on mammography.     

Open access gastroscopy: too much to swallow?

OBJECTIVES--To ascertain the proportion of endoscopic examinations with normal findings in patients referred for gastroscopy through hospital medical staff or directly by their general practitioner and to assess the likely effect of targeting endoscopy in older patients. DESIGN--Retrospective audit of the gastroscopy practice of one consultant from 1986 to 1988 from information recorded on a standard form completed at the time of the examination, which contained details of patients, their endoscopic findings, and mode of referral (open access or clinic). SETTING--One district general hospital. PATIENTS--1545 Consecutive patients from primary catchment area attending for their first gastroscopy; 454 were referred through the outpatient clinic or by hospital colleagues (clinic group) and 1091 were accepted for endoscopy solely on their general practitioner''s clinical diagnosis (open access group). RESULTS--Similar numbers (about 40%) of examinations with normal findings were performed in each group, although in patients aged over 40 the proportion with normal findings was significantly higher in the clinic group (p less than 0.03). Endoscopic evidence of gastro-oesophageal reflux disease, peptic ulceration, and gastroduodenal inflammation was equally common in each group; upper gastrointestinal malignancy, however, was significantly more common in patients referred through hospital doctors (5%, 23/454 v 2%, 22/1091 respectively; p less than 0.005) (although many of these patients had already been extensively investigated). IMPLICATIONS--Open access gastroscopy does not increase the number of unnecessary examinations and should become more widely available. Targeting this service to patients aged over 40 would reduce the number of requests but increase the diagnostic yield.     

How should we interpret noncompliance with screening mammography?

Primary care practitioners have an important role to play in recommending breast cancer screening to patients in the target age group. In this issue of CMAJ (see pages 1335 to 1343) Dr. Marie-Dominique Beaulieu and associates report the results of a program designed to maximize utilization of screening mammography. Only two thirds of eligible women for whom screening mammography was prescribed obtained a mammogram within the 2-month study period. However, when taken in context, this compliance rate is fairly encouraging. There are many possible reasons for noncompliance such as a need for more information or for repeated suggestions. Family physicians should not become disheartened in their efforts to increase the use of screening procedures and may find that collaboration with others in giving consistent messages will help to maximize screening rates within their patient population.     

Open access to orthopaedic appliances for general practitioners.

A clinic to which general practitioners can refer patients for some types of orthopaedic appliances was opened in North Clwyd in 1983. During 1985, 956 patients were referred by 82 general practitioners; 860 patients received an appliance, and the average waiting time was less than five weeks. Most referrals were for soft collars (44%), lumbar sacral supports (30%), and dorsilumbar supports (7%). Thirty eight patients failed to attend, 54 declined an appliance, and four referrals were considered to be inappropriate. A few patients were subsequently referred to consultant outpatient clinics, 22 for physiotherapy and 34 were referred simultaneously to the open access clinic. The referral rates for general practitioners with access to community hospitals were low. Such an arrangement merits wider consideration.     

Factors associated with annual-interval mammography for women in their 40s

Background: Evidence is mounting that annual mammography for women in their 40s may be the optimal schedule to reduce morbidity and mortality from breast cancer. Few studies have assessed predictors of repeat mammography on an annual interval among these women. Methods: We assessed mammography screening status among 596 insured Black and Non-Hispanic white women ages 43–49. Adherence was defined as having a second mammogram 10–14 months after a previous mammogram. We examined socio-demographic, medical and healthcare-related variables on receipt of annual-interval repeat mammograms. We also assessed barriers associated with screening. Results: 44.8% of the sample were adherent to annual-interval mammography. A history of self-reported abnormal mammograms, family history of breast cancer and never having smoked were associated with adherence. Saying they had not received mammography reminders and reporting barriers to mammography were associated with non-adherence. Four barrier categories were associated with women's non-adherence: lack of knowledge/not thinking mammograms are needed, cost, being too busy, and forgetting to make/keep appointments. Conclusions: Barriers we identified are similar to those found in other studies. Health professionals may need to take extra care in discussing mammography screening risk and benefits due to ambiguity about screening guidelines for women in their 40s, especially for women without family histories of breast cancer or histories of abnormal mammograms. Reminders are important in promoting mammography and should be coupled with other strategies to help women maintain adherence to regular mammography.     

Mammography screening and breast self-examination among minority women in public housing projects: the impact of physician recommendation.

This exploratory study examined the impact of physician recommendations and other factors on mammography screening and breast-self examination (BSE) among African American and Hispanic women in public housing communities. We surveyed a randomly selected sample of low-income households from three low-income communities (n = 291), which included both African Americans and Hispanic women. Data for this paper are reported only on women who were 40 years and older head of the households (n = 120 women, including 74 Hispanics and 46 African Americans), since they meet the age criterion for mammography screening. Our analyses indicated that only 46% of women obtained mammography in the previous 12 months, with no significant differences between the Hispanic and African American women in mammography rates. Physicians' recommendations were among the most significant and substantial predictors of obtaining a mammogram or performing BSE. Further, odds were also higher for those who had insurance coverage. In addition, our data also indicated that almost one out of four women, aged 40 and older participants in this study, claimed that their health care providers never told them they needed a mammogram or never told them that they should perform BSE, with no significant differences between Hispanic and African Americans. Our analyses points to an urgent need for intervention to inform and motivate the service providers in underserved communities to motivate breast cancer screening (BCS) among minority women. Additionally, our examination points to the need for urgent interventions targeting minority women, particularly women with no medical insurance for breast cancer screening.     

Early diagnosis of breast cancer: experience in a consultant breast clinic.

Of 2839 women referred to a consultant breast clinic for clinical, mammographic and thermographic examination, 480 underwent biopsy and 126 were found to have cancer. Ten percent of the tumours were occult and were classified as very early biologic disease; they were identified by routine mammography in women whose breasts were clinically normal. Biopsy of solid mass lesions non-suspicious on mammography identified 20% of the cancers; half these lesions, classified as early biologic disease, were discovered by doctors at routine annual clinical breast examination, though the earliest cancers were detected by women who were confident and competent in monthly self-examination of the breasts. Biopsy of solid mass lesions suspicious on mammography identified 70% of the cancers; these were classified as late biologic disease. Skin or nipple dimpling or retraction was evident in two thirds of the patients; their lesions seemed to be later biologically than the lesions of the patients without clinical signs, and 75% had discovered the lesions themselves accidentally.     

Diagnosing breast carcinoma in young women.

OBJECTIVE--To assess the individual and combined diagnostic accuracy of clinical examination, mammography, and fine needle aspiration biopsy in young women with breast cancer. DESIGN--Analysis based on case notes of patients presenting with breast cancer during 1971-89. SETTING--A combined breast clinic. PATIENTS--Consecutive series of 81 women aged less than 36 with histologically proved breast cancer presenting with a discrete mass over 19 years. MAIN OUTCOME MEASURES--Results of clinical examination, xeromammography or conventional mammography, fine needle aspiration biopsy, and examination of tissue removed by surgery. RESULTS--The clinical diagnosis was correct in 47 women and radiography in 35. Fine needle aspiration biopsy was correct in 47 of the 63 women in whom it was successfully performed. Fine needle aspiration was significantly more accurate than mammography (78% v 45%, p less than 0.01). Ten (16%) patients had negative results on clinical examination, mammography, and fine needle aspiration. CONCLUSION--Mammography alone seems inadequately sensitive to detect breast cancer in young patients. When all investigations give negative results excision biopsy is the only way of obtaining a definitive diagnosis.     

Experience with indeterminate mammograms.

Most radiologists recommend follow-up mammography in 3 to 6 months for asymptomatic patients with mammographic lesions that do not appear suspicious enough to warrant immediate biopsy. In this retrospective cohort study, the medical records of 776 patients were audited 24 to 35 months after mammography to estimate the frequency of indeterminate lesions, the probability of malignancy, and the rate of patients'' compliance with recommendations. Almost 2% of patients retested after an indeterminate mammogram were found to have breast cancer (95% confidence limits 0.2% and 5.9%). Only 26% of the patients retested during the audit period had the test within the suggested upper limit of 6 months. We conclude that timely follow-up after an indeterminate mammogram is advisable and that for the population we studied, compliance with this recommendation is low.     

Management of female breast disease by Southampton general practitioners.

One hundred and two Southampton general practitioners were interviewed about female breast disease. There was agreement about clinical management and the need to both teach and promote breast self-examination. The general practitioners, however, were divided as to whether any breast screening facilities were needed in Southampton. Records kept by the general practitioners of women seen with breast symptoms showed that one-quarter of all new episodes were referred to hospital at the first visit. That the general practitioners considered early diagnosis to be important was made evident from a number of the results. This attitude is encouraging in view of the evidence showing that long-term survival may be greater when delays are shorter.     

Making physiotherapy more accessible: open access for general practitioners to a physiotherapy department.

Open access to a physiotherapy outpatient department of a district general hospital was offered to general practitioners to whom domiciliary physiotherapy was already available. The effects of the new service have been monitored. Delays are reduced and consultants economise on time spent in merely confirming need for physiotherapy. Policies determining treatment, placing emphasis on prevention and self-help rather than prolonged treatment, are adhered to equally well by physiotherapists whether patients are referred directly or indirectly. It had proved unnecessary to restrict access to physiotherapy by insisting that general practitioners refer all patients first to consultant clinics. General practitioners have been sufficiently selective in referral and physiotherapists sufficiently economical in selecting treatment and determining its duration for the service to remain within the limits of available resources.     

Does genetic counseling have any impact on management of breast cancer risk?

Despite there being an increasing literature on the impact of cancer genetic counseling on risk perception and mental health, there is a lack of data describing impact on risk management. Genetic counseling and testing for cancer predisposition genes aims to improve the future health of those at high risk through appropriate surveillance and screening. However, management of breast cancer risk in women with a family history of this disease is an area of controversy. Counseling services may recommend specific risk management options to women, who then rely on their local screening service to make provision. This study investigated the impact of genetic counseling on management of breast cancer risk in women attending Cancer Family Clinics. A total of 293 women attending four genetic clinics were enrolled. Rates of breast self-examination, clinical breast examination, mammography, biopsy, detected cancers, and other screenings were documented. Participants' perceived benefits and barriers to mammography were assessed along with cancer worry. Results show that rates of mammography, clinical breast examination, and breast self-examination were increased following clinic attendance (p < 0.001). Women in the under 35 age-group had limited access to screening. Rates for biopsy and detected cancers were low. Women reported positive attitudes to mammography, with few reported barriers. Contrary to previous studies, there was no evidence that anxiety about breast cancer impedes uptake of health surveillance methods. Genetic counseling had a positive impact on management of breast cancer risk. Whether this translates into future health gains remains to be established.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Mammography screening in the county of Fyn. November 1993-December 1999

This report covers the outcome of the first three invitation rounds of the organised mammography screening programme in the county of Fyn. The programme started in November 1993, and the third invitation round ended on 31 December 1999. The screening takes place either at a special clinic located at University Hospital Odense or in a mobile unit. Women living in and around the city of Odense are examined at the clinic (about 55%), while the rest are examined in the mobile unit. Two-view mammography is used at the first screening. Women with dense breast tissue will continue to have two-view mammography (about 60%), whereas the rest will have singleview mammography at the subsequent screens. All screening images are exposed at the mammography-screening clinic and evaluated with double reading in the clinic. The programme targets women aged 50-69, except those undergoing treatment for breast cancer or going for regular check-ups following breast cancer. Based on the updated population register, the IT-Centre of the county of Fyn issues the invitations. Invited are all women aged 50-69 and living in the county of Fyn when their general practitioners' patients are invited. During the first 3 invitation rounds, 136,079 screening tests were made. Of these, 129,375 tests were made in the women aged 50-69 targeted by the programme. In addition, 6682 screening tests were made in women aged 70 and above, and 22 screening tests were made in women below the age of 50. As a consequence of the mammography screening 2657 assessments were made, 1145 women had surgery, 782 women were diagnosed with invasive breast cancer, and 109 women were diagnosed with ductal carcinoma in situ. A participation rate for the first invitation round was calculated immediately after the end of the round based on the number of participants divided by the number of women invited. This percentage was 88%. Invitation data are, however, not stored. It is therefore not possible now to calculate the participation rates in previous invitation rounds based on the same method. We have therefore chosen to calculate the participation rate as the coverage, i.e. the number of participants divided by the average number of women in the county of Fyn during a given invitation round. Calculated in this way, 84% participated in the first round, 84% in the second round, and 82% in the third round. It should be remembered that these figures do not take into account that some women are not invited because they 1) were undergoing current treatment for breast cancer or going for regular check-ups following breast cancer, or 2) did not participate in the previous round (and never actively informed the programme that they wanted an invitation to the next invitation round), relevant only for the second and third invitation round. For the second and third invitation rounds, the programme only invited women who participated in the previous invitation round, asked the clinic for an invitation, or entered the target population since the last invitation round. Therefore the participation rate in the second invitation round among actually invited women will be close to 94%, as 94% of those participating in the first round came for the second round. For the third invitation round, the participation rate among actually invited women will be close to 96%, as 96% of those participating in the first and second rounds came for the third round. One per cent of the participants in the first invitation round were diagnosed with invasive breast cancer or ductal carcinoma in situ. The detection rate was 0.5% in both the second and third invitation rounds. Ductal carcinoma in situ cases constituted 14% of the detected cases in the first and second rounds, and 10% in the third round. The percentage of invasive breast cancer 10 mm of less was 38%, 31%, and 32%, respectively, and 68%, 74%, and 73%, respectively, were node-negative. The screening programme of the county of Fyn fulfilled all the quality assessment parameters specified by the European guidelines on breast cancer screening, except two. The proportionate interval cancer rate was higher than specified in the guidelines, probably mainly due to the fact that the Fyn programme operates without early recalls. The proportion of stage II+ cancers was higher than specified in the guidelines, which seems, however, to be due to inconsistency between some of the performance indicators in the European guidelines. This analysis of the outcome from the first three invitation rounds of the mammography screening programme in the county of Fyn thus showed that it is a programme of high quality with a favourable profile of the prognostic indicators. The screening programme is hopefully well on its way to reducing breast cancer mortality in the county of Fyn.     

Breast cancer screening among Asian immigrant women in Canada

Objective: The objective of this study was to examine the pattern of breast cancer screening among Asian immigrant women aged 50–69 years and compare it with corresponding non-immigrant women in Canada. Methods: Data from the Canadian Community Health Survey cycle 2.1 (2003) were utilized. Self-reported screening histories were used as outcome variables: socioeconomic status and medical histories were used as predictive variables. Analyses were weighted to represent the target population. Multivariate logistic regression analyses were performed to compare the screening pattern among Asian immigrant women and corresponding non-immigrant Canadians. Results: In total, 508 Asian immigrant women were included in this study. The results suggest that 71% and 60% of Asian immigrant women reported ever having had and recent mammogram use, respectively, while the corresponding figures for non-immigrant women were 89% and 72%. The observed differences were statistically significant and could not be explained by confounding factors. The ability to speak one of the two official languages is an important barrier to mammography screening among Asian immigrant women. Conclusion: The findings show lower rates of mammography screening among Asian immigrant women in Canada. If breast screening is to remain a health policy objective in Canada, targeted efforts to increase the recruitment of Asian immigrant women need to be developed or strengthened.     

Breast Cancer Screening in Saudi Arabia: Free but Almost No Takers

Introduction

Mammography ensures early diagnosis and a better chance for treatment and recovery from breast cancer. We conducted a national survey to investigate knowledge and practices of breast cancer screening among Saudi women aged 50 years or older in order to inform the breast cancer national health programs.

Materials and Methods

The Saudi Health Interview Survey is a national multistage survey of individuals aged 15 years or older. The survey included questions on socio-demographic characteristics, tobacco consumption, diet, physical activity, health-care utilization, different health-related behaviors, and self-reported chronic conditions. Female respondents were asked about knowledge and practices of self and clinical breast exams, as well as mammography.

Results

Between April and June 2013, a total of 10,735 participants completed the survey. Among respondents, 1,135 were women aged 50 years or older and were included in this analysis. About 89% of women reported not having a clinical breast exam in the past year, and 92% reported never having a mammogram. Women living in Al Sharqia had the highest rate of mammography use. Women who were educated, those who had received a routine medical exam within the last two years, and those who were diagnosed with hypertension were more likely to have had a mammogram in the past two years.

Discussion

Our results show very low rates of breast cancer screening in the Kingdom of Saudi Arabia, a country with free health services. This calls for educational campaigns to improve breast cancer screening. Addressing the barriers for breast cancer screening is a public health imperative.     

Geographic patterns of change over time in mammography: Differences between Black and White U.S. Medicare enrollees

U.S. Black women have higher breast cancer mortality compared to White women while their rate of ever having a mammogram has become equal to or slightly surpassed that of Whites. We mapped the distribution of change in screening mammography for Black and White female Medicare enrollees ages 67–69 from 2008 to 2012 by hospital referral region across the contiguous U.S., performed cluster analysis to assess spatial autocorrelation, and examined the screening differences between these groups in 2008 and 2012 respectively. Changes in screening mammography are not consistent across the U.S.: Black and White women have increased and decreased their use of mammography in different regions and Black women’s change patterns vary more widely.     

Screening and genetic counselling for relatives of patients with colorectal cancer in a family cancer clinic.

OBJECTIVE--To introduce and monitor a screening programme for first degree relatives of patients with colorectal cancer based on their calculated lifetime risk. DESIGN--Lifetime risks were calculated for first degree relatives of patients with colorectal cancer and used to offer screening based on estimated risk. SETTING--A family cancer clinic was set up as part of the North East Thames Regional Genetic Service for relatives of patients who had developed colorectal cancer before the age of 45 and members of families in which multiple cancer had occurred. PATIENTS--Self referrals as well as patients referred by general and hospital practitioners. INTERVENTION--Relatives with a lifetime risk of 1 in 10 or greater (high risk group) were offered screening five yearly by colonoscopy, and those whose risk was between 1 in 10 and 1 in 17 were offered yearly screening for faecal occult blood. Women with family histories compatible with Lynch type II cancer family syndrome were offered screening for breast and pelvic tumours. RESULTS--In four years 715 patients were seen. Acceptance of screening was 90% (644 patients). Of 151 patients screened for faecal occult blood, two were found to have polyps. This screening test was unsatisfactory for the high risk group, having a negative predictive value of 78% in 59 patients tested. Regular screening by colonoscopy was offered to 382 high risk patients; 62 patients with polyps and five with colonic cancer were found. One hundred and ten pedigrees were identified with the Lynch type II cancer family syndrome, and four of 35 women screened were found to have breast cancer. Of 14 relatives aged over 65 with a 1 in 2 risk of site specific colonic cancer or Lynch type II cancer family syndrome, seven were found to have polyps, one of whom had carcinoma in situ. CONCLUSIONS--Family history can be used to identify those at risk of colonic cancer and to target appropriate screening. Colonoscopy detected a high number of premalignant colonic polyps, but faecal occult blood testing was unsatisfactory for those at high risk of colorectal cancer.     

Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease.

Case notes of 1113 consecutive new patients referred to a consultant ophthalmologist at a district general hospital were reviewed to determine the source and efficacy of referrals and the current screening practices of general practitioners and ophthalmic opticians. General practitioners initiated referral in 546 cases (49%) and ophthalmic opticians referral in 439 (39%). Visual loss or visual disturbance was the most important single reason for referral (345 cases; 31%), followed by suspected glaucoma (145 cases; 13%), abnormalities of binocular vision (140; 12.5%), disorders of eyelids or ocular adnexa (127; 11%), and red eye (86; 8%). General practitioners referred many more patients with disorders of the eyelids and adnexa and ophthalmic opticians many more patients with suspected glaucoma. Ophthalmic opticians were far more likely than general practitioners to refer patients with suspected glaucoma correctly. A total of 180 patients (16%) were referred from ocular screening, in 149 cases by ophthalmic opticians and in 10 by general practitioners. Seventy patients had glaucoma or incomplete features of glaucoma, all of them referred by ophthalmic opticians. Of eight diabetic patients referred by ophthalmic opticians, three had asymptomatic disease and in two diabetes was diagnosed as a result of ocular screening. No patient was referred for asymptomatic diabetic retinopathy from screening by general practitioners. Ophthalmic opticians were more likely than general practitioners to diagnose retinopathy requiring photocoagulation. Use of a community based service to screen for glaucoma could save unnecessary consultant outpatient appointments. A similar service could facilitate detection of diabetic retinopathy at a stage when treatment is most effective.